Individuals with Chronic Primary Cardiovascular and Pulmonary Dysfunction



Individuals with Chronic Primary Cardiovascular and Pulmonary Dysfunction


Elizabeth Dean and Donna Frownfelter



Key Terms













This chapter reviews the pathophysiology and medical management in relation to the comprehensive physical therapy management of individuals with chronic primary cardiovascular and pulmonary pathology. Exercise testing and training are major components of the comprehensive physical therapy management of individuals with chronic primary cardiovascular and pulmonary conditions, and this topic is presented in detail in Chapter 24.


Because the heart and lungs are interdependent and function as a single unit, primary lung or heart disease must be considered with respect to the other organ and in the context of oxygen transport overall.1,2 Despite a plethora of research and numerous official position statements and clinical practice guidelines, the definition and diagnoses of chronic heart disease and chronic lung disease and their management remain inconsistent in practice.3 Although there is consensus regarding the effectiveness of both cardiac and pulmonary rehabilitation,4 this inconsistent practice is associated with the underuse, overuse, and misuse of therapies regardless of their established effectiveness.


Although there is no clear line between obstructive and restrictive patterns of lung disease, the distinction is based on the primary underlying pathophysiological problems. The primary conditions that are discussed include obstructive lung disease (i.e., chronic airflow limitation, asthma, bronchiectasis, and cystic fibrosis) and restrictive lung disease (i.e., interstitial pulmonary fibrosis). Lung cancer, which has the characteristics of both obstructive and restrictive patterns of pathology, is also presented.


The long-term physical therapy management of people with heart disease is then presented, with special attention given to angina, myocardial infarction, and heart valve disease. Chronic vascular conditions including peripheral vascular disease (PVD), hypertension, and type 2 diabetes mellitus with its associated angiopathies are also presented.


The principles of the physical therapy management of people with various chronic primary cardiovascular and pulmonary conditions are presented rather than treatment prescriptions, which cannot be discussed without consideration of a specific patient (see Case Study Guide to accompany the text on-line). In this context, the general goals of the long-term management of people with each condition are presented, followed by the essential monitoring required and the primary interventions for maximizing cardiovascular and pulmonary function and oxygen transport. The selection of interventions for any given patient is based on the physiological hierarchy. The most physiological interventions are exploited first, followed by less physiological interventions and those whose effectiveness is less well documented (see Chapter 17).


The principles outlined in this chapter also apply to the individual who has a secondary diagnosis of one or more chronic primary cardiovascular and pulmonary conditions. These principles can be used to modify physical therapy management prescribed for some other condition or indicate the need for special monitoring.


A template of care is shown in Table 31-1. Although there are many commonalities of physical therapy management across patients, only a detailed knowledge of each specific patient, in terms of his or her underlying pathologies and other factors, will lead to the optimal management plan and treatment prescriptions.




Individuals with Primary Cardiovascular Disease


Angina


Pathophysiology and Medical Management


Angina pectoris refers to pain resulting from reduced blood flow to the myocardium. Even though it is usually elicited during exercise, angina may be triggered by stress or in severe cases may occur at rest. Atherosclerosis of one or more of the coronary arteries is the principal cause. Coronary vasospasm is a less common cause of angina. The pathophysiology of angina is described in detail in Chapter 5. A history of angina necessitates further examination to establish the severity of the coronary artery occlusion. Individuals with manifestations of heart disease are categorized according to their limitation during physical activity based on the New York Heart Association (NYHA) Functional Classification (Table 31-2).



If angina is severe and refractory to medical management, the patient is scheduled for coronary bypass surgery (Chapters 29 and 30) to restore normal coronary blood flow. The acute and long-term management of the surgical cardiac patient is presented in Chapter 30. In less severe cases, angina is managed conservatively with medications (e.g., sublingual nitroglycerin, nitroglycerin patch, education, and physical therapy). After the patient’s condition has stabilized, a graded exercise tolerance test may be conducted under supervision in a cardiac stress testing facility where 12-lead electrocardiogram (ECG) monitoring can be performed. The exercise intensity at which the patient exhibits angina (i.e., the anginal threshold) can be quantified and serve as the basis for the prescription of physical activity and exercise.



