Blood Vessel Conditions

Blood Vessel Conditions

Definitions:

ARTERITIS: Inflammation of an artery

PHLEBITIS:Inflammation of a vein

ANGIITIS:Inflammation of a blood vessel or lymph vessel

VASCULITIS:same meaning as Angiitis

A) Arteritis and Phlebitis

Often have similar causes:

Infection:

Local: infected wound, abscess, surgery etc

Systemic: septicemia (infection circulating in the blood), septic embolism

Inflammatory Conditions:

Autoimmune diseases (eg. Rheumatoid arthritis, Lupus)

Hypersensitivity Reactions:

Allergic and hypersensitive reactions to an allergen; may be localized or systemic (eg. Beurger’s Disease, sensitivity reactions to medications etc)

Direct Trauma:

More common in veins because they are more superficial

Some causes are idiopathic.

Phlebitis and phlebothrombosis are also fairly common:

Post childbirth

With prolonged bedrest or prolonged immobilization of body parts.

Signs and Symptoms of Arteritis and Phlebitis

Significant local inflammation:

With more superficial blood vessels, there is usually a distinct hot red streak apparent on the skin surface above the inflamed vessel; with deeper vessels, more generalized heat and redness are likely.

Edema:

Local edema is always present to some extent; in phlebitis, distal swelling is also typical as the inflamed section of the vein acts as a n impediment to venous return.

Pain:

Very tender locally; pain often radiates from the site in a more dispersed intense achiness. Pain may be ischemic in nature if blood flow in interrupted.

HOMAN”S SIGN (indicates deep vein thrombosis in the calf):

Pain in the calf which may radiate into the popliteal space elicited when the ankle is dorsiflexed. The same pain may occur with squeezing the calf muscles. It should be noted that this maneuver should not be used as a primary test for DVT as it may cause a thrombus to be dislodged. When Homan’s Sign is elicited during routine massage therapy, you should consider referral for further medical investigation.

Concerns for the RMT

1. Platelet activation is inevitable when the wall of a blood vessel is inflamed. This increases the risk of thrombosis and related complications.

On-site massage could:Intensify the injury or irritation

Intensify thrombosis at the site

Promote embolism

Spread infection if present

Weaken or rupture the vessel wall

On-site massage is, therefore, contraindicated until medical clearance is received. When the inflammation is in a large/core vessel, massage therapy may be completely C/I’d.

2. Medications:

Anti-inflammatory and anti-coagulant use is common with these conditions.

Lytic substances may be injected locally, or given intravenously to break up a thrombus. Analgesics may also be in use.

Other medications may be in use to treat underlying pathologies or causes.

3. The massage therapist should always be alert to the possibility of inflammatory conditions in blood vessels following an injury or surgery, and as a risk factor in conditions where vasculitis is part of the condition’s profile.

4. The possibility of residual thrombosis is always a factor when a client has a history of blood vessel injury or inflammation. The RMT should weigh the factors carefully and consult with the MD if there is a question about current risk.

B) Temporal Arteritis

An idiopathic, low grade arteritis of the superficial temporal artery.

Most common in persons over 50, generally affects men and women equally.

Can be bilateral but is usually unilateral.

Signs and Symptoms

Very often none –a silent process.

When present: Unilateral headache, often confused with migraine headache

Ipsilateral facial pain, numbness, and/or parasthesia

Ipsilateral vision problems varying in severity from blurring to loss of

sight in the eye in rare cases

RMT Concerns

1. Thrombosis will occur, although it is usually reasonably stable due to the slow progressive inflammatory process preceding its development. Some degree of risk will still be present from direct manipulation of the artery which is very superficial. Local petrissage/friction types of massage application are, therefore, contraindicated.

Since this is a relatively common condition that may be clinically asymptomatic, it is good practice to palpate the superficial temporal arteries of client over age 50 before massaging locally. Unaffected arteries are not palpable except for their pulse. Affected arteries feel elevated, stiff, “lumpy”, and tortuous. On the person with little hair, an affected superficial temporal artery is often clearly visible.

