Chapter 5: Circulatory System Conditions
Introduction
General Function: the Circulatory System
Delivers nutrients, fuel,
Delivers oxygen
Removes wastes
Maintains temperature
Clotting
Protection from pathogens
Chemical balance
Massage can support or impair this function
Structure and Function: the Heart
Septum divide L/R
Right side pumps to pulmonary circuit
Left side pumps to systemic circuit
AV valves divide into top and bottom halves
Atria, ventricles
“lub-dup” is closing of AV and semilunar valves
Ventricles work harder than atria
Implications for seriousness of heart attacks
(Fig. 5.1)
Structure and Function: Blood Vessels
Aorta → arteries → arterioles → capillaries → venules → veins → vena cava →
heart
Closed system: platelets and RBCs should not be able to leave
60,000 miles of vessels
3-ply construction of veins and arteries:
Tunica intima (endothelium)
Tunica media (smooth muscle)
Tunica externa/ adventitia (connective tissue)
Capillaries are simple squamous epithelium: excellent for permeability
Structure and Function: the Blood
Red blood cells (erythrocytes)
Born in bone marrow
Production stimulated by EPO from kidneys
98% of all blood cells
Lifespan = 4 months
Dead RBCs removed by spleen
Turnover: 2 million/second
No nuclei, lots of hemoglobin (iron-based)
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5 million per mm3
Biconcave discs: all identical, smooth and flexible
White blood cells (leukocytes)
Translucent
Different types for different functions
Neutrophils, basophils, eosinophils, monocytes, lymphocytes
(Fig. 5.2)
Platelets (thrombocytes)
Fragments of larger cells (megakaryocytes)
Smooth until stimulated, then spiky, sticky
Release chemicals that weave fibrin
Make thrombi, crusts
Blood Disorders
Anemia
Embolism, thrombus
Hemophilia
Leukemia
Myeloma
Sickle cell disease
Thrombophlebitis, deep vein thrombosis
Vascular Disorders
Aneurysm
Atherosclerosis
Hypertension
Raynaud syndrome
Varicose veins
Heart Conditions
Heart attack
Heart failure
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Anemia
Definition
Insufficient 02 carrying capacity
Often a symptom or complication rather than freestanding problem
Etiology
Either a shortage of RBCs or a shortage of hemoglobin
Leads to low O2 carrying capacity
Process depends on type of anemia
Types of Anemia
Idiopathic a.:
May be due to poor nutritional uptake due to stress or other factors
Nutritional a.:
Something vital is missing from the diet:
iron
folic acid
vitamin B12
Can lead to pernicious anemia, brain damage
Copper, protein, some others…
(Fig. 5.3)
Hemorrhagic a.:
From blood loss
Trauma (acute)
Slow leak (chronic)
Ulcers, kidney disease, heavy menstruation
Hemolytic a.:
Premature destruction of RBCs
Splenomegaly, jaundice may also be present
Reticulocytes (immature RBCs) increase
Aplastic a.:
Bone marrow is not functioning
All blood cells are affected
Can be autoimmune, renal failure, folic acid deficiency, viral, exposure
to radiation…
Myelodysplastic anemia: bone marrow makes non-functioning
cells: risk of leukemia, myeloma
Secondary a.:
Due to underlying cause:
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Ulcers
Kidney disease
Hepatitis
Acute infection
Blood cancer
Signs and Symptoms
Fatigue
Pallor
Dyspnea, rapid breathing
Rapid heartbeat
Intolerance to cold
Heart problems
Treatment
Depends on underlying cause
Medication
Transfusion, stem cell implants, other strategies
Medications
Oral, injected nutritional supplements
Steroidal anti-inflammatories for autoimmune disease
Synthetic EPO to boost RBC production
Massage
Risks: Anemia can be part of other diseases that contraindicate massage.
Anything that compromises sensation (pernicious anemia) or that is related
to infection or cancer requires special adaptation for bodywork.
Benefits: Massage may help with fatigue, but probably makes no changes in
blood cell production or nutrition. A client who manages anemia and can
adapt to the changes that massage brings about is a good candidate for
bodywork.