Principles of Physical Therapy Management


Patients may be referred to physical therapy with a history of angina as a primary or secondary problem. Regardless, angina is managed with the same care and vigilance because it can be a life-threatening condition either way. A patient for whom antianginal medication is prescribed must have the medication present. The medication must not have expired and must be within visible access during treatment. The physical therapist should examine the medication before treatment to ensure that the expiratory date has not passed and to take responsibility for positioning the medication near the patient for access to it should the patient develop angina during treatment.


The goals of long-term management of the patient with angina include the following:



Patient monitoring includes hemodynamic monitoring (i.e., heart rate, blood pressure, rate-pressure product, and dyspnea). Subjective responses to treatment, particularly exercise, should also be recorded (e.g., Borg’s rating of perceived exertion). Signs of chest pain, dyspnea, anxiety, lightheadedness, dizziness, disorientation, discoordination, cyanosis, coughing, and chest sound changes (i.e., a gallop) must be monitored. Angina is not an acceptable symptom under any circumstance. Should it occur, treatment is immediately discontinued and emergency measures instituted as indicated. Treatments will be safer and more precisely prescribed with continuous ECG monitoring. Without ECG monitoring, treatments must be conservative. If there is any doubt at any time concerning the hemodynamic stability of a patient and his or her ability to tolerate treatment safely, the patient should be referred to a general practitioner or cardiologist for clearance before being treated.


Medication that is necessary to maximize treatment response is administered before treatment. Knowledge of the type of medication, its administration route, and time to as well as duration of peak efficacy is essential if treatment is to be maximally effective.


For the long-term management of patients with angina, interventions include some combination of education, aerobic exercises, strengthening exercises, chest wall mobility exercises, relaxation, activity pacing, and energy conservation. Education includes information about heart disease and risk factors (i.e., smoking, diet, stress, weight, alcohol, coffee, and being physically active in hot environments) and appropriate preventative strategies (i.e., smoking reduction and cessation, low-fat diet, reduced alcohol consumption, exercise, relaxation, activity pacing, and stress management).


Patients with angina are at risk of having an infarction; therefore vigilance and stringent monitoring are necessary to detect angina or frank myocardial infarction. These patients are potentially hemodynamically unstable; thus their hemodynamic responses before, during, and after treatment, particularly aerobic and strengthening exercises, should be monitored and recorded. Minimally, heart rate, blood pressure, and rate-pressure product should be recorded, along with the patient’s subjective responses to treatment. Heavy lifting, static exercise, straining, the Valsalva maneuver, and heavy, repetitive upper-extremity work are avoided during physical activity and exercise. These activities are associated with a disproportionate hemodynamic response. Physical activity and aerobic exercise are prescribed at a target heart rate or perceived exertion ranges that are below the anginal threshold based on a graded exercise tolerance test (see Chapters 19 and 24). Peak exercise tests in patients with cardiac dysfunction that may elicit angina or ST-segment changes are performed in a cardiac stress testing laboratory, usually under the supervision of a cardiologist unless in a specialized facility where physical therapists perform such testing.


The body position in which aerobic exercise is performed is important in patients with heart disease. Positions of recumbency increase the volume of fluid shifted from the periphery to the central circulation. This increases venous return and the work of the heart. Therefore upright body positions have long been known to minimize cardiac work during exercise in these patients and during rest after exercise.5,6


Sexual dysfunction is common in individuals with systemic atherosclerosis owing in part to underlying pathology (dyslipidemia, vascular insufficiency, and diabetes), medication, and the psychological impact of heart disease.7 In terms of energy demands, those of sexual activity are comparable to those of other daily activities (e.g., walking 1 mile on the level). Optimizing health in general with diet and exercise can contribute to regression of atherosclerosis and improved peripheral circulation. Breathing control, body positioning, and energy conservation strategies such as exercising at a high energy time of day may also help minimize symptoms. Also, patients should be advised to avoid sexual activity within an hour of eating, and even then not to consume a heavy meal.