2. Anti-inflammatory and/or anticoagulant medications may be in use.

C) Beurger’s Disease (aka Thromboangiitis Obliterans – TAO)

A genetically conditioned hypersensitivity condition.

“Genetically conditioned” means a genetic/inherited predisposition or susceptibility to develop a condition.

In the case of Beurger’s Disease, a known group of persons, based on their genetic make-up are known to be more susceptible to developing a hypersensitivity reaction to cigarette smoke.

Typical Sufferer (90% +)

Male

Aged 19-40 at the time of diagnosis

Jewish or Arabic descent

Heavy cigarette smoker

Clinical Presentation

Acute Inflammation Episodes

Flare-ups of acute angiitis primarily affecting the medium sized arteries and veins of the leg (distal to the knee) and possibly the forearm

Intensely painful – pain from the blood vessel(s), nearby tissues (from direct irritation) and ischemic pain in tissues supplied by the affected vessel(s) (may present as intermittent claudication).

Signs and Symptoms of acute inflammation (S.H.A.R.P.)

Very high risk of thromboembolism

Flare-up and remission pattern of varying frequency

Ongoing problems

With each attack of acute angiitis, additional blood vessel wall damage occurs, especially stenotic scarring.

Ongoing thrombosis and stenosis related risks:

• Very high risk of pulmonary and brain embolism
• Ischemia and infarction in tissues supplied by affected vessels leading to risk of ulceration, necrosis, gangrene, tissue dystrophy, edema etc
• Risk of blood vessel rupture

If the individual stops smoking, the condition arrests without further flare-ups. Blood vessel damage to that point is generally permanent.

RMT Concerns

1. The RMT must consider this condition as precluding massage therapy, especially when the person is an active smoker and the condition is in an active phase. Medical consultation and clearance is advised.

Massaging unaffected body parts may be reasonable as long as the risk of promoting risks associated with a systemic increase is circulation is considered and evaluated.

2. Modified relaxation work and light cool/cold applications may be beneficial during a flare-up.

3. Medications:

Anti-inflammatory, anticoagulant, analgesic, and/or muscle relaxant medications may be in use.

4. There is often reduced sensation in affected body parts due to reduced perfusion affecting peripheral nerves.

5. If medically cleared for massage therapy, the RMT must continue to consider and be aware complications of reduced perfusion and drainage of tissues such as tissue fragility. Massage and Hydrotherapy approaches should avoid mobilization of large volumes of blood that damaged vessels may not be able to handle effectively. It is also important to evaluate the safety of “pumping” modalities such as contrast bathing or muscle squeezing and the associated risk of complications of thrombosis. More passive approaches like elevation and Beurger’s Exercises may be safer.

Use the persons ADL’s (re: regular exercise habits and tolerances, hydrotherapy practices) as well as Physician recommendations as guidelines for acceptable modality use in your treatments. Introduce new modalities conservatively.

Exercise prescription should emphasize gradual improvement of Cardiovascular fitness and should de-emphasize leg work (and forearm activity if involved). Strenuous activities should be avoided. Prolonged post-exercise tenderness is common, therefore, be sure to emphasize good warm-up and cool-down periods. Daily practice of Beurger’s Exercises is recommended.

Beurger’s Exercises:

1. Client lies supine with hips flexed to 45 degrees (feet up on pillows) until the feet blanche. This usually takes 2-3 minutes.

2. Client then sits up fully (high seated) until blood flow (and color) returns to the feet. This usually takes another 2-3 minutes.

3. Client lies supine without elevating legs for 2-3 minutes.

This process is repeated 4-5 times, 2-3 times daily.

D) Varicose Veins (Varicosities)

Result from valvular incompetence in veins.

