copyright © 2013 wolters kluwer health | lippincott williams & wilkins a massage therapist’s...

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

A Massage Therapist’s Guide to Pathology 5e

A Massage Therapist’s Guide to Pathology 5e

Chapter Five

Circulatory System Conditions


Chapter 5 IntroductionChapter 5 Introduction

• General Function: the Circulatory System

– Delivers nutrients, fuel,

– Delivers oxygen

– Removes wastes

– Maintains temperature

– Clotting

– Protection from pathogens

– Chemical balance

• Massage can support or impair this function


Chapter 5 Introduction, cont.Chapter 5 Introduction, cont.

• Structure and Function: the Heart

– Septum divide L/R

• Right side pumps to pulmonary circuit

• Left side pumps to systemic circuit

– AV valves divide into top and bottom halves

• Atria, ventricles

• “lub-dup” is closing of AV and semilunar valves

– Ventricles work harder than atria

• Implications for seriousness of heart attacks


Chapter 5 Introduction, cont.Chapter 5 Introduction, cont.• Structure and Function: Blood Vessels

– Aorta → arteries → arterioles → capillaries → venules → veins → vena cava → heart

– Closed system: platelets and RBCs should not be able to leave

• 60,000 miles of vessels

– 3-ply construction of veins and arteries:

• Tunica intima (endothelium)

• Tunica media (smooth muscle)

• Tunica externa/ adventitia (connective tissue)

– Capillaries are simple squamous epithelium: excellent for permeability


Chapter 5 Introduction, cont.Chapter 5 Introduction, cont.Structure and Function: the Blood

• Red blood cells (erythrocytes)

– Born in bone marrow

– Production stimulated by EPO from kidneys

– 98% of all blood cells

– Lifespan = 4 months

• Dead RBCs removed by spleen

• Turnover: 2 million/second

– No nuclei, lots of hemoglobin (iron-based)

– 5 million per mm3

– Biconcave discs: all identical, smooth and flexible



• White blood cells (leukocytes)

– Translucent

– Different types for different functions

• Neutrophils, basophils, eosinophils, monocytes, lymphocytes



• Platelets (thrombocytes)

– Fragments of larger cells (megakaryocytes)

– Smooth until stimulated, then spiky, sticky

– Release chemicals that weave fibrin

• Make thrombi, crusts



• Blood Disorders

– Anemia

– Embolism, thrombus

– Hemophilia

– Leukemia

– Myeloma

– Sickle cell disease

– Thrombophlebitis, deep vein thrombosis


Chapter 5 Introduction, cont.Chapter 5 Introduction, cont.• Vascular Disorders

– Aneurysm

– Atherosclerosis

– Hypertension

– Raynaud syndrome

– Varicose veins

• Heart Conditions

– Heart attack

– Heart failure


AnemiaAnemia

• Definition:

– Insufficient 02 carrying capacity

– Often a symptom or complication rather than freestanding problem


Anemia, cont.Anemia, cont.

• Etiology: what happens?

– Either a shortage of RBCs or a shortage of hemoglobin

– Leads to low O2 carrying capacity

– Process depends on type of anemia


Anemia, cont.Anemia, cont.Types of anemia

• Idiopathic a.:

– May be due to poor nutritional uptake due to stress or other factors



Types of anemia

• Nutritional a.:

– Something vital is missing from the diet:

• iron

• folic acid

• vitamin B12

• Can lead to pernicious anemia, brain damage

• Copper, protein, some others…



Types of anemia

• Hemorrhagic a.:

– From blood loss

• Trauma (acute)

• Slow leak (chronic)

• Ulcers, kidney disease, heavy menstruation



Types of anemia

• Hemolytic a.:

– Premature destruction of RBCs

– Splenomegaly, jaundice may also be present

– Reticulocytes (immature RBCs) increase



Types of anemia

• Aplastic a.:

– Bone marrow is not functioning

• All blood cells are affected

– Can be autoimmune, renal failure, folic acid deficiency, viral, exposure to radiation…

– Myelodysplastic anemia: bone marrow makes non-functioning cells: risk of leukemia, myeloma



Types of anemia

• Secondary a.:

– Due to underlying cause:

• Ulcers

• Kidney disease

• Hepatitis

• Acute infection

• Blood cancer


Anemia, cont.Anemia, cont.• Signs and Symptoms:

– Fatigue

– Pallor

– Dyspnea, rapid breathing

– Rapid heartbeat

– Intolerance to cold

– Heart problems



• Treatment:

– Depends on underlying cause

– Medication

– Transfusion, stem cell implants, other strategies

• Medications:

– Oral, injected nutritional supplements

– Steroidal anti-inflammatories for autoimmune disease

– Synthetic EPO to boost RBC production



• Massage

– Risks: Anemia can be part of other diseases that contraindicate massage. Anything that compromises sensation (pernicious anemia) or that is related to infection or cancer requires special adaptation for bodywork.