Myocardial Infarction


Pathophysiology and Medical Management


Angina frequently precedes frank myocardial ischemia and infarction. Myocardial ischemia is reversible, whereas infarction denotes myocardial injury and cell death (i.e., necrosis). Injured myocardial cells either recover or die during the healing period. Thus minimizing further damage and maximizing the healing during this 6-week period is critical. Myocardial infarctions can range from being silent and unnoticed by the patient to being life-threatening. They can occur anywhere in the myocardium but occur primarily in the ventricles (in the left more frequently than in the right ventricle). The greater the severity, the greater the risk of ventricular insufficiency, acute pulmonary edema, and left ventricular failure. Because myocardial ischemia and infarction impair the pumping action of the heart and thus cardiac output, patients tend to be hypoxemic and in need of oxygen. Even after the oxygen has been discontinued and the myocardium has healed, the patient may continue to be vulnerable hemodynamically. The myocardium will have some scarring that will affect both the electrical excitability (producing dysrhythmias) and the mechanical function of the heart. In addition, the patient may continue to have low-normal arterial blood gases. Hypoxemia is lethal in that it triggers dysrhythmias and predisposes tissues to hypoxia. Thus hypoxemia must be avoided. After myocardial infarction, patients are usually discharged home on several medications (e.g., nitroglycerin, calcium antagonists, beta blockers, and diuretics). Depending on the severity of involvement, patients usually continue to require one or more of these medications over the long term. The need for oxygen is usually short term and restricted to the patient’s hospital stay.


The patient’s ECG will be important for determining the parameters of exercise, the level of monitoring required, and education. Dysrhythmias are described in Chapter 4, and basic ECG reading is presented in Chapter 12. Ventricular dysrhythmias can be lethal. Occasional premature ventricular contractions must be monitored to ensure that their frequency remains low and that coupling does not occur. Atrial fibrillation is considered a relatively serious dysrhythmia. It is associated with a high incidence of coronary disease, stroke, and overall mortality.8 Medication or a pacemaker may be necessary.


Central sleep-disordered breathing is highly prevalent in individuals with left ventricular dysfunction and is associated with abnormal cardiac autonomic control and increased dysrhythmias.9 Although sleep-disordered breathing may not be related to the severity of hemodynamic dysfunction, loss of recuperative sleep will affect functional capacity as well as capacity and motivation to participate in an exercise program and be physically active.


Health-related quality of life reported by individuals with chronic heart failure is associated with function and exercise capacity, not with ejection fraction.10 Health-related quality of life should be an outcome measure for all individuals managed for heart failure because it provides important supplemental information that is independent of physiological indices of cardiac function and the NYHA classification of function (see Table 31-2).


Nonpharmacological approaches to the management of individuals with heart failure are an essential component to the overall management of the condition.11 These measures are incorporated into an individualized program of health behavior change, and include the following:



All patients with cardiovascular risk factors can benefit from cardiac rehabilitation. After a cardiac event, patients are typically discharged with drugs, the prospect of surgery, and rather infrequently with referral to an individual physical therapist or one who is a member of the cardiac rehabilitation team. There is a high incidence of recurrence and repeated surgery with further associated mortality and burden of disease. The physical therapist as a noninvasive practitioner has a primary responsibility to help avoid recurrence of symptoms and repeated surgeries. This is consistent with the physical therapist’s overriding objective of reducing the need for invasive care (i.e., drugs and surgery) and developing a sustainable, lifelong health plan with the patient.


Risk factor modification is a major goal. A marker of inflammation such as C-reactive protein along with appropriate lipid testing findings may be a more discriminating risk factor than lipid profiling alone.12 Refining the risk factor definition on the basis of C-reactive protein level will help target management (e.g., indicate necessity for intensified exercise programs, weight loss, and smoking cessation).



Principles of Physical Therapy Management


After discharge from the hospital, many patients who have had a myocardial infarction see a physical therapist either privately or through a cardiac rehabilitation program. Patients may remain on a supervised rehabilitation program, including an exercise program, for 6 to 12 months in a specialized center (see Chapter 24).