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Embolism, thrombus
Definition
Embolism: traveling clot
Thrombus: lodged clot
(Fig. 5.4)
Etiology
Platelets flow through circulatory system; activated by any rough spot or
inflammatory chemicals
Clots form at sites of damage, areas of slow, irregular blood flow
Clots are constantly forming and melting
Sometime pro-clotting mechanism is stronger than anti-clotting
Clots may stay in place (thrombi) or fragment and travel (emboli)
Emboli travel until vessel is too small to pass through
Types of Embolism, Thrombus
Venous thrombosis: see thrombophlebitis, deep vein thrombosis
Pulmonary embolism:
From a clot that forms on venous side of systemic circuit: fragments
and travels to lungs
Often related to deep vein thrombosis, complications of trauma,
orthopedic surgery
Risk factors:
Other cardiovascular disease
Pregnancy
Overweight
Smoking
Hormone supplements
(Fig. 5.5)
Arterial thrombus:
Complication of atherosclerosis
Made worse with chronic inflammation, stress
Clots can grow on site to occlude the artery or they can fragment and
travel (= embolism)
Arterial embolism:
Complication of atherosclerosis, atrial fibrillation, rheumatic heart
disease
Often made of clotted blood, can be other debris
Brain, coronary arteries, kidneys, legs are most common sites;
damaged tissue is infarction
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(Fig. 5.6)
Signs and Symptoms
May be silent
Pulmonary embolism
Dyspnea, hemoptysis, lightheadedness, chest pain, sweating
Arterial embolism:
Sharp, tingling pain, tissue damage and death
Treatment
Medications
Surgery
Supplement O2 if necessary
Compression stockings
Medications
Antiplatelet drugs
Anticoagulants
Thrombolytics
Massage
Risks: A client with a tendency to form clots may not be able to adapt to
mechanical types of bodywork; whether the risk is local or systemic depends
on the type of bodywork.
Benefits: Non-mechanical forms of bodywork may be soothing and
supportive for clients at risk for embolism or thrombus. Clients with a
history of problems but no lingering problems can enjoy massage with no
cautions.
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Hemophilia
Definition
Genetic disorder:
Usually x-linked
Absence of various clotting factors
Etiology
12 distinct clotting factors help form clots
Person with hemophilia has difficulty forming solid, long-lasting clots
because of clotting factor insufficiency
Don’t bleed faster, do bleed longer than others
Rated as mild, moderate, severe
Severe hemophilia = 60% of diagnoses; <1% normal clotting factors
Usually an x-linked genetic mutation
Carried by mothers, passed on to sons
Complications
Leading COD in children with hemophilia is intracranial bleeding
Bleeding into joint capsules with inflammation and extensive damage:
Hemophiliac arthritis
Muscle and nerve damage
Compartment syndrome, contracture
Infected blood products
Types of Hemophilia
Type A:
Most common form, about 80% of all cases
Deficiency of clotting factor VIII
Type B:
AKA Christmas disease
Insufficient Factor IX
About 15% of cases
Von Willebrand disease:
Dysfunction of von Willebrand factor
Helps Factor VIII
Genetic mutation, ranges in severity
Not x-linked; men and women affected equally
Signs and Symptoms
Signs at birth: umbilical cord bleeds excessively
Early childhood: infant/toddler accidents
Bruising, hematomas, nosebleeds, hematuria, joint pain from bleeds into
capsule
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Can be from trauma or spontaneous
Treatment
Supplement clotting factors
Can be done at home now, prophylactically or after injury
Careful exercise, weight control
Medications
Concentrated clotting factors
Recombinant clotting factors
Desmopressing to promote clotting factor production
Antifibrinolytics to slow clot breakdown
Massage
Risks: Severe hemophilia contraindicates rigorous bodywork or anything
that might cause bruising. Consult with client and health care team for other
cautions.