– Benefits: Massage may help with fatigue, but probably makes no changes in blood cell production or nutrition. A client who manages anemia and can adapt to the changes that massage brings about is a good candidate for bodywork.


Embolism, thrombusEmbolism, thrombus

• Definition: – Embolism: traveling clot

– Thrombus: lodged clot


Embolism, thrombus, cont.Embolism, thrombus, cont.

• Etiology: what happens? – Platelets flow through circulatory system; activated

by any rough spot or inflammatory chemicals

– Clots form at sites of damage, areas of slow, irregular blood flow

• Clots are constantly forming and melting

• Sometime pro-clotting mechanism is stronger than anti-clotting

• Clots may stay in place (thrombi) or fragment and travel (emboli)

– Emboli travel until vessel is too small to pass through



Types of embolism, thrombus

• Venous thrombosis: see thrombophlebitis, deep vein thrombosis




• Pulmonary embolism:

– From a clot that forms on venous side of systemic circuit: fragments and travels to lungs

– Often related to deep vein thrombosis, complications of trauma, orthopedic surgery

– Risk factors:

• Other cardiovascular disease

• Pregnancy

• Overweight

• Smoking

• Hormone supplements


Embolism, thrombus, cont.Embolism, thrombus, cont.Types of Types of embolism, thrombus

• Arterial thrombus:

– Complication of atherosclerosis

– Made worse with chronic inflammation, stress

– Clots can grow on site to occlude the artery or they can fragment and travel (= embolism)




• Arterial embolism:

– Complication of atherosclerosis, atrial fibrillation, rheumatic heart disease

– Often made of clotted blood, can be other debris

– Brain, coronary arteries, kidneys, legs are most common sites; damaged tissue is infarction



• Signs and Symptoms:

– May be silent

– PE:

• Dyspnea, hemoptysis, lightheadedness, chest pain, sweating

– Arterial embolism:

• Sharp, tingling pain, tissue damage and death

–



• Treatment:

– Medications

– Surgery

– Supplement O2 if necessary

– Compression stockings

• Medications:

– Antiplatelet drugs

– Anticoagulants

– Thrombolytics


Embolism, thrombus, cont.Embolism, thrombus, cont.• Massage

– Risks: A client with a tendency to form clots may not be able to adapt to mechanical types of bodywork; whether the risk is local or systemic depends on the type of bodywork.

– Benefits: Non-mechanical forms of bodywork may be soothing and supportive for clients at risk for embolism or thrombus. Clients with a history of problems but no lingering problems can enjoy massage with no cautions.


HemophiliaHemophilia

• Definition:

– Genetic disorder:

• Usually x-linked

• Absence of various clotting factors


Hemophilia, cont.Hemophilia, cont.

• Etiology: what happens?– 12 distinct clotting factors help form clots

– Person with hemophilia has difficulty forming solid, long-lasting clots because of clotting factor insufficiency

• Don’t bleed faster, do bleed longer than others

– Rated as mild, moderate, severe

• Severe hemophilia = 60% of diagnoses; <1% normal clotting factors

– Usually an x-linked genetic mutation

• Carried by mothers, passed on to sons


Hemophilia, cont.Hemophilia, cont.• Complications:

– Leading COD in children with hemophilia is intracranial bleeding

– Bleeding into joint capsules with inflammation and extensive damage:

• Hemophiliac arthritis

– Muscle and nerve damage

• Compartment syndrome, contracture

– Infected blood products



Types of hemophilia

• Type A:

– Most common form, about 80% of all cases

– Deficiency of clotting factor VIII


Hemophilia, cont.Hemophilia, cont.Types of hemophilia

• Type B:

– AKA Christmas disease

– Insufficient Factor IX

– About 15% of cases



Types of hemophilia

• Von Willebrand disease:

– Dysfunction of von Willebrand factor

– Helps Factor VIII

– Genetic mutation, ranges in severity

– Not x-linked; men and women affected equally




– Signs at birth: umbilical cord bleeds excessively

– Early childhood: infant/toddler accidents

– Bruising, hematomas, nosebleeds, hematuria, joint pain from bleeds into capsule