Regardless of the setting, physical therapy includes education, psychosocial support, and a supervised setting for exercising safely and developing confidence during physical exertion. In addition, an exercise program is specifically prescribed for the patient to enhance oxygen transport (i.e., delivery, uptake, and utilization at the tissue level), thereby minimizing the metabolic demand on the heart.


Depression is a common symptom reported by individuals with coronary artery disease and is associated with increased morbidity and mortality. Individuals with depressive symptoms are more likely to exhibit myocardial ischemia during mental stress testing and during activities of daily living.13 Myocardial ischemia induced by mental stress may be a mechanism by which depression increases the risk of morbidity and mortality in individuals with coronary artery disease. Although aggressive type A individuals are thought to have an increased incidence of heart disease compared with passive type B personalities, anger and hostility have been identified as the toxic negative emotions most implicated in morbidity and mortality related to heart disease.14


A graded exercise tolerance test is conducted before the patient leaves the hospital or when he or she is enrolled in an exercise program. The time between the exercise test and the exercise prescription and implementation of the exercise program should be minimal. Peak (formerly referred to as maximal) exercise tests are conducted in the presence of a cardiologist (unless in a specialized facility where physical therapists may do such testing) and provide the optimal basis for an exercise prescription. Submaximal exercise tests can be conducted by the physical therapist and can provide the basis for an exercise program; however, the prescription should be conservative compared with the prescription based on the peak exercise test. The principles and practice of exercise testing are described in Chapters 19, 24, and 25. Such testing is both an art and an exacting science and should be carried out in a rigidly standardized manner to ensure the test results are maximally valid, reliable, and useful.


As with the patient with angina and no overt infarction, the following caution must be adhered to with the patient who has a history of myocardial infarction. A patient for whom antianginal medication is prescribed must have the medication present. The medication must not have expired and must be within visible access during treatment. The physical therapist should examine the medication before treatment to ensure that the expiratory date has not passed and take responsibility for positioning the medication near the patient for access to it should the patient develop angina during treatment.


The goals of long-term management of the patient with myocardial infarction include the following:



Patient monitoring includes hemodynamic monitoring (i.e., heart rate, blood pressure, and rate-pressure product). Subjective responses to treatment, particularly exercise, should also be recorded (e.g., Borg’s rating of perceived exertion). Angina is not an acceptable symptom under any circumstance. Should it occur, treatment is immediately discontinued and emergency measures instituted. Treatments will be safer and more precisely prescribed with continuous ECG monitoring. Without ECG monitoring, treatments must be conservative. If there is any doubt at any time about the hemodynamic stability of a patient and his or her ability to tolerate treatment safely, the patient should be referred to a general practitioner for clearance before being treated.


Medication that is needed to maximize treatment response is administered before treatment (e.g., antidysrhythmic agents). Knowledge of the type of medication, its administration route, and time to and duration of peak efficacy is essential if treatment is to be maximally efficacious.


The primary interventions for maximizing cardiovascular and pulmonary function and oxygen transport in patients with myocardial infarction include some combination of education, aerobic exercise, strengthening exercises, chest wall mobility exercises, body positioning, breathing control and coughing maneuvers, relaxation, activity pacing, and energy conservation. An ergonomic assessment of both work and home environments may be indicated to minimize myocardial strain.


Education focuses on teaching the basic pathophysiology of heart disease, its risk factors, and prevention. Health promotion practices are advocated (e.g., smoking reduction and cessation, good nutrition, weight control, hydration, high-quality rest, and sleep periods). In addition, types of physical activity that impose undue myocardial strain, increase intrathoracic pressure, and restrict venous return and cardiac output, such as heaving lifting, straining, or the Valsalva maneuver, are avoided. The patient is taught to monitor and practice vigilance in monitoring his or her own condition (e.g., new signs of infarction). These patients are potentially hemodynamically unstable and thus their hemodynamic responses before, during, and after treatments, particularly exercise, should be monitored and recorded (i.e., heart rate, blood pressure, and rate-pressure product should be taken, along with their subjective responses to treatment).


