A Massage Therapist’s Guide to
Pathology 5e
Chapter Five
Circulatory System Conditions
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 5 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
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Chapter 5 Introduction, cont.
• 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
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 5 Introduction, cont.
• 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
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Chapter 5 Introduction, cont.
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)
– 5 million per mm3
– Biconcave discs: all identical, smooth and flexible
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Chapter 5 Introduction, cont.
• White blood cells (leukocytes)
– Translucent
– Different types for different functions
• Neutrophils, basophils, eosinophils, monocytes,
lymphocytes
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 5 Introduction, cont.
• Platelets (thrombocytes)
– Fragments of larger cells (megakaryocytes)
– Smooth until stimulated, then spiky, sticky
– Release chemicals that weave fibrin
• Make thrombi, crusts
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Chapter 5 Introduction, cont.
• Blood Disorders
–
Anemia
–
Embolism, thrombus
–
Hemophilia
–
Leukemia
–
Myeloma
–
Sickle cell disease
–
Thrombophlebitis, deep vein thrombosis
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 5 Introduction, cont.
• Vascular Disorders
–
Aneurysm
–
Atherosclerosis
–
Hypertension
–
Raynaud syndrome
–
Varicose veins
• Heart Conditions
–
Heart attack
–
Heart failure
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anemia
• Definition:
– Insufficient 02 carrying capacity
–
Often a symptom or complication rather than
freestanding problem
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Anemia, cont.
• Etiology: what happens?
– Either a shortage of RBCs or a shortage of
hemoglobin
– Leads to low O2 carrying capacity
– Process depends on type of anemia
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Anemia, cont.
Types of anemia
• Idiopathic a.:
– May be due to poor nutritional uptake due to
stress or other factors
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Anemia, cont.
Types of anemia
• 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…
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anemia, cont.
Types of anemia
• Hemorrhagic a.:
– From blood loss
• Trauma (acute)
• Slow leak (chronic)
• Ulcers, kidney disease, heavy
menstruation
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Anemia, cont.
Types of anemia
• Hemolytic a.:
– Premature destruction of RBCs
– Splenomegaly, jaundice may also be present
– Reticulocytes (immature RBCs) increase
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Anemia, cont.
Types of anemia
• 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
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Anemia, cont.
Types of anemia
• Secondary a.:
– Due to underlying cause:
• Ulcers
• Kidney disease
• Hepatitis
• Acute infection
• Blood cancer
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Anemia, cont.
• Signs and Symptoms:
– Fatigue
– Pallor
– Dyspnea, rapid breathing
– Rapid heartbeat
– Intolerance to cold
– Heart problems
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Anemia, cont.
• 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
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Anemia, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Embolism, thrombus
• Definition:
– Embolism: traveling clot
– Thrombus: lodged clot
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Embolism, thrombus, cont.
• Etiology: what happens?
– 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
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Embolism, thrombus, cont.
Types of embolism, thrombus
• Venous thrombosis: see thrombophlebitis, deep
vein thrombosis
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Embolism, thrombus, cont.
Types of embolism, thrombus
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Embolism, thrombus, cont.
Types of Types of embolism, thrombus
• 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)
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Embolism, thrombus, cont.
Types of embolism, thrombus
• 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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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Embolism, thrombus, cont.
• Signs and Symptoms:
– May be silent
– PE:
• Dyspnea, hemoptysis, lightheadedness,
chest pain, sweating
– Arterial embolism:
• Sharp, tingling pain, tissue damage and
death
–
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Embolism, thrombus, cont.
• Treatment:
– Medications
– Surgery
– Supplement O2 if necessary
– Compression stockings
• Medications:
– Antiplatelet drugs
– Anticoagulants
– Thrombolytics
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Embolism, thrombus, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hemophilia
• Definition:
– Genetic disorder:
• Usually x-linked
• Absence of various clotting factors
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Hemophilia, cont.
• Etiology: what happens?
–
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
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Hemophilia, cont.
• 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
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Hemophilia, cont.
Types of hemophilia
• Type A:
– Most common form, about 80% of all cases
– Deficiency of clotting factor VIII
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Hemophilia, cont.