• Can be from trauma or spontaneous


Hemophilia, cont.Hemophilia, cont.• Treatment:

– Supplement clotting factors

• Can be done at home now, prophylactically or after injury

– Careful exercise, weight control

• Medications:

– Concentrated clotting factors

– Recombinant clotting factors

– Desmopressing to promote clotting factor production

– Antifibrinolytics to slow clot breakdown


Hemophilia, cont.Hemophilia, cont.• Massage

– Risks: Severe hemophilia contraindicates rigorous bodywork or anything that might cause bruising. Consult with client and health care team for other cautions.

– Benefits: Gentle or energetic massage can help with pain and stress. For milder cases massage that fits within the limitations of the tissues to avoid bruising is appropriate


LeukemiaLeukemia• Definition:

– “White blood”:

– Cancer of bone marrow

– Overlap between leukemia and lymphoma

– 38,000 diagnoses in US/year

– 200,000 survivors alive today


Leukemia, cont.Leukemia, cont.


– Myeloid or lymphoid cells make most WBCs in bone marrow

– Leukemia happens when mutation leads to production of non-functioning WBCs

– Can be acute (aggressive) or chronic (slow-growing)

– Usually acquired (not inherited) genetic mutations

• Exposure to toxins, radiation

– Untreated disease leads to death from excessive bleeding, infection



Types of leukemia

• Acute myelogenous leukemia (AML):

– Aggressive cancer of meyloid cells

– Mostly in people 65+

– Linked to exposure to…

• Radiation

• Chemo for other cancers

• Benzene

– Can form tumors outside marrow



Types of leukemia

• Chronic myelogenous leukemia (CML):

– Slowly progressive

– Affects myeloid cells

– Traced to specific chromosome

– Not usually very aggressive

• Can change to behave like AML



Types of leukemia

• Acute lymphocytic leukema (ALL):

– Aggressive cancer of all lymphocytes

– Most common among children

– All other marrow activity is suppressed

– Mutated cells can gather in nodes, CNS



Types of leukemia

• Chronic lymphocytic leukemia (CLL):

– Slowly progressive

– Affects lymphocytes

• Mostly B-cells

– Can be stable and non-progressive for long periods




– Bone marrow dysfunction

– Suppressed production of normal blood cells

• Fatigue, anemia

• Easy bruising, bleeding

• Chronic infections

• Others: fever, headache, weight loss, abdominal pain, enlarged lymph nodes



• Treatment:

– Depends on what cells have been affected

– Chemotherapy

– Radiation therapy if nonresponsive to chemo

– Bone marrow transplant

– Biologic (targeted) therapies

– Treatments can exacerbate symptoms



• Medications:

– Chemotherapy

– Biologic (targeted) therapy, e.g., interferon, monoclonal antibodies

– Drugs to mitigate side effects of chemotherapy


Leukemia, cont.Leukemia, cont.• Massage

– Risks: Patients have a high risk of bruising, bleeding and infection. It is best to consult with the patient and health care team about timing massage with treatment options for the best outcomes.

– Benefits: Bodywork has many benefits to offer cancer patients, as long as appropriate precautions are taken.


MyelomaMyeloma

• Definition:

– “Mye”= marrow; “oma”= tumor

– Cancer of bone marrow, specifically maturing B-cells

– Mostly in people 50 years +

– Twice as common among African Americans compared to general population


Myeloma, cont.Myeloma, cont.• Etiology: what happens?

– Normally, only a few B-cells stay in bone marrow instead of migrating to lymph tissue

– B-cells may experience a DNA mutation

• Proliferate into tumors

• Secrete cytokines that block osteoblast activity, stimulate osteoclasts

• Bone thinning, holes, fractures

• Produce faulty antibodies

– Tumors can interfere with bone marrow function

– Faulty antibodies are shed in urine (causing kidney damage)


Myeloma, cont.Myeloma, cont.