Peak exercise tests in cardiac patients that may elicit angina or ST-segment changes are performed in a cardiac stress testing laboratory under the supervision of a cardiologist. The parameters of the exercise prescription are set based on a peak exercise test. Intensity is set within a heart rate, oxygen consumption, and exertion range (e.g., 70% to 85% of the anginal threshold) (see Chapter 19).


Aerobic exercise of large muscle groups rather than small muscle groups (e.g., arm ergometry) is selected to minimize the increased hemodynamic demand and strain and the increased work of the heart associated with working smaller, upper-body muscles. Hot and humid conditions also place additional stress on the heart; therefore exercising under these conditions should be avoided.


As with patients with angina, the body position in which aerobic exercise is performed by patients with myocardial infarction is important. Positions of recumbency increase the volume of fluid shifted from the periphery to the central circulation. This increases venous return and the work of the heart. Therefore upright body positions are selected for these patients to minimize cardiac work during exercise and during rest after exercise.5,6,15



Valve Disease


Pathophysiology and Medical Management


Valve dysfunction is either congenital or acquired and may require treatment as a primary condition or be present as a secondary condition. Any of the heart and pulmonary valves may be affected. Rheumatic fever was a common cause of rheumatic heart disease and in particular mitral valve insufficiency. Interconnecting lymphatic vessels between the tonsils and the heart are thought to be responsible. Calcification of valves that impairs opening and closing is another example of an acquired valve dysfunction.


Clinically, patients with valve disease may demonstrate exertional dyspnea, excessive fatigue, palpitations, fluid retention, and orthopnea. These signs and symptoms are often relieved when exertion is discontinued. Aerobic exercise, however, has been shown to reduce the symptoms of prolapsed valve.16 Anxiety has been reported to decrease general well-being. If effectively managed, however, reduced anxiety can improve or reduce chest pain, fatigue, and dizziness.


Prophylactic antibiotics against endocarditis are administered to most patients with significant valvular involvement and in mild disease before procedures such as dental work.



Principles of Physical Therapy Management


The goals of long-term management of the patient with valvular heart disease include the following:



Physical therapists are involved in the management of patients with valve defects with regard to both the medical aspects, either as a primary or secondary problem, and surgical aspects. After surgery these patients progress well; the principles of their management are presented in Chapter 30. With respect to the medical management of valve defects, the goal is to optimize oxygen transport in the patient for whom surgery is not indicated either because the defect is not sufficiently severe or because the patient cannot or refuses to undergo surgery. Although the mechanical defect cannot be improved, oxygen transport may be improved in some patients with judicious exercise prescription. The parameters of the exercise prescription are usually moderate in that inappropriate exercise doses can further disrupt the inappropriate balance between oxygen demand and supply and thus further exacerbate symptoms. In addition, there is the potential for further valvular dysfunction if the myocardium is mechanically strained.


The goal of the aerobic exercise prescription is to identify the exercise dose that will optimize the efficiency of other steps in the oxygen transport pathway such that the available oxygen delivered to the peripheral tissues is maximally used without constituting a significant mechanical strain on the heart. Maximizing work output over time is the goal. Thus, the severely compromised patient will perform a greater volume of functional work over time with short, frequent sessions of exercise rather than longer, less-frequent sessions.


If the valve defect is a secondary problem, the physical therapist must assess the severity of the defect and its functional consequences. The following questions must be addressed:



Comparable with management of the patient with a history of angina with or without a history of myocardial infarction, body positions, activities, and respiratory maneuvers that are associated with increased hemodynamic strain are avoided.


Medication that is necessary to maximize treatment response is administered before treatment. Knowledge of the type of medication, its administration route, and time to and duration of peak efficacy is essential if treatment is to be maximally effective.