Types of hemophilia
• Type B:
– AKA Christmas disease
– Insufficient Factor IX
– About 15% of cases
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Hemophilia, cont.
Types of hemophilia
• Von Willebrand disease:
– Dysfunction of von Willebrand factor
– Helps Factor VIII
– Genetic mutation, ranges in severity
– Not x-linked; men and women affected equally
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Hemophilia, cont.
• 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
• Can be from trauma or spontaneous
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Hemophilia, cont.
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hemophilia, cont.
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Leukemia
• Definition:
– “White blood”:
– Cancer of bone marrow
– Overlap between leukemia and lymphoma
– 38,000 diagnoses in US/year
– 200,000 survivors alive today
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Leukemia, cont.
• Etiology: what happens?
–
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
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Leukemia, cont.
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
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Leukemia, cont.
Types of leukemia
• Chronic myelogenous leukemia (CML):
– Slowly progressive
– Affects myeloid cells
– Traced to specific chromosome
– Not usually very aggressive
• Can change to behave like AML
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Leukemia, cont.
Types of leukemia
• 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
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Leukemia, cont.
Types of leukemia
• Chronic lymphocytic leukemia (CLL):
– Slowly progressive
– Affects lymphocytes
• Mostly B-cells
– Can be stable and non-progressive for long
periods
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Leukemia, cont.
• 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
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Leukemia, cont.
• 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
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Leukemia, cont.
• Medications:
– Chemotherapy
– Biologic (targeted) therapy, e.g., interferon,
monoclonal antibodies
– Drugs to mitigate side effects of chemotherapy
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Leukemia, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
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Myeloma, cont.
• Etiology: what happens?
– 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)
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Myeloma, cont.
Types of myeloma
• Multiple myeloma:
– Tumors grow simultaneously at multiple sites
– Most common form, 90% of all diagnoses
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Myeloma, cont.
Types of myeloma
• Solitary myeloma:
– A single tumor in bone marrow
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Myeloma, cont.
Types of myeloma
• Extramedullary plastocytoma:
– Growth of tumors outside of bone tissue
• Skin, muscle, lung, elsewhere
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Myeloma, cont.
• 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)
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Myeloma, cont.
• Treatment:
–
“Watchful waiting”
– Chemotherapy, bone marrow stem cell
transplantation
• Medications:
– Chemotherapy
– Drugs to slow angiogenesis
– Corticosteroids, esp. for amyloidosis
– Bisphosphonates to promote bone density
– Synthetic EPO for RBC production
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Myeloma, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sickle cell disease, cont.
• Etiology: what happens?
– 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
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sickle cell disease, cont.
• 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
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sickle cell disease, cont.
• Signs and Symptoms:
– Inadequate O2 carrying capacity
• Fatigue
• Shortness of breath
• Pallor
– Jaundice, splenomegaly
– Other complications
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Sickle cell disease, cont.
• Treatment:
– Work to limit severity, frequency of SC crises
• OTC pain meds, hot pack
• Heavier painkillers
• Prophylaxis for pneumonia
• Medications:
– Analgesics
– Prophylactic antibiotics
– Chemotherapeutic agents for adults
– Supplement folate
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sickle cell disease, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
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Thrombophlebitis, deep vein
thrombosis, cont.
• Etiology: what happens?
– Thrombi= stationary clots; they can fragment and
travel
• Usually to lung → pulmonary embolism
– Virchow triad:
• Injury to endothelium
• Hypercoagulability
• Venous stasis
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Thrombophlebitis, deep vein
thrombosis, cont.
–
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
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Thrombophlebitis, deep vein
thrombosis, cont.
• 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
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Thrombophlebitis, deep vein
thrombosis, cont.
• Treatment:
– Thrombolytics to break clots; anticoagulants to
prevent future ones
• Risk of bruising, bleeding
– Pneumatic compression, support hose for DVT
– Superficial thrombophlebitis: hot packs,
analgesics, gentle exercise
– Vena cava filter
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Thrombophlebitis, deep vein
thrombosis, cont.