Benefits: Gentle or energetic massage can help with pain and stress. For
milder cases massage that fits within the limitations of the tissues to avoid
bruising is appropriate
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Leukemia
Definition
“White blood”:
Cancer of bone marrow
Overlap between leukemia and lymphoma
38,000 diagnoses in US/year
200,000 survivors alive today
Etiology
Myeloid or lymphoid cells make most WBCs in bone marrow
Leukemia happens when mutation leads to production of non-functioning
WBCs
Can be acute (aggressive) or chronic (slow-growing)
Usually acquired (not inherited) genetic mutations
Exposure to toxins, radiation
Untreated disease leads to death from excessive bleeding, infection
Types of Leukemia
Acute myelogenous leukemia (AML):
Aggressive cancer of meyloid cells
Mostly in people 65+
Linked to exposure to…
Radiation
Chemo for other cancers
Benzene
Can form tumors outside marrow
Chronic myelogenous leukemia (CML):
Slowly progressive
Affects myeloid cells
Traced to specific chromosome
Not usually very aggressive
Can change to behave like AML
Acute lymphocytic leukema (ALL):
Aggressive cancer of all lymphocytes
Most common among children
All other marrow activity is suppressed
Mutated cells can gather in nodes, CNS
Chronic lymphocytic leukemia (CLL):
Slowly progressive
Affects lymphocytes
Mostly B-cells
Can be stable and non-progressive for long periods
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Signs and Symptoms
Bone marrow dysfunction
Suppressed production of normal blood cells
Fatigue, anemia
Easy bruising, bleeding
Chronic infections
Others: fever, headache, weight loss, abdominal pain, enlarged lymph nodes
Treatment
Depends on what cells have been affected
Chemotherapy
Radiation therapy if nonresponsive to chemo
Bone marrow transplant
Biologic (targeted) therapies
Treatments can exacerbate symptoms
Medications
Chemotherapy
Biologic (targeted) therapy, e.g., interferon, monoclonal antibodies
Drugs to mitigate side effects of chemotherapy
Massage
Risks: Patients have a high risk of bruising, bleeding and infection. It is best
to consult with the patient and health care team about timing massage with
treatment options for the best outcomes.
Benefits: Bodywork has many benefits to offer cancer patients, as long as
appropriate precautions are taken.
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Myeloma
Definition
“Mye”= marrow; “oma”= tumor
Cancer of bone marrow, specifically maturing B-cells
Mostly in people 50 years +
Twice as common among African Americans compared to general population
Etiology
Normally, only a few B-cells stay in bone marrow instead of migrating to
lymph tissue
B-cells may experience a DNA mutation
Proliferate into tumors
Secrete cytokines that block osteoblast activity, stimulate osteoclasts
Bone thinning, holes, fractures
Produce faulty antibodies
Tumors can interfere with bone marrow function
Faulty antibodies are shed in urine (causing kidney damage)
Types of Myeloma
Multiple myeloma:
Tumors grow simultaneously at multiple sites
Most common form, 90% of all diagnoses
Solitary myeloma:
A single tumor in bone marrow
Extramedullary plastocytoma:
Growth of tumors outside of bone tissue
Skin, muscle, lung, elsewhere
Signs and Symptoms
Silent early; proteins may be tracked by urinalysis
Bone pain, fractures
Anemia, infections, bleeding
Kidney problems
Amyloidosis (inflammatory proteins congregate in heart, lungs, other
organs)
Treatment
“Watchful waiting”
Chemotherapy, bone marrow stem cell transplantation
Medications
Chemotherapy
Drugs to slow angiogenesis
Corticosteroids, esp. for amyloidosis
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Bisphosphonates to promote bone density
Synthetic EPO for RBC production
Massage
Risks: Myeloma patients have a high risk for fractures. Other complications
may be related to the cancer or its treatment; consult with the patient and
health care team for best results.
Benefits: Gentle work can be helpful for pain, anxiety, sleep and other
benefits.
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Sickle cell disease (SCD)
Definition
Autosomal recessive genetic condition
Production of abnormal hemoglobin
Most common in blacks, Hispanics, Mediterraneans, from Middle East
2 million in US have SC trait
30,000 in US have SCD
Etiology
Having 1 gene: sickle cell trait
Having 2 genes: sickle cell disease
Hemoglobin production is abnormal
RBCs have sickle shape
RBCs get caught at capillaries
RBC lifespan is shortened
(Fig. 5.7)
Complications
Sickle-cell crises: infarctions
Hand-foot syndrome
Organ damage
Esp. spleen, liver, kidneys, brain
Infections (lost spleen function)
Gallstones
Vision loss
Acute chest syndrome (looks like pneumonia)
Others:
Delayed growth, chronic skin ulcers at lower legs, priapsim
(Fig. 5.8)
Signs and Symptoms
Inadequate O2 carrying capacity
Fatigue
Shortness of breath
Pallor
Jaundice, splenomegaly
Other complications
Treatment
Work to limit severity, frequency of SC crises
OTC pain meds, hot pack
Heavier painkillers
Prophylaxis for pneumonia
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Medications
Analgesics
Prophylactic antibiotics
Chemotherapeutic agents for adults
Supplement folate
Massage
Risks: Clients with SCD have compromised circulatory function; any
bodywork must be adapted to respect this serious limitation.