Patients with valve disease are potentially hemodynamically unstable; thus their hemodynamic responses before, during, and after treatments, particularly exercise, should be monitored and recorded. Monitoring includes hemodynamic monitoring (i.e., heart rate, blood pressure, and rate-pressure product). Subjective responses to treatment (e.g., rating of perceived exertion) should also be recorded. Signs of dyspnea, chest pain, lightheadedness, dizziness, disorientation, discoordination, cyanosis, coughing, and chest sound changes (i.e., a gallop) must be monitored. Treatments will be safer and more precisely prescribed with continuous ECG monitoring. Without ECG monitoring, treatments must be conservative. If there is any doubt about the hemodynamic stability of a patient and his or her ability to tolerate treatment safely, the patient should be referred to his or her general practitioner for clearance before being treated.


The primary interventions for maximizing cardiovascular and pulmonary function and oxygen transport in patients with cardiac defects include some combination of education, aerobic exercise, strengthening exercises, chest wall mobility exercises, body positioning, breathing control, coughing maneuvers, relaxation, activity pacing, and energy conservation. An ergonomic assessment of both work and home environments may be indicated to minimize myocardial strain.


Exercise prescription for patients with valvular heart disease is modified to ensure that the energy demand is commensurate with oxygen supply. Otherwise excessive oxygen demand will worsen the patient’s response to physical activity and lead to further distress and possibly to reduced functional capacity. Aerobic exercise of large muscle groups rather than small muscle groups (e.g., arm ergometry) is selected to minimize the increased hemodynamic demand and strain and the increased work of the heart associated with working smaller, upper-body muscles. As for other types of cardiac conditions, exercising in hot and humid conditions should be avoided.


The body position in which aerobic exercise is performed is important in patients with heart disease. Positions of recumbency increase the volume of fluid shifted from the periphery to the central circulation. This increases venous return and the work of the heart. Therefore upright body positions are selected for these patients to minimize cardiac work during exercise and during rest after exercise.5,6



Peripheral Vascular Disease


Pathophysiology and Medical Management


Peripheral vascular disease refers to diseases of the arteries and the veins. Peripheral arterial disease results primarily from atherosclerosis and occlusion of the peripheral arteries (e.g., thoracic aorta, femoral artery, and popliteal artery).17 The diagnosis may be overlooked until serious limb ischemia is evident.18 Diabetes mellitus, which can result in microangiopathy and autonomic polyneuropathy, is another important cause of PVD in the lower extremities. Venous disease results in phlebitis, venous stasis, and thromboembolus and leads to valvular incompetence of the veins of the legs.


Arterial occlusion results in reduced blood flow to the extremities and hence reduced segmental blood pressure distal to the occlusion (i.e., lower ankle-brachial index). In mild cases of arterial stenosis the patient may be asymptomatic because considerable stenosis has to occur before there is significant reduction in peripheral blood flow. If atherosclerosis develops gradually, collateral circulation may develop sufficiently to offset progressive vessel narrowing. Clinically the patient reports limb pain on exercise, coldness in the affected leg, and possibly numbness. The characteristic limb pain results from ischemia and is referred to as intermittent claudication. Mild to moderately severe cases are managed conservatively. Pain at rest is suggestive of severe stenosis and significant reduction of blood flow to the limb. Significantly reduced blood flow leads to ischemic color changes, skin breakdown, ulceration, and eventually gangrene. Bypass surgery is performed to revascularize a threatened limb. In severe cases in which gangrene has developed, amputation of the limb is indicated. The severity of PVD is a significant predictor of cardiovascular mortality. Individuals with PVD show a systemic endothelial dysfunction and an increase in the serum concentration of white blood cells, endothelin, and C-reactive protein that may trigger acute coronary syndromes.


Individuals with intermittent claudication can have a marked decrease in exercise tolerance and thus can benefit from aerobic exercise, which may stimulate the development of collateral blood vessels around the stenosed vessel. This condition can severely restrict mobility, which reduces function in addition to aerobic capacity and efficient oxygen transport overall.


Individuals with PVD from diffuse systemic atherosclerosis can be expected to have stenosis of the coronary arteries even though they may be asymptomatic. These individuals are monitored as stringently as if they had overt ischemic heart disease.