• Medications:
– Aspirin
– Anticoagulants
• Heparin, warfarin
– Thrombolytics
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Thrombophlebitis, deep vein
thrombosis, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Aneurysm
• Definition:
– Bulge in blood vessel wall or heart
–
Usually at aorta or in brain
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Aneurysm, cont.
• Etiology: what happens?
– 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
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Aneurysm, cont.
– Factors:
• Compromised smooth muscle
• Smoking
• Congenitally weak arterial wall muscle
• Inflammation
• Untreated syphilis
• Trauma
– Rupture is almost always fatal
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Aneurysm, cont.
Types of aneurysm
• Saccular a.:
– Usually at thoracic or abdominal aorta
– Wall bulges like a rounded sack
– Throbbing and pressure on other structures
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Aneurysm, cont.
Types of aneurysm
• Fusiform a.:
– Common version
– Bulge is tubular for a few inches
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Aneurysm, cont.
Types of aneurysm
• Berry a.:
– Small bulges in the brain
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Aneurysm, cont.
Types of aneurysm
• 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
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Aneurysm, cont.
• Signs and Symptoms:
– Sometimes silent
– May press on other structures:
• Dysphagia, chest pain, hoarseness, coughing
(thoracic aorta)
• Throbbing lump near umbilicus back pain
(abdominal aorta)
• Headache, numbness, weakness (brain)
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Aneurysm, cont.
• Treatment:
– Endovascular or open surgery
• Replacement graft, Dacron substitute, stent
– Small bulges may not need immediate repair
• Medications:
– Antihypertensives
– Analgesics
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Aneurysm, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Atherosclerosis
• Definition:
– Subtype of arteriosclerosis
– Hardening of large, medium-sized arteries
due to plaque
• Damage causes spasm, blood clots
• Diameter is occluded
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Atherosclerosis, cont.
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Atherosclerosis, cont.
• Etiology: what happens?
–
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
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Atherosclerosis, cont.
• Complications
– Hypertension (circular relationship)
– Aneurysm
– Arrhythmia
– Thrombus, embolism
– Angina pectoris
• Stable
• Unstable
– Heart attack
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Atherosclerosis, cont.
• 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
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Atherosclerosis, cont
– Other risk factors:
• C-reactive protein
• Homocysteine
• Others: BMI, fibrinogen, lipoproteins,
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Atherosclerosis, cont.
Types of atherosclerosis
• Carotid artery disease:
– Plaques form in carotid arteries
– Set-up for TIA, ischemic stroke
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Atherosclerosis, cont.
Types of atherosclerosis
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Atherosclerosis, cont.
Types of atherosclerosis
• Peripheral artery disease:
– Atherosclerosis away from the neck, heart
– Abdomen, legs are frequent sites
• Intermittent claudication
• Erectile dysfunction
• Stasis dermatitis
• Gangrene
• Skin ulcers
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Atherosclerosis, cont.
• Signs and Symptoms:
– None early: 50% occlusion before
dysfunction
• (angiogenesis, adaptability)
– Later: poor stamina, shortness of breath,
complications
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Atherosclerosis, cont.
• Treatment:
– Diet and exercise
– Drugs
– Surgery:
• Bypass, angioplasty, endarterectomy
• Medications:
– Cholesterol management drugs
– Antihypertensives
– Anticoagulants, anti-platelet drugs
– Anti-angina drugs
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Atherosclerosis, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
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Hypertension, cont.
• Etiology: what happens?
– 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
Category
Systolic
Diastolic
Optimal
<120
<80
Pre-hypertension
120-139
80-89
Stage 1
140-149
90-99
Stage 2
160+
100+
Hypertension
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
• Complications
– Edema
– Atherosclerosis
– Stroke
– Enlarged heart, heart failure
– Aneurysm
– Kidney disease
– Retinopathy
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
Types of hypertension
• Essential h.:
– Not dependent on underlying factor
– About 95% of all diagnoses
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
Types of hypertension
• Secondary h.:
– A temporary complication of another disorder
• Pregnancy, kidney disease, adrenal tumor,
etc.