Types of myeloma

• Multiple myeloma:

– Tumors grow simultaneously at multiple sites

– Most common form, 90% of all diagnoses



Types of myeloma

• Solitary myeloma:

– A single tumor in bone marrow



Types of myeloma

• Extramedullary plastocytoma:

– Growth of tumors outside of bone tissue

• Skin, muscle, lung, elsewhere




– Silent early; proteins may be tracked by urinalysis

– Bone pain, fractures

– Anemia, infections, bleeding

– Kidney problems

– Amyloidosis (inflammatory proteins congregate in heart, lungs, other organs)



• Treatment:

– “Watchful waiting”

– Chemotherapy, bone marrow stem cell transplantation

• Medications:

– Chemotherapy

– Drugs to slow angiogenesis

– Corticosteroids, esp. for amyloidosis

– Bisphosphonates to promote bone density

– Synthetic EPO for RBC production


Myeloma, cont.Myeloma, cont.• Massage

– Risks: Myeloma patients have a high risk for fractures. Other complications may be related to the cancer or its treatment; consult with the patient and health care team for best results.

– Benefits: Gentle work can be helpful for pain, anxiety, sleep and other benefits.


Sickle cell disease (SCD)Sickle cell disease (SCD)

• Definition:

– Autosomal recessive genetic condition

– Production of abnormal hemoglobin

– Most common in blacks, Hispanics, Mediterraneans, from Middle East

– 2 million in US have SC trait

– 30,000 in US have SCD


Sickle cell disease, cont.Sickle cell disease, cont.• Etiology: what happens?

– Having 1 gene: sickle cell trait

– Having 2 genes: sickle cell disease

• Hemoglobin production is abnormal

• RBCs have sickle shape

• RBCs get caught at capillaries

• RBC lifespan is shortened


Sickle cell disease, cont.Sickle cell disease, cont.

• Complications:

– Sickle-cell crises: infarctions

• Hand-foot syndrome

– Organ damage

• Esp. spleen, liver, kidneys, brain

– Infections (lost spleen function)

– Gallstones

– Vision loss

– Acute chest syndrome (looks like pneumonia)

– Others:• Delayed growth, chronic skin ulcers at lower legs,

priapsim


Sickle cell disease, cont.Sickle cell disease, cont.


– Inadequate O2 carrying capacity

• Fatigue

• Shortness of breath

• Pallor

– Jaundice, splenomegaly

– Other complications


Sickle cell disease, cont.Sickle cell disease, cont.• Treatment:

– Work to limit severity, frequency of SC crises

• OTC pain meds, hot pack

• Heavier painkillers

• Prophylaxis for pneumonia

• Medications:

– Analgesics

– Prophylactic antibiotics

– Chemotherapeutic agents for adults

– Supplement folate


Sickle cell disease, cont.Sickle cell disease, cont.• Massage

– Risks: Clients with SCD have compromised circulatory function; any bodywork must be adapted to respect this serious limitation.

– Benefits: Massage for pain and anxiety relief, without intrusive mechanical intent can be an important part of an SCD patient’s quality of life.


Thrombophlebitis, deep vein thrombosisThrombophlebitis, deep vein thrombosis

• Definition:

– Veins have become obstructed with clots

• Usually calves, thighs, pelvis

– Thrombophlebitis = lesser, greater saphenous veins

– DVT= popliteal, femoral, iliac veins


Thrombophlebitis, deep vein thrombosis, cont.Thrombophlebitis, deep vein thrombosis, cont.


– Thrombi= stationary clots; they can fragment and travel

• Usually to lung → pulmonary embolism

– Virchow triad:

• Injury to endothelium

• Hypercoagulability

• Venous stasis



– Possible triggers:

• Physical trauma

• Varicose veins

• Local infection

• Physical restriction

• Immobility

• Pregnancy and childbirth

• Certain types of cancer

• Surgery

• Hormone supplements

• Other factors: cigarette smoking, hypertension, paralysis, and some genetic conditions




– May be obvious with signs of inflammation

– Itchy, hard cord

– Sometimes distal edema

– Chronic problem → skin rashes, ulcers

– With infection: fever, malaise

– DVT is more dangerous, higher risk of serious damage

• May show pitting edema



• Treatment:

– Thrombolytics to break clots; anticoagulants to prevent future ones

• Risk of bruising, bleeding

– Pneumatic compression, support hose for DVT

– Superficial thrombophlebitis: hot packs, analgesics, gentle exercise

– Vena cava filter



• Medications:

– Aspirin

– Anticoagulants

• Heparin, warfarin

– Thrombolytics



• Massage

– Risks: A client with a diagnosed blood clot is not a good candidate for rigorous massage until the situation is stable. Clients who use anticoagulants are at risk for bleeding and bruising.

– Benefits: A client who has successfully treated a clot is a good candidate for massage.