Benefits: Massage for pain and anxiety relief, without intrusive mechanical
intent can be an important part of an SCD patient’s quality of life.
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Thrombophlebitis, Deep Vein Thrombosis
Definition
Veins have become obstructed with clots
Usually calves, thighs, pelvis
Thrombophlebitis = lesser, greater saphenous veins
DVT= popliteal, femoral, iliac veins
Etiology
Thrombi= stationary clots; they can fragment and travel
Usually to lung → pulmonary embolism
Virchow triad:
Injury to endothelium
Hypercoagulability
Venous stasis
Possible triggers:
Physical trauma
Varicose veins
Local infection
Physical restriction
Immobility
Pregnancy and childbirth
Certain types of cancer
Surgery
Hormone supplements
Other factors: cigarette smoking, hypertension, paralysis, and some
genetic conditions
Signs and Symptoms
May be obvious with signs of inflammation
Itchy, hard cord
Sometimes distal edema
Chronic problem → skin rashes, ulcers
With infection: fever, malaise
DVT is more dangerous, higher risk of serious damage
May show pitting edema
(Fig. 5.9)
Treatment
Thrombolytics to break clots; anticoagulants to prevent future ones
Risk of bruising, bleeding
Pneumatic compression, support hose for DVT
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Superficial thrombophlebitis: hot packs, analgesics, gentle exercise
Vena cava filter
Medications
Aspirin
Anticoagulants
Heparin, warfarin
Thrombolytics
Massage
Risks: A client with a diagnosed blood clot is not a good candidate for
rigorous massage until the situation is stable. Clients who use anticoagulants
are at risk for bleeding and bruising.
Benefits: A client who has successfully treated a clot is a good candidate for
massage.
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Aneurysm
Definition
Bulge in blood vessel wall or heart
Usually at aorta or in brain
Etiology
If walls of high-pressure arteries lose elasticity, they can bulge
As aneurysm grows, walls get thinner
Usually happens at thoracic or abdominal aorta, or base of brain
Identified when diameter is 150% of normal
Can happen at multiple sites
Sometimes the whole ventricle of heart can bulge
Factors:
Compromised smooth muscle
Smoking
Congenitally weak arterial wall muscle
Inflammation
Untreated syphilis
Trauma
Rupture is almost always fatal
Types of Aneurysm
Saccular a.:
Usually at thoracic or abdominal aorta
Wall bulges like a rounded sack
Throbbing and pressure on other structures
Fusiform a.:
Common version
Bulge is tubular for a few inches
Berry a.:
Small bulges in the brain
Dissecting a.:
AKA “false aneurysm”
Least common, most painful
The aorta wall splits between the tunica intima and tunica media
Aorta may dissect without an aneurysm
(Figs. 5.10 and 5.11)
Signs and Symptoms
Sometimes silent
May press on other structures:
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
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Dysphagia, chest pain, hoarseness, coughing (thoracic aorta)
Throbbing lump near umbilicus back pain (abdominal aorta)
Headache, numbness, weakness (brain)
Treatment
Endovascular or open surgery
Replacement graft, Dacron substitute, stent
Small bulges may not need immediate repair
Medications
Antihypertensives
Analgesics
Massage
Risks: Research suggests that massage can have a variable affect on blood
pressure. A client with an aneurysm may have a limited capacity to adapt to
these challenges.
Benefits: A client with a stable aneurysm can receive massage that doesn’t
challenge his/her capacity for cardiovascular adaptation.
Options: Bodywork focused on dropping blood pressure without adding
cardiovascular challenge is probably safe for aneurysm patients.