Venous insufficiency can lead to thromboemboli, skin lesions, and poorly healing ulcers of the lower extremities. Furthermore, the risk of infection and slow healing is increased.


Individuals with PVD secondary to diabetes mellitus have accelerated atherosclerosis compared with age-matched individuals without diabetes. Diabetes affects the macrocirculation and microcirculation; thus wounds must be prevented, particularly in the lower legs and feet, and managed aggressively should they occur. These individuals may be at risk for lower extremity lesions because of autonomic neuropathy and angiopathy. To restore insulin sensitivity and promote weight loss, activity levels must be significantly increased, and a formal exercise program instituted. Weight-bearing activities are safe for individuals with poor sensation in the feet and do not increase the risk of reulceration.19



Principles of Physical Therapy Management


It should be assumed that individuals with peripheral arterial disease have coronary and cerebral arterial disease necessitating aggressive risk factor management to reduce the risk of myocardial infarction, stroke, and death.20 Primary interventions include smoking cessation; treatment of hypertension, glucose intolerance, and diabetes; and management of low-density lipoprotein cholesterol.


The goals of long-term management of the patient with PVD secondary to atherosclerosis include the following:



image Maximize the patient’s quality of life, general health, and well-being through maximizing physiological reserve capacity


image Educate regarding atherosclerosis, heart disease, and other sequelae, self-management, nutrition, weight control, smoking reduction and cessation, risk factors, disease prevention, medications, lifestyle, activities of daily living, and avoidance of static exercise, straining, and the Valsalva maneuver


image If impaired peripheral perfusion of the limbs is present, educate regarding self-assessment of the skin; sock type, care, and cleanliness; shoe fitting; and wound care if indicated


image Maximize aerobic capacity and efficiency of oxygen transport


image Optimize the work of the heart


image Optimize physical endurance and exercise capacity


image Optimize general muscle strength and thereby peripheral oxygen extraction


image Design comprehensive lifelong health and rehabilitation programs with the patient


The goals of long-term management of the patient with PVD secondary to diabetes mellitus must incorporate both the principles for the management of the patient with PVD secondary to atherosclerosis and secondary to diabetes mellitus.


Patient monitoring includes hemodynamic monitoring (i.e., heart rate, blood pressure, and rate-pressure product). Subjective responses to treatment, particularly exercise, should also be recorded (e.g., pain scale and Borg’s rating of perceived exertion). These patients have an increased risk of angina. Angina is not an acceptable symptom under any circumstance. Thus, before undertaking a therapeutic exercise program, patients should be cleared by their physicians or cardiologists. Individuals with diabetes are potentially hemodynamically unstable; thus their hemodynamic responses before, during, and after treatment, particularly exercise, should be monitored and recorded (i.e., heart rate, blood pressure, and rate-pressure product should be taken), along with their subjective responses to exercise (e.g., pain and perceived exertion). If there is any doubt at any time about the hemodynamic stability of a patient and his or her ability to tolerate treatment safely, the patient should be referred to a general practitioner for clearance to begin or continue treatment.


Medication that is needed to maximize treatment response is administered before treatment. Knowledge of the type of medication, its administration route, and time to and duration of peak efficacy is essential if treatment is to be maximally effective.


The primary interventions for maximizing cardiovascular and pulmonary function and oxygen transport in patients with PVD secondary to atherosclerosis include some combination of education, aerobic exercises, strengthening exercises, relaxation, activity pacing, and energy conservation. Exercise, in particular walking, is an important component of management to ameliorate symptoms and improve functional capacity and quality of life.18,21 Pharmacotherapy may help relieve symptoms in the short term, whereas exercise benefits are likely to be long term in terms of addressing systemic atherosclerosis. An ergonomic assessment of both work and home environments may be indicated to minimize myocardial strain.


Individuals with PVD may underestimate their increased risk of cardiovascular disease22

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  3. Complementary Therapies as Cardiovascular and Pulmonary Physical Therapy Interventions
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Jun 11, 2016 | Posted by in RESPIRATORY | Comments Off on Individuals with Chronic Primary Cardiovascular and Pulmonary Dysfunction

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