AneurysmAneurysm

• Definition:

– Bulge in blood vessel wall or heart

– Usually at aorta or in brain


Aneurysm, cont.Aneurysm, cont.


– If walls of high-pressure arteries lose elasticity, they can bulge

• As aneurysm grows, walls get thinner

– Usually happens at thoracic or abdominal aorta, or base of brain

– Identified when diameter is 150% of normal

• Can happen at multiple sites

• Sometimes the whole ventricle of heart can bulge



– Factors:

• Compromised smooth muscle

• Smoking

• Congenitally weak arterial wall muscle

• Inflammation

• Untreated syphilis

• Trauma

– Rupture is almost always fatal



Types of aneurysm

• Saccular a.:

– Usually at thoracic or abdominal aorta

– Wall bulges like a rounded sack

– Throbbing and pressure on other structures



Types of aneurysm

• Fusiform a.:

– Common version

– Bulge is tubular for a few inches



Types of aneurysm

• Berry a.:

– Small bulges in the brain


Aneurysm, cont.Aneurysm, cont.Types of aneurysm

• Dissecting a.:

– AKA “false aneurysm”

– Least common, most painful

– The aorta wall splits between the tunica intima and tunica media

• Aorta may dissect without an aneurysm




– Sometimes silent

– May press on other structures:

• Dysphagia, chest pain, hoarseness, coughing (thoracic aorta)

• Throbbing lump near umbilicus back pain (abdominal aorta)

• Headache, numbness, weakness (brain)



• Treatment:– Endovascular or open surgery

• Replacement graft, Dacron substitute, stent

– Small bulges may not need immediate repair

• Medications:

– Antihypertensives

– Analgesics


Aneurysm, cont.Aneurysm, cont.• Massage

– Risks: Research suggests that massage can have a variable affect on blood pressure. A client with an aneurysm may have a limited capacity to adapt to these challenges.

– Benefits: A client with a stable aneurysm can receive massage that doesn’t challenge his/her capacity for cardiovascular adaptation.

– Options: Bodywork focused on dropping blood pressure without adding cardiovascular challenge is probably safe for aneurysm patients.


Atherosclerosis Atherosclerosis

• Definition:

– Subtype of arteriosclerosis

– Hardening of large, medium-sized arteries due to plaque

• Damage causes spasm, blood clots• Diameter is occluded


Atherosclerosis, cont.Atherosclerosis, cont.


Atherosclerosis, cont.Atherosclerosis, cont.• Etiology: what happens?

– Multifactoral process

– Basic progression:

– 1. Endothelial damage: Occurs most readily at branches or sharp curves

– 2. Monocytes move in, become macrophages

– 3. Macrophages take up LDL: Become “foam cells”: beginning of plaque

– 4. Foam cells infiltrate and damage smooth muscle tissue.

5. Platelets arrive:

Secrete growth factors

Form clots

Cause vascular spasm

See animation at thePoint.lww./Werner5e


Atherosclerosis, cont.Atherosclerosis, cont.• Complications

– Hypertension (circular relationship)

– Aneurysm

– Arrhythmia

– Thrombus, embolism

– Angina pectoris

• Stable

• Unstable

– Heart attack


Atherosclerosis, cont.Atherosclerosis, cont.• Risk Factors• Non-modifiable risk factors:

– Heredity, genetics

– Gender

– Age

– Kidney disorders

• Modifiable risk factors:

– Smoking:

– High cholesterol levels

– High blood pressure

– Sedentary lifestyle

– Diabetes


Atherosclerosis, contAtherosclerosis, cont

– Other risk factors:

• C-reactive protein

• Homocysteine

• Others: BMI, fibrinogen, lipoproteins,



Types of atherosclerosis

• Carotid artery disease:

– Plaques form in carotid arteries

– Set-up for TIA, ischemic stroke




• Coronary artery disease:

– Atherosclerosis at coronary arteries surrounding the heart

– Occlusion can lead to heart damage– heart attack

– See animation at thePoint.lww.com/Werner5e




• Peripheral artery disease:

– Atherosclerosis away from the neck, heart

– Abdomen, legs are frequent sites

• Intermittent claudication

• Erectile dysfunction

• Stasis dermatitis

• Gangrene

• Skin ulcers




– None early: 50% occlusion before dysfunction

• (angiogenesis, adaptability)

– Later: poor stamina, shortness of breath, complications



• Treatment:

– Diet and exercise

– Drugs

– Surgery:

• Bypass, angioplasty, endarterectomy

• Medications:

– Cholesterol management drugs

– Antihypertensives

– Anticoagulants, anti-platelet drugs

– Anti-angina drugs


Atherosclerosis, cont.Atherosclerosis, cont.• Massage

– Risks: It is safe to assume that most adults have some level of atherosclerosis in the US. If this has led to other forms of heart disease or has compromised function, then bodywork must be appropriately adjusted.