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Page 18
Atherosclerosis
Definition
Subtype of arteriosclerosis
Hardening of large, medium-sized arteries due to plaque
Damage causes spasm, blood clots
Diameter is occluded
(Fig. 5.12)
Etiology
Multifactoral process
Basic progression:
1. Endothelial damage: Occurs most readily at branches or sharp curves
2. Monocytes move in, become macrophages
3. Macrophages take up LDL: Become “foam cells”: beginning of plaque
4. Foam cells infiltrate and damage smooth muscle tissue.
5. Platelets arrive:
Secrete growth factors
Form clots
Cause vascular spasm
See animation at thePoint.lww./Werner5e
Complications
Hypertension (circular relationship)
Aneurysm
Arrhythmia
Thrombus, embolism
Angina pectoris
Stable
Unstable
Heart attack
Risk Factors
Non-modifiable risk factors:
Heredity, genetics
Gender
Age
Kidney disorders
Modifiable risk factors:
Smoking:
High cholesterol levels
High blood pressure
Sedentary lifestyle
Diabetes
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
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Other risk factors:
C-reactive protein
Homocysteine
Others: BMI, fibrinogen, lipoproteins,
Types of Atherosclerosis
Carotid artery disease:
Plaques form in carotid arteries
Set-up for TIA, ischemic stroke
(Fig. 5.13)
Coronary artery disease:
Atherosclerosis at coronary arteries surrounding the heart
Occlusion can lead to heart damage– heart attack
See animation at thePoint.lww.com/Werner5e
(Fig. 5.14)
Peripheral artery disease:
Atherosclerosis away from the neck, heart
Abdomen, legs are frequent sites
Intermittent claudication
Erectile dysfunction
Stasis dermatitis
Gangrene
Skin ulcers
(Fig. 5.15)
Signs and Symptoms
None early: 50% occlusion before dysfunction
(angiogenesis, adaptability)
Later: poor stamina, shortness of breath, complications
Treatment
Diet and exercise
Drugs
Surgery:
Bypass, angioplasty, endarterectomy
Medications
Cholesterol management drugs
Antihypertensives
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Anticoagulants, anti-platelet drugs
Anti-angina drugs
Massage
Risks: It is safe to assume that most adults have some level of
atherosclerosis in the US. If this has led to other forms of heart disease or has
compromised function, then bodywork must be appropriately adjusted.
Benefits: A person with atherosclerosis who is active and engaged in his or
her health can enjoy many benefits from massage that is geared to fit within
adaptive capacity.
Options: Because no major blood vessels are accessible on the back, it is
possible to give a satisfying massage without putting potentially
compromised arteries at risk. Be careful at the anterior trapezius, because of
the carotid arteries.
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Hypertension
Definition
High blood pressure
Persistently above 140/90
About 1/3 of all US adults
Men > women till age 65
Men = women after age 65
African-Americans more vulnerable than other races
Etiology
Internal and external pressure on arteries
See animation at thePoint.lww.com/Werner5e
Damage begins to accrue at 155+ over 75+
Damage is progressive and silent, leading to many complications
Complications
Edema
Atherosclerosis
Stroke
Enlarged heart, heart failure
Aneurysm
Kidney disease
Retinopathy
Types of Hypertension
Essential h.:
Not dependent on underlying factor
About 95% of all diagnoses
Secondary h.:
A temporary complication of another disorder
Pregnancy, kidney disease, adrenal tumor, etc.
Malignant h.:
Can be essential or secondary
Diastolic rises very quickly (over weeks or months)
High risk for stroke
Can be fatal
Signs and Symptoms
“Silent Killer”
Shortness of breath; headache/dizziness; swelling of ankles; sweating,
anxiety
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Treatment
About 1/3 of people with hypertension who treat it at all, treat it successfully
DASH diet
Exercise
Medication
Medications
Diuretics
Vasodilators to reduce cardiac load
Beta blockers, alpha blockers
Massage
Risks: Clients with advanced or poorly managed hypertension may have
serious complications that alter the forms of bodywork that are most
appropriate. Also be aware that antihypertensive medications can make
people feel fatigued and dizzy: these clients may need extra transition time at
the end of a session.
