List the components for skilled documentation of compression therapy and document a physical therapy session for compression intervention.
- Patient education/instructions- explain process and why, explain HEP if going to do it at home.
- Pre/post assessments- HR and BP (and position) (BP taken on opposite limb if performing compression on UE), skin integrity and sensation.
- Circumferential measurements pre and post (if global measure entire limb, if local measure joint area). Note how often you measure (every 2-3 inches). Note landmarks.
- Cycle- 3:1 ex. 45:15 seconds
- Tx duration
- RESPONSE to pt ed and compression pump use
Demonstrate patient education for issues related to edema control.
RICE, don’t stay seated for more than an hour at a time, stay active, when sitting or laying perform AP’s frequently .
To be continued…. when discussed in class
Demonstrate patient education for care/use of external compression bandages/garments as well as foot care for diabetes and CVI.
Care of bandage/garment-
Use of bandage/garment-
Foot care- keep feet clean and dry, check feet daily, wear proper foot wear..
to be continued…when discussed in class
Discuss and demonstrate wrapping an upper and lower extremity with an ACE (long stretch) Bandage to control edema
Start bandage at distal portion on a diagonal. Pressure should be higher distally and will decrease proximally. Overlap the wrap 1/3 of width. Work the bandage with the roll on top - “snail”. Wrap the extremity diagonally, reversing the direction with each turn using a figure eight pattern creating a criss-cross effect. Make sure heel is completely enclosed and no gaps will occur for full AROM. When finished ask patient to perform AP’s to ensure wrap will not have gaps with movement. Check toes for pink or warmness. There should not be numbness or tingling. If present, re-wrap.
Discuss and demonstrate measurement of an extremity for a custom-made compression garment.
Start measurement at a bony landmark, record the distance of each measurement and record the circumference of the limb. Distance should be 2-3 inches or what PT wants. Mark skin (with permission) at each measurement.
Discuss and demonstrate the use of an intermittent compression device to decrease edema.
The use of an IPC pump is to stabilize edema by facilitating venous return by intermittently compressing the extremity. Indicated for edema, DVT prevention, venous stasis ulcers and residual limb reduction. Refer to Intermittent pnuematic pump procedure worksheet for demonstration instructions.
Indications and Contraindications for external compression (IPC pump, pre-fab/custom compression garments, short stretch bandages, Circ -Aid)
Indications: edema, DVT prevention, venous stasis ulcers and residual limb reduction.
Contraindications:
- An ABI of < 0.8
- kidney dysfunction (kidney may not be able to excrete the additional fluid)
- Heart failure or pulmonary edema
- Recent or acute DVT, thrombophlebitis, or pulmonary embolism
- Odstructed lymphatic return or venous return
- Severe peripheral arterial disease or ulcers resulting from arterial insuffiency
- Acute local skin infection
- Significant hypoproteinemia (protein levels <2 gm/dL)
- Acute trauma or fx
- Arterial revascularization
Discuss the anatomy of the following as it relates to the peripheral vascular system: arterial system, venous system, and lymphatic system.
The peripheral vascular system = veins and arteries of the arms, hands, legs, and feet.
The circulatory system consists of 2 types of blood vessels; veins, and arteries.
Arteries; carry oxygen nutrient rich blood from the heart to organs and cells.
Veins; carry oxygen depleted blood and wastes through the kidneys, liver, and lungs. After wastes are removed, venous blood is filled with oxygen in the lungs and returned back to the heart.
Arteries and veins are interconnected by small weblike vessels called capillaries.
Lymphatic System; to prevent lymph from accumulating in the interstitial space, the lymphatic system acts as an accessory channel and returns this fluid to the blood circulation.
-the lymphatic system relies on a peristaltic motion and valvular closure to move fluid toward the central ducts that empty into the VENOUS SYSTEM.
Define edema and discuss ways to treat edema.
Edema= increased fluid in the interstitial spaces.
Interventions for Edema:
- heat for chronic edema
- cold
- EMS
- elevation of body part above the heart
- massage to decrease venous and lymphatic edema
- exercise to manage/control edema
- external compression
Discuss the pathology and signs and symptoms of Arteriosclerosis Obliterans
AKA: PAD, Peripheral Artery Disease, Peripheral Vascular Disease, PVD
arterial dysfunction:
“Hardening of the arteries”
Symptoms:
- intermittent claudication
- rest pain- pain during rest, sleeping, or anytime limb is in non-dependent position (anytime leg is not hanging down). Associated with 80-90% occlusion.
Discuss the pathology and signs and symptoms of Thromboangiitis Obliterans
AKA: Buerger’s Disease
arterial dysfunction:
-Recurring, progressive inflammation and clotting of small and medium arteries and veins appearing in distal extremities first (hands and feet) and then progresses proximally.
- Similar to arteriosclerosis but different in that it occurs primarily in young, male smokers.
- Nicotine is a potent vasoconstrictor and in this disease this is an inflammatory process with eventual tissue necrosis.
- Condition is arrested if person stops smoking.
Symptoms:
- pain in hands and feet
- fingers and toes become pale, red, bluish or cold
- intermittent claudication
Discuss the pathology and signs and symptoms of Raynaud’s Phenonmenom
arterial dysfunction:
-disease characterized by spasms of the arteries in the extremities especially in the fingers.
