Master Arterial vs. Venous Insufficiency Interventions with Picmonic for Physical Therapy

Arterial Insufficiency describes a condition wherein the tissues within regions of the body become starved of vital oxygen due to inadequate oxygen delivery. This condition may occur whenever the arteries leading to the tissues are narrowed or completely obstructed. Without oxygen, wounds in the affected limbs may fail to heal properly, leading to tissue death. In addition, patients may complain of decreased sensation, heightened pain, and weakness. When palpated, the affected limb may feel colder than other parts of the body, and the pulse within this limb may present as fainter.

Venous insufficiency results from a deficit in venous return to the heart. Typically, the veins carry deoxygenated blood back to the heart, but damage to the veins or legs, such as broken bones, can impair this function. Persistent venous insufficiency can lead to chronic venous insufficiency, also known as postphlebitic syndrome, which heightens the risk of swelling and edema, and venous stasis ulcers. Unlike arterial insufficiency, venous insufficiency primarily affects the legs. During venous insufficiency, wounds are most likely to develop along the medial malleolus and the dorsum of the foot due to excessive friction.

Aerobic activity, specifically supervised exercise therapy, or SET, can effectively mitigate symptoms of intermittent claudication, which is common in patients with arterial insufficiency. During SET, a patient under the supervision of a professional such as a physician may participate in interval training in which rest is balanced with activity to help mitigate any associated lower leg pain. Aerobic activity has been shown, in some cases, to be just as, if not more, effective than more invasive surgeries such as vascular surgeries. Non-supervised prescribed aerobic exercise will generally consist of 30-45 minutes of aerobic activity, such as walking or light jogging, three to four times a week.

Strength training has been shown to improve walking capacity and tolerance in patients affected by arterial insufficiency, particularly those who participate in treadmill or flat-ground walking exercises. The best results have been seen with higher-intensity workouts that focus on the musculature of the lower extremities.

Physicians can perform soft tissue mobilization and joint mobilization to relieve pain and promote circulation in the extremities. Post-exercise soft tissue mobilization, in particular, has been shown to reduce inflammation within the blood vessels and improve blood flow to the limbs. Prior to application, therapists should screen for contraindications such as skin infections, DVTs, or the presence of acute inflammation.

In general, smoking cessation is considered the top priority for patients with arterial insufficiency, followed by weight loss and exercise. These interventions, as well as other lifestyle modifications, can aid in lowering blood pressure and cholesterol and ultimately may improve blood flow to oxygen-starved regions.

Vascular surgery may be indicated when patients have arterial insufficiency that is advanced or not responding to more conservative treatments such as diet and exercise. During vascular surgery, a blood vessel, either artificial or from another area of the patient’s body, is used to help redirect blood flow around the areas of occlusion and restore blood flow. Patients may also receive an angioplasty in which a balloon is inserted into the blood vessel and inflated to restore blood flow, after which they may have stents placed within the arteries to aid in keeping the arteries dilated.

Compression therapy is an important part of treatment in many cases of venous insufficiency, particularly in cases where wounds such as venous ulcers have begun to form. Compression stockings or bandages can improve blood flow back to the heart while simultaneously reducing swelling, with best results between 20-30 mmHg of pressure. Physical therapists should ensure that arterial insufficiency has been appropriately ruled out prior to application because restricted blood flow to an ischemic limb can result in further complications and, ultimately, even amputations when not properly screened.

Aerobic exercises, such as walking or cycling, and lower limb strengthening exercises can help improve circulation by activating the calf muscles. Contraction of the calf muscles during exercise causes a pumping action that helps move blood from the lower extremities back to the heart, leading to a reduction of symptoms such as swelling and possibly even aiding in wound healing. Intermittent plantarflexion and dorsiflexion of the ankles during sitting or supine positions can also aid in reducing venous insufficiency symptoms and improving circulation.

Manual therapeutic techniques such as joint mobilizations and ROM exercises can improve circulation and reduce pain and swelling within the lower extremities. Joint mobilizations will often focus on restoring the range of motion to the ankle joints and may incorporate plantarflexion and dorsiflexion mobilizations to help aid the natural pumping mechanism of the calves. Therapists may also focus on ROM exercises and positions that elevate the legs to aid in venous return to the heart. Other manual techniques, such as Manual Lymph Drainage, or MLD, emphasize controlled motions towards the heart to help move fluids back to the heart from the lower extremities and aid in reducing swelling in the affected areas.

Proper skin care can prevent skin breakdown and manage any skin changes that may have occurred as a result of venous insufficiency. Typically, wounds due to venous insufficiency will appear over the medial part of the lower leg, around or near the medial malleolus of the ankle, or near any part of the leg that was exposed to excessive trauma. Patients are encouraged to use an absorptive dressing, such as the "unna boot," that can soak up any excessive drainage from venous insufficiency wounds and also aid in limb compression and return of blood back to the heart.

Similar to arterial insufficiency, patients with venous insufficiency are at higher risk of having other comorbidities such as obesity and diabetes. Maintaining a healthy lifestyle, such as engaging in physical activity, avoiding standing or sitting for long periods, and maintaining a healthy weight, can help improve blood flow and relieve symptoms. Physicians are encouraged to provide education to patients with venous insufficiency on the benefits of regular physical activity and dietary changes.