PERIPHERAL
VASCULAR DISEASES
DR. Mohamed Seyam PhD. PT.
Assistant Professor Of Physical Therapy
For Cardiovascular /Respiratory Disorder
Objectives
• Understand/describe the normal structure and function of the
lymphatic system.
• Identify risk factors affecting the normal drainage of the
lymphatic system.
• Discuss diseases or procedures that could predispose a patient to
lymphedema.
• Explain assessment of a patient with lymphedema
• Discuss management of lymphedema.
Lymphatic system( tissues and vessels)
• The
lymphatic system filters and collects lymph and large molecules in the
interstitial space that come from the intravascular space.
Main functions:
• Helps
balance the body’s fluid and Protects the body from infection
• Normally,
the heart pumps so strongly that it causes 20-30 liters of plasma
per day to leak from the capillaries. This is the interstitial fluid, which the
lymphatic system drains, filters, and returns to the heart.
• Lymphatic
vessels are similar to veins, but with thinner walls to allow
larger proteins to permeate through.
• unidirectional
flow and no circulation.
Lymph nodes
1. Supraclavicular
2. Retroperitoneal
3. Trachea
4. Thoracic
5. Abdominal
6. Axilla
7. The pelvic area
8. Inguinal
9. Tonsils
10. spleen
11.Intestinal wall
12.bone marrow.
• Lymph
nodes filter harmful substances and contain lymphocytes that
activate the immune system.
• The lymph system carries the lymphocytes throughout the body to
respond to antigens and communicate responses to other parts of the
body.
• Lymph then travels through multiple lymphatic channels and nodes
before returning to the venous system by the thoracic duct.
• Under normal conditions, the entry of fluid and other materials into the
interstitial space is balanced by outflow of the lymphatic fluid from the
limb, which maintains standard volume.
• Lymphedema occurs when there is an interruption or obstruction of the
lymphatic system that causes an accumulation of fluid in the limb.
• A healthy adult has approximately 600-700 lymph nodes.
Lymphedema
• Lymphedema is
an abnormal accumulation
of high-protein concentrated fluid, usually
in the arms and legs.
• Lymphedema is a swelling of the
extremities or rarely the face and genitalia,
due to malfunction of the lymphatic
system as obstruction of lymphatic vessels
• Lymphedema is described as an abnormal
collection of protein, edema, fibrosis and
chronic inflammation.
Risk Factor (Secondary): Surgery
• Any
surgery that dissects or removes lymph nodes
increases the risk of lymphedema by impairing the lymph
flow.
• Common cancers
that may require surgical alterations of
the lymph nodes include breast cancer, head and neck,
prostate, testicular, bladder, or colon cancer.
• Surgical disruption of
• Vascular
surgery
lymphatic system
• Risk Factor: Radiation
Radiation therapy to the axillary or groin region around the
lymph node can cause fibrosis and scarring of the tissue and
therefore cause lymphedema to occur
• Risk
Factor: Lymphedema and Breast Cancer
It is estimated that 15-20% of patients with breast cancer will
experience lymphedema.
Types of Lymphedema
1- Pitting edema
Short duration edema
Finger indentation of the skin
2- Brawny edema
Tissue feels hard upon palpation
Indicates fibrotic changes
3- Weeping
Fluid leaks, wound healing is impaired
Occurs mostly in the lower extremities
Stages of lymphedema
Stage I
• Considered reversible
• There is lower than 3 cm difference between extremities.
Stage II
• Considered irreversible
• There is 3 to 5 cm difference between extremities.
Stage III
• Tissues are hard and may have cartilage formation developing.
• There is more than 5 cm difference between extremities.
Signs and symptoms
• Painless
swelling of the arms or legs, which may get worse
during the day and better at night.
• Redness, Warmth
or achiness in the extremity.
• A feeling
of tightness, heaviness, tingling, numbness, or
weakness in the affected extremity.
• Bracelets,
•A2
rings, or shoes may become tight.
cm difference between extremities is a general classification.
• Tends
to occur distal to proximal
• Increased
pigmentation/superficial veins
• Secondary
cellulitis
Measurement Methods
Water displacement – “gold standard”
2. Circumference
3. Perometry
4. Bioelectrical impedance
1.
Water Displacement (Volumetric
measurement)

“Gold standard” for
volume
measurement
(edema size)
1- Water displacement – “gold standard
Circumference

Most commonly used
method to assess limb
volume

Measurements taken at
various points of arm or leg

Time-consuming

Requires considerable
experience
2- Circumference
Examination (Cont)
- Girth measurements of the extremity
(evaluating edema size).
Limb measurements must be done at the set levels
and ideally repeated by the same person. These
measurements are taken in:
1. The upper limb at:
(a) Axilla.
(b) 8 cm proximal to olecranon.
(c) 11 cm distal to olecranon.
(d) Wrist.
(e) Level with web of thumb
Upper limb circumference.
Examination (Cont)
2.
(a)
(b)
(c)
(d.)
(e)
The lower limb at:
Groin
15 cm above base of patella.
15 cm below apex of patella.
Ankle (malleoli).
Middle of metatarsals.
lower limb circumference.
Perometry