- vasospastic disease
- can be predicated by exposure to cold or stress
- one PT intervention = contrast baths
Symptoms:
- cold fingers and toes
- sequence of color changes in skin in response to cold or stress
- numb, prickly feeling upon warming.
Discuss the pathology and signs and symptoms of Diabetes Mellitus
arterial dysfunction:
-caused by deficiency of insulin which results in failure to metabolize sugars and starch.
- accelerated atherosclerosis with angiopathy (disfunction of the vessels) and neuropathy (numbness and tingling)
- decreased sensation/poor healing
- diabetic ulcers are most commonly located on the plantar aspect of the foot
Symptoms:
- frequent urination
- excessive thirst
- unexplained weight loss
- extreme hunger
- sudden vision changes
Discuss the pathology and signs and symptoms of Varicose Veins
venous dysfunction:
- swollen, twisted and painful veins that have filled with an abnormal collection of blood. (large bulbous enlargements of the veins beneath the skin). Usually attributed to incompetent valves.
- Linked to family history
Symptoms:
- veins that are dark purple or blue
- veins that appear twisted or bulging
Discuss the pathology and signs and symptoms of Chronic Venous Insufficiency
venous dysfunction:
AKA CVI
- Characterized by micro and macro circulatory dysfunction of the venous system causing distention (the state of being stretched beyond normal dimensions)
- Valves fail and do not close properly leading to venous reflux. (backward flow of blood through a distended vein.)
- Veins can’t pump enough oxygen poor blood back to the heart.
Symptoms:
- extreme edema in lower legs
- new varicose veins
- aching or tiredness in legs
- dermatitis
- stasis pigmentation (hemosiderin)
Discuss the pathology and signs and symptoms of Primary Lymphedema
lymphatic dysfunction:
Primary Lymphedema- occurs on its own. A condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system.
-Can affect from one to as many as four limbs and/or other parts of the body, can be present at birth, develop at the onset of puberty (praecox) or in adulthood (tarda), all from unknown causes, or associated with vascular anomolies such as hemangioma, lymphangioma, Port Wine Stain, Klippel Trenaury.
Discuss the pathology and signs and symptoms of Secondary Lymphedema
lymphatic dysfunction:
Secondary Lymphedema- caused by another disease or condition.
- acquired lymphedema, can develop as a result of surgery, radiation, infection or trauma. Specific surgeries, such as surgery for melanoma or breast, gynecological, head and neck, prostate or testicular, bladder or colon cancer, all of which currently require removal of lymph nodes, put patients at risk of developing secondary lymphedema. If lymph nodes are removed, there is always a risk of developing lymphedema.
- can develop immediately post-operatively, or weeks, months, even years later.
Define Acrocyanosis
persistent blue discoloration of the extremities. Most commonly the hands but can occur in the feet.
Define Erythromelalgia
bilateral vasodilatation affecting the extremities by redness, burning, and throbbing sensations and increased skin temperatures.
-condition characterized by episodes of pain, redness, and swelling in various parts of body particularly the feet and hands.
Define Cyanosis
Appearance of blue or purple discoloration of the skin due to tissues being low on oxygen.
Define Trophic Changes
changes resulting from interruption of nerve supply.
Define intermittent claudication
the supply of blood is less than the muscle demand which produces pain and cramping in the involved muscles. (usually the calf muscles).
-Intermittent Claudication is associated with 50% occlusion of the affected vessel.
Define Hemosiderin Staining
development of patches of brownish to yellow deposits just under the skin. It usually occurs as a byproduct of the breakdown of red blood cells, and patients can develop such deposits in the wake of surgery or hemorrhage. These patches also occur as a result of heart failure, vascular insufficiency, and other cardiovascular diseases.
Discuss the PT’s exam/eval of a patient with suspected PVD (peripheral vascular disease)
Exam/Eval Includes:
1.history-
2.systems review-may indicate referral to other practitioners.
- tests and measures:
a. )aerobic capacity/endurance
b. )anthropometric measurement; which includes height and weight, volumetric measurement, and girth measurement.
c. )palpation and pitting
d. )arousal and attention - circulation;
a. )temperature and arterial perfusion (checking for circulation through arteries),
b. )grading of the pulse,
c. )dorsalis pedis and posterior tibial arterial perfusion.
d. )ABI assessment-measure of arterial perfusion.
e. )arterial trophic changes; skin color, loss of hair growth on lower leg, dry and thickened nails.
f. )pain, arterial vs venous issues, intermittent claudication
g. )special tests- includes tests for DVT, Stemmer’s Sign, Rubor of Dependency - ) Gait, Locomotion, and Balance
- ) Integumentary Integrity- includes observation and palpation, trophic changes, fibrosis, coloration, wounds.
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*1.PTA 200-Intro to Physical Agents16
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*2.PTA 200-Documentation21
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*3.PTA 200-Superficial Thermal Agents23
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*4.PTA 200-Light Physical Agents41
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*5.PTA 200-Ultrasound27
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*6.PTA 200-Compression22
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*7.PTA 200-Therapeutic Massage18
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*8.PTA 200-Wound Management Part 120
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*9.PTA 200-Wound Management Part 225
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*10.PTA 200-Wound Management Part 315
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*11.PTA 200-Wound Management Part 417
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*PTA 200- Compression Objectives34
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*PTA 200- Therapeutic Massage Objectives20
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*PTA 200- Wound Management Objectives43