Benefits: A client who is encouraged to exercise is generally a good
candidate for massage. If activity is limited due to hypertension or heart
disease, accommodations can be made to maximize the stress-reduction
aspects of massage and minimize any adaptive requirements.
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Page 23
Raynaud syndrome
Definition
Vasoconstriction of arterioles, usually in hands
Can be feet, nose, ears, lips
Can be primary (R. disease)
Can be secondary (R. phenomenon)
Etiology
Arterioles in hands, feet: constrict, then dilate
Temporary episodes, can become permanent (esp. with R. phenomenon)
Types of Raynaud Syndrome
Raynaud disease:
Primary, freestanding form
Triggers include…
Stress
Cold
Mechanical irritation (vibrating machinery)
Raynaud phenomenon:
Secondary reaction to underlying condition
Faster onset, higher risk of complications
Causes include…
Occlusive arterial diseases
Autoimmune connective tissue diseases
Drug sensitivities
Signs and Symptoms
Usually bilateral
Cycle of colors:
White/ ashy gray
Blue
Red
Episodes last < 1minute-several hours
Secondary can be extreme and long-lasting: atrophy, ulcerations, skin and
nail damage
(Fig. 5.16)
Treatment
Depends on cause
Quit smoking, avoid vasoconstrictors, soak in warm water, dress for weather,
protect hands when working in cold, etc.
Deal with stress: biofeedback, exercise, massage
Medication to dilate blood vessels, counteract norepinephrine
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Surgery: sympathectomy
Medications
Calcium channel blockers, ACE inhibitors for vasodilation
Selective serotonin reuptake inhibitors for peripheral vasodilation
Massage
Risks: Raynaud syndrome can be a symptom of a serious underlying
disorder that requires some adaptation of bodywork. Clients may use
vasodilating drugs that also require some changes in bodywork strategies.
Benefits: Primary Raynaud disease indicates massage as long as the skin is
intact and any medications are accommodated.
Options: Many Raynaud syndrome patients enjoy warm hydrotherapy or
paraffin baths on the affected areas.
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Varicose veins
Definition
Varix”= “twisted”
Valves in superficial veins weaken; vein is stretched, distorted
Usually in legs, can be elsewhere
Women > men
(Fig. 5.17)
Etiology
In the leg:
Small veins pick up blood from internal muscle capillaries
Run on superficial aspect, feed into larger veins that perforate leg muscles
Muscle contraction/ relaxation moves blood from superficial to deep, and up
legs
Damage to valves in superficial veins:
Wear and tear
Standing all day
Mechanical obstruction
Knee socks, brace, pregnancy
Vein becomes enlarged, distorted
Complications
Varicose ulcers, dermatitis
Leg cramps
Blood clots (melt easily)
Risk of DVT, especially with sudden onset or change in size
Types of Varicose Veins
Esophageal varices:
Large veins at distal end of esophagus
Most common with liver disease or bulimia
Risk of rupture, internal bleeding
Hemorrhoids:
Clusters of vascular tissue around the anus
Veins, capillaries, small arterioles
Can develop inside rectum or externally
Associated with constipation, straining during bowel movements
Telangiectasias:
“Spider veins”
Ankles, legs, face
Usually harmless; can indicate underlying circulatory problem
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Varicoceles:
Dilated venous structures that supply spermatic cord
Can be painless
Can interfere with fertility, testosterone production
Signs and Symptoms
Lumpy, bluish wandering lines
Protrude from skin
Back, medial aspect of calf and thigh
Itching, throbbing pain
(Fig. 5.18)
Treatment
Support hose, elastic bandages
Avoid long periods on feet, rest with feet elevated
Avoid constricting clothes
Surgery:
Vein stripping
Ambulatory phlebectomy
Other:
Sclerosing injections
Laser
Radiofrequency
Massage
Risks: Very extreme veins with skin damage at least locally contraindicate
anything but the lightest massage. Be aware that superficial veins have some
connectors to deeper veins, which could lead to DVT.
Benefits: Massage is unlikely to change v. veins, but flat, gliding pressure
toward the heart is safe for this condition as long as the skin is intact and the
risk of blood clots is minimal.