Imaging device

Measures limb volume,
circumference, contour,
cross-sectional area

Convenient

Expensive
3- Perometry
4- Bioelectrical impedance
I stage of Lymphedema
• Recommendations
about change of a way of life
• The elastic compression
• Preventive and medical rehabilitation programs
Magnetic stimulation,
Pneumo-compression,
Magnetic laser therapy,
Pulse matrix laser therapy,
Balneotherapy (‫(العالج بالمياه المعدني‬
Thalassotherapy . )‫)العالج بمياه البحر‬
II stage of Lymphedema
• recommendations
about change of a way of life
• compression therapy
• courses
of medicamentous treatment are spent 2 times a year.
• medical
rehabilitation programs:
a
pneumocompression,
magnetic
laser therapy or pulse matrix laser therapy
magnetic
stimulation,
cryotherapy,
manual
balneotherapy, thalassotherapy,
lymph drainage and bandaging of the limb.
III stage of Lymphedema
• to
change of a way of life,
• compression
therapy,
• Medical
rehabilitation programs (a pneumo-compression, magnetic
laser therapy, magnetic stimulation, pulse laser therapy,
cryotherapy, balneotherapy, thalassotherapy, manual lymph drainage
and bandaging of the limb) are spent 2-3 times a year.
•
Medicamentous treatment is spent by courses for 4-6 months and
includes preventive appointment of the prolonged antibiotics for
prevention of relapses of an erysipelatous inflammation.
IV stage of Lymphedema
•patients
accept surgical treatment with carrying
out of conservative preoperative preparation.
•postoperative rehabilitation with use specified
physiotherapeutic and medicamentous methods.
Physical Therapy Components Of A
Decongestive Lymphatic Therapy Program
1.
Elevation
2.
Manual lymphatic drainage
3.
Compression bandaging and Garment
4.
Exercise
5.
Pneumatic Pumps
6.
Electro modalities
7.
Skin care
8.
Daily living precautions
1- Elevation
*Elevate the involved limb when
using a sequential compression
pump
*Elevate limb when sleeping,
resting, and during sedentary
activities
*Compressive bandages or
garment should be worn during
periods of elevation
1- Position
Elevation of the feet for 10-15 minutes 3-4
times a day
2- Manual Lymphatic Drainage
* Slow, very light, repetitive
stroking and circular massage
movements performed in a
specific sequence, limb elevated
whenever possible.
* Proximal congestion in the trunk,
groin, buttock, or axilla is cleared
first.
* Direction of massage is towards
specific lymph nodes.
* Usually involves distal to proximal
stroking.
3- Compression bandaging and
Garment.
* Compression Garments.
* Once a manageable size has been
achieved from wrapping, a
compression stocking may be worn
to maintain the size and prevent
increased swelling.
* Bandages may be applied to
increase tissue pressure and
counteract the elastic insufficiency
of the connective tissue.

Compression Bandaging

Bandages may be applied to increase tissue
pressure and counteract the elastic
insufficiency of the connective tissue.

Thiadens, 2005
Used with permission from lymphacare.com
Compressive Bandages
4- Exercise
Exercise
* Active range of motion, stretching,
circulatory and low-intensity resistance
exercise is incorporated with manual
drainage techniques.
* Exercises should be performed
with compressive bandages or
garment
* Exercises are performed in a specific
sequence, often with the limb elevated
* Low-intensity
cardiovascular/pulmonary
endurance activities.
* Deep breathing and relaxation.
Exercises
Elbow
flexion
Elbow
extention
10
repetitions
each
Shoulder
horizontal
adduction
Shoulder
abduction
Shoulder
flexion
5-
Sequential, Pneumatic Pumps
3- Compression pump (pneumatic pump unit)
•Contraindications
•Indications
•Varicose veins
•Thrombosis
•Lymphedema
•Kidney or
cardiac
diseases
•Chronic
venous
insufficiency
•Cancers
Vasotrain 447
6- Electro modalities
• Ultrasound
: Pulsed , 0.1-0.3 W/cm2; for 5-8 minutes
• Pulsed ultrasound at a lower intensity will produce
mechanical and non thermal effects that will soften
fibrotic tissues.
• Ultrasound may be used for its fibrinolitic effects on
lymphostatic fibrosis.
7- Good skin care
• Keep
the skin clean and dry
• Apply moisturizer daily
• Protect skin with sunscreen and insect repellant
• Use care with razors
• Wear gloves during activities
• Avoid extreme temperatures
Daily living precautions
• No blood draws, finger pricks for blood sugar testing, IVs,
blood pressures, or injections should be taken on the affected
extremity.
• Anything that may cause pressure needs to be avoided
including:
*Blood pressure cuffs
*Tourniquets
*Tight clothes (waist bands, bra straps, socks)
• This constricts collateral circulation
Precautions
• Heat
may cause vasodilatation, which causes more fluid to move
from the blood vessels into the tissues. Avoid hot showers and
saunas.
• Cold may cause rebound swelling or chapped skin
• Air travel more than 2 hours increases the risk of swelling because
of continuous reduction of cabin pressure.
• It is recommended to wear a compression stocking while flying.
• Avoid carrying a purse, briefcase, or other heavy item with the
affected extremity.
• If the lower extremity is affected, avoid standing or sitting for long
periods of time and do not cross legs.
Thank you