Usually seen in the lower limbs, but can also occur in the vicinity of old injuries. Anal varicosities are called hemorrhoids, esophageal varicosities are a potentially dangerous complication of liver problems (eg. Complication of alcoholism)

Causes:

1. Chronically elevated hydrostatic pressure in a vein (most common cause).

Pregnancy

Prolonged standing, sitting, kneeling, leg crossing etc

CCHF

Hypertension

Visceroptosis (a condition in which the internal organs are compressed and displaced by poor posture, the enlarging womb of pregnancy, tight waisted corsets etc.)

Chronic atonic constipation

Chronic diaphragm tension

Restrictive clothing

2. Inheritance

A tendency for varicosities does run in families, slightly more statistically common in males.

3. Direct damage to vessels

Trauma, surgery, phlebitis, disease states affecting veins.

Clinical Presentation

Vein becomes progressively elevated, tortuous, “lumpy”

Bluish segments indicate stasis of blood

Local tissue becomes dystrophic, more fragile

Ulcerations may develop in severe cases

Significant distal edema may develop

Achy pain, “heaviness” in limb

RMT Considerations

1. The slow developing layered type of thrombosis that may develop is exceptionally stable and almost never gives off emboli. However, direct, aggressive on-site work should be avoided (will further irritate the vein, contribute to thrombosis etc)

2. Avoid overloading or traumatizing the affected vessel

3. Maintain awareness of local tissue fragility. Assess tissues around and deep to varicosities before deciding on a treatment approach.

4. Some clients may be receiving lytic injections into affected veins to reduce build-up of static blood to enhance both esthetic appearance and function of the vein. As a general rule, on-site massage is contraindicated for 48 hours post-injection.

5. Some clients have “stripping” operations where veins are essentially pulled out of the lower limb. Small incisions are made in section, usually at the top and bottom of the affected vein and in “bend” areas. It is important to avoid overloading the venous circulation for a period of time following this type of procedure to allow the collateral channels time to accommodate for increased demands.

E) Raynaud’s Disease, Raynaud’s Phenomenon

Raynaud’s conditions are characterized by:

“attacks” of arteriolar spasm

typically affect the hands, but may involve feet, nose and ears

during an attack the affected part blanches and may become cyanotic

ischemic pain

episodes may last from a few minutes to a few days

appears to be an irritation or over-reaction of sympathetic nervous system function

Raynaud’s Disease vs. Raynaud’s Phenomenon

There is poor consistency among medical texts and professionals between these two terms. For class purposes, use the following classifications:

Raynaud’s Disease

Idiopathic, affecting otherwise healthy individuals

Typical sufferer is somewhat more likely to be female

Attacks are not associated with development of thrombosis or ongoing blood vessel or tissue damage

Generally not treated medically, person may use analgesics during an attack

Raynaud’s Phenomenon

Is associated with a known cause.

1. Occupational use of vibrating equipment like hydraulic drills or jackhammers.

In this context, is often called “white hand”. Avoidance of symptoms/attacks requires compliance to strict limitations of time spent using this type of equipment.

2. Secondary to autoimmune conditions like SLE and sometimes to cancer.

In this context, why Raynaud’s Phenomenon develops in some people and not in others is not clear, but a predictable percentage do develop it.

Attacks are typically more severe and frequently associated with ongoing blood vessel damage. Thrombosis may be present and trophic changes in supplied tissues may occur.

Treatment is often related to managing the causative condition where possible.

Anti-inflammatory and anticoagulant medications may be used as well as analgesics.

RMT Considerations

1. Consult with each client as to their specific attack triggers.

Cold exposure is the most common trigger. Avoid cold hydrotherapy and allowing your client to get too cold (use blankets). Care should be taken with overall hydrotherapy applications; altered vasodilation and/or vasoconstriction nay increase risks of burns.

Stress is the next most common trigger. For some clients, sympathetic activation (pain, heavy tapotement) may need to be avoided.

A small percentage of persons are triggered by an allergen such as cigarette smoke or other airborne chemicals.

2. Adapt to medication use as indicated.

3. If the client has blood vessel damage associations, carefully assess their tissue health and thrombosis status. Modify techniques appropriately.