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Hypertension, cont.
Types of hypertension
• Malignant h.:
– Can be essential or secondary
– Diastolic rises very quickly (over weeks or
months)
– High risk for stroke
– Can be fatal
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
• Signs and Symptoms:
–
“Silent Killer”
– Shortness of breath; headache/dizziness; swelling
of ankles; sweating, anxiety
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
• Treatment:
– About 1/3 of people with hypertension who
treat it at all, treat it successfully
– DASH diet
– Exercise
– Medication
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
• Medications:
– Diuretics
– Vasodilators to reduce cardiac load
– Beta blockers, alpha blockers
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hypertension, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
• Etiology: what happens?
– Arterioles in hands, feet: constrict, then dilate
–
Temporary episodes, can become permanent
(esp. with R. phenomenon)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
Types of Raynaud syndrome
• Raynaud disease:
– Primary, freestanding form
– Triggers include…
• Stress
• Cold
• Mechanical irritation (vibrating machinery)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
Types of Raynaud syndrome
• Raynaud phenomenon:
– Secondary reaction to underlying condition
– Faster onset, higher risk of complications
– Causes include…
• Occlusive arterial diseases
• Autoimmune connective tissue diseases
• Drug sensitivities
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
• 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
• Surgery: sympathectomy
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
• Medications:
– Calcium channel blockers, ACE inhibitors for
vasodilation
– Selective serotonin reuptake inhibitors for
peripheral vasodilation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Raynaud syndrome, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins
• Definition:
– Varix”= “twisted”
– Valves in superficial veins weaken; vein is
stretched, distorted
• Usually in legs, can be elsewhere
– Women > men
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
• Etiology: what happens?
–
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
• Complications:
– Varicose ulcers, dermatitis
– Leg cramps
– Blood clots (melt easily)
– Risk of DVT, especially with sudden onset or
change in size
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
Types of varicose veins
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
Types of varicose veins
• Telangiectasias:
– “Spider veins”
– Ankles, legs, face
– Usually harmless; can indicate underlying
circulatory problem
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
Types of varicose veins
• Varicoceles:
– Dilated venous structures that supply spermatic
cord
– Can be painless
– Can interfere with fertility, testosterone
production
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
• Signs and Symptoms:
– Lumpy, bluish wandering lines
– Protrude from skin
– Back, medial aspect of calf and thigh
– Itching, throbbing pain
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Varicose veins, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart attack, cont.
• Etiology: what happens?
– 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart attack, cont.
• Etiology, cont.
– Related conditions:
• Atrial, ventricular fibrillations (can be very
dangerous)
• Arrhythmia
• Embolism
• Aneurysm
• Heart failure
• Shock
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart attack, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart attack, cont.
• Treatment:
– Identify location of blockage, break it up ASAP
• Thrombolytics
• Percutaneous transluminal coronary
angioplasty
• Oxygen, pain management
– Later care: anticoagulants, nitroglycerin,
observation, evaluation
– Surgery if necessary
– Lifestyle changes
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart attack, cont.
• Medications:
–
Emergency care:
• Aspirin (anti-platelet)
• Analgesics
• Nitroglycerin
• Thrombolytics, anticoagulants
–
After-care
• Nitroglycerin
• Anticoagulants, anti-platelet drugs
• Cholesterol management drugs
• Anti-hypertensives
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart attack, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
• Etiology: what happens?
–
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
Types of heart failure
• Right-sided heart failure:
– AKA cor pulmonale
– Resistance on the right side (lungs: could be a
complication of left-sided heart failure)
– Right ventricle is weakened; back-up of fluid
accumulates in legs (if ambulatory), abdomen
(if bed-ridden)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
Types of heart failure
• 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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
• 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…
– Usually slow onset
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
• Treatment:
– Depends on location, severity
– Rest, change in diet, modify physical activity
– Medications
– Surgery: repair damaged valves, mesh bag,
transplant
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
• Medications:
– Anticoagulants
– Beta blockers, ACE inhibitors
– Digitalis
– Diuretics
– Statins for cholesterol management
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Heart failure, cont.
• 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins