Vascular Rehabilitation

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Background

Peripheral Arterial Disease

Peripheral Arterial Disease (PAD)is a degenerative vascular condition which results in inadequate blood flow leading to chronic narrowing of arteries typically in the lower limbs, which can result in acute thrombotic events.

These vascular events often affects a large and multilevel arteries causing complications. The initial narrowing of an artery reduces the blood flow capacity to the limb which eventually limits the exercise tolerance. Patients exhibit pain on exertion with an altered gait typical of intermittent claudication, while ~50% describe atypical symptoms that limit exercise.

Usually, the vascular lesions often progress leading to even greater limitation to mobility. In its extreme, blood flow(BF) can become limiting at rest, leading to frank ischemia, ulcerations, pathological changes, gangrene, and, all too often,amputation of the distal tissues. .

Introduction

The VRP(vascular rehabilitation program) is an essential and effective exercise program designed to improve exercise tolerance and decrease the risk of progressive cardiovascular disease. It is a complex, interprofessional intervention aimed to improve physical reconditioning and risk factor modification. Vascular rehabilitation programs aim to reduce the risk of mortality secondary to CVD and to limit the psychological and physiological stresses of PAD, and enhance cardiovascular function to help patients achieve a better quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient's self-confidence and hence functional independence.

They require a team approach, including a multidisciplinary the multidisciplinary team including:

• Multi-Disciplinary Team
  • Vascular Consultant
  • Clinical Nurse Specialist
  • Physiotherapists
  • Clinical nutritionist/Dietitian
  • Occupational Therapist
  • Orthotist
  • Pharmacist
  • Psychologist
  • Smoking cessation counsellor/nurse
  • Social worker
  • Vocational counsellor
  • Clerical Administration

It is essential that all vascular rehabilitation staff have essential training, qualifications, skills, and competencies to practice within their scope of practice and recognise and respect the professional skills of all other disciplines involved in providing comprehensive vascular rehabilitation.

Goals of Vascular Rehabilitation

Comprehensive vascular rehabilitation program should contain specific core components.

These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on:

• Patient assessment nutritional counseling
• Weight management
• Blood pressure management
• Lipid management
• Diabetes management
• Tobacco cessation
• Psychosocial management
• Physical activity counseling
• Exercise training

Individual Risk Assessment

History

• Claudication
• Other non–joint-related exertional lower extremity symptoms (not typical of claudication) n
• Impaired walking function
• Ischemic rest pain

Physical Examination

• Abnormal lower extremity pulse examination
• Vascular bruit
• Non-healing lower extremity wound
• Lower extremity gangrene
• Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)

Risk Factors

• Smoking (82%)
• Hypertension (50%)
• Diabetes mellitus (26%)
• Previous myocardial infarction (24%)
• Hypercholesterolemia (18%)
• Stroke (6%)
• Obesity

Other factors to consider

• Family Support
• Social History
• Occupation

Vascular Rehabilitation Participation

Inclusion in vascular rehabilitation programs should be available to all vascular patients who require it. Age is not and should not be a barrier to exercise unless not cardiovascularly fit.

Inclusion:

1. Acute limb ischemia
2. Angioplasty
3. Reduced ankle-brachial index
4. Atypical leg symptoms
5. Claudication/intermittent claudication
6. Critical limb ischemia/severe limb ischemia
7. Foot wound/ulcer
8. Peripheral arterial disease/peripheral vascular disease
9. Lower extremity arterial disease
10. Vascular surgery

Types of Rehabilitation

Structured exercise program

• Planned program that provides individualized recommendations for type, frequency, intensity, and duration of exercise.
• Program provides recommendations for exercise progression to assure that the body is consistently challenged to increase exercise intensity and levels as functional status improves over time.

There are 2 types of structured exercise program for patients with PAD:

1. Supervised exercise program

Supervised exercise program takes place in a hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality.

• Program can be standalone or can be made available within a cardiac rehabilitation program.
• Program is directly supervised by qualified healthcare provider(s).
• Training is performed for a minimum of 30 to 45 min per session, in sessions performed at least 3 times/wk for a minimum of 12 wk.
• Patients may not initially achieve these targets, and a treatment goal is to progress to these levels over time.
• Training involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest.
• Warm-up and cool-down periods precede and follow each session of walking.

2. Structured community- or home-based exercise program

Structured exercise program that takes place in the personal setting of the patient rather than in a clinical setting.

• Program is self-directed with the guidance of healthcare providers who prescribe an exercise regimen similar to that of a supervised program.
• Patient counseling ensures that patients understand how to begin the program, how to maintain the program, and how to progress the difficulty of the walking (by increasing distance or speed).
• Program may incorporate behavioral change techniques, such as health coaching and/or use of activity monitors.