Options: Mild v. veins can respond to hydrotherapy: alternating hot and cold.
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Heart attack
Definition
Damage to cardiac muscle from ischemia
CAD
Muscle tissue doesn’t repair; replaced by scar tissue
Damaged area = “infarct”
Heart attack = myocardial infarction
1.5 million heart attacks in US/year
500,000 deaths
#1 COD for men and women
(Fig. 5.19)
Etiology
A portion of myocardium dies due to lack of O2
Usually a blockage in coronary artery
Could be clot, debris, that travels from elsewhere
Prolonged coronary spasm (drug overdose)
New plaques more likely to break off, rupture than old ones
Cardiac cells die from ischemia
Can’t contract with coordination
Related conditions:
Atrial, ventricular fibrillations (can be very dangerous)
Arrhythmia
Embolism
Aneurysm
Heart failure
Shock
Signs and Symptoms
Angina pectoris
Stable
Unstable
Spreading pain
Shortness of breath without chest pain
Stomach, abdominal pain
It is important to pay attention to early symptoms: heart attacks progressively
destroy tissue; early intervention is life-saving.
Treatment
Identify location of blockage, break it up ASAP
Thrombolytics
Percutaneous transluminal coronary angioplasty
Oxygen, pain management
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Later care: anticoagulants, nitroglycerin, observation, evaluation
Surgery if necessary
Lifestyle changes
Medications
Emergency care:
Aspirin (anti-platelet)
Analgesics
Nitroglycerin
Thrombolytics, anticoagulants
After-care
Nitroglycerin
Anticoagulants, anti-platelet drugs
Cholesterol management drugs
Anti-hypertensives
Massage
Risks: The safety of bodywork in this context depends largely on the
adaptive capacity of the client. If activity is limited due to pain or the risk of a
repeat event, massage must likewise be limited in its demands on the body.
Benefits: Gentle massage for pain and anxiety is helpful even for clients with
a recent heart attack. A client with a history of heart problems but who is
physically active can probably adapt to any changes that massage might
bring about.
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Page 29
Heart failure
Definition
Progressive loss of heart function
Not cardiac arrest
5 million patients in the US
300,000 deaths/year
Prevalence doubles with each decade
Etiology
Heart pumps 2,000 gallons/day
If resistance develops, heart compensates
Heart grows (cardiomegaly)
Ventricles become stiff, inelastic
Stress-related hormones boost short-term function, damages in long-term
Heart muscle may fibrillate → circulatory system collapse
Heart failure usually related to other CV disease
Can be related to congenital weakness with heart muscle or valves
Types of Heart Failure
Left-sided heart failure:
Left ventricle pushes against resistance in the aorta (atherosclerosis)
Fluid backs up into lungs
Causes shortness of breath, coughing, pneumonia risk
(Fig. 5.20)
Right-sided heart failure:
AKA cor pulmonale
Resistance on the right side (lungs: could be a complication of leftsided heart failure)
Right ventricle is weakened; back-up of fluid accumulates in legs (if
ambulatory), abdomen (if bed-ridden)
(Fig. 5.21)
Biventricular heart failure:
Left and right sided failure simultaneously
Tends not to respond to medication
Patient may be a candidate for transplant surgery
See animation and video at thePoint.lww.com/Werner5e
Signs and Symptoms
Depends on which side of heart is dysfunctional
Shortness of breath, low stamina, edema, chest pain, indigestion, arrhythmia,
distended vessels in neck, cold sweaty skin…
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Page 30
Usually slow onset
Treatment
Depends on location, severity
Rest, change in diet, modify physical activity
Medications
Surgery: repair damaged valves, mesh bag, transplant
Medications
Anticoagulants
Beta blockers, ACE inhibitors
Digitalis
Diuretics
Statins for cholesterol management
Massage
Risks: Most people with heart failure have a history of other cardiovascular
disease, and limitations on physical activities. Massage must likewise be
adjusted to fit within those limitations. Be aware the medications to manage
heart failure have side effects that must be accommodated for.
Benefits: Gentle bodywork that invites (rather than imposes) change may
help to reduce blood pressure, decrease stress.
Werner, A Massage Therapist’s Guide to Pathology, 5th ed.: Lecture Notes, Ch 5
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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