– Benefits: A person with atherosclerosis who is active and engaged in his or her health can enjoy many benefits from massage that is geared to fit within adaptive capacity.

– Options: Because no major blood vessels are accessible on the back, it is possible to give a satisfying massage without putting potentially compromised arteries at risk. Be careful at the anterior trapezius, because of the carotid arteries.


HypertensionHypertension

• Definition:

– High blood pressure

• Persistently above 140/90

– About 1/3 of all US adults

• Men > women till age 65

• Men = women after age 65

– African-Americans more vulnerable than other races


Hypertension, cont.Hypertension, cont.


– Internal and external pressure on arteries

– See animation at thePoint.lww.com/Werner5e

– Damage begins to accrue at 155+ over 75+

– Damage is progressive and silent, leading to many complications



Category Systolic Diastolic

Optimal <120 <80

Pre-hypertension 120-139 80-89

Hypertension

Stage 1 140-149 90-99

Stage 2 160+ 100+



• Complications

– Edema

– Atherosclerosis

– Stroke

– Enlarged heart, heart failure

– Aneurysm

– Kidney disease

– Retinopathy



Types of hypertension

• Essential h.:

– Not dependent on underlying factor

– About 95% of all diagnoses




• Secondary h.:

– A temporary complication of another disorder

• Pregnancy, kidney disease, adrenal tumor, etc.




• Malignant h.:

– Can be essential or secondary

– Diastolic rises very quickly (over weeks or months)

– High risk for stroke

– Can be fatal




– “Silent Killer”

– Shortness of breath; headache/dizziness; swelling of ankles; sweating, anxiety



• Treatment:

– About 1/3 of people with hypertension who treat it at all, treat it successfully

– DASH diet

– Exercise

– Medication



• Medications:

– Diuretics

– Vasodilators to reduce cardiac load

– Beta blockers, alpha blockers



• Massage

– Risks: Clients with advanced or poorly managed hypertension may have serious complications that alter the forms of bodywork that are most appropriate. Also be aware that antihypertensive medications can make people feel fatigued and dizzy: these clients may need extra transition time at the end of a session.

– Benefits: A client who is encouraged to exercise is generally a good candidate for massage. If activity is limited due to hypertension or heart disease, accommodations can be made to maximize the stress-reduction aspects of massage and minimize any adaptive requirements.


Raynaud syndromeRaynaud syndrome

• Definition:

– Vasoconstriction of arterioles, usually in hands

• Can be feet, nose, ears, lips

• Can be primary (R. disease)

• Can be secondary (R. phenomenon)


Raynaud syndrome, cont.Raynaud syndrome, cont.• Etiology: what happens?

– Arterioles in hands, feet: constrict, then dilate

– Temporary episodes, can become permanent (esp. with R. phenomenon)


Raynaud syndrome, cont.Raynaud syndrome, cont.Types of Raynaud syndrome

• Raynaud disease:

– Primary, freestanding form

– Triggers include…

• Stress

• Cold

• Mechanical irritation (vibrating machinery)


Raynaud syndrome, cont.Raynaud syndrome, cont.

Types of Raynaud syndrome

• Raynaud phenomenon:

– Secondary reaction to underlying condition

– Faster onset, higher risk of complications

– Causes include…

• Occlusive arterial diseases

• Autoimmune connective tissue diseases

• Drug sensitivities


Raynaud syndrome, cont.Raynaud syndrome, cont.


– Usually bilateral

– Cycle of colors:

• White/ ashy gray

• Blue

• Red

– Episodes last < 1minute-several hours

– Secondary can be extreme and long-lasting: atrophy, ulcerations, skin and nail damage


Raynaud syndrome, cont.Raynaud syndrome, cont.• Treatment:

– Depends on cause

• Quit smoking, avoid vasoconstrictors, soak in warm water, dress for weather, protect hands when working in cold, etc.

• Deal with stress: biofeedback, exercise, massage

• Medication to dilate blood vessels, counteract norepinephrine

• Surgery: sympathectomy


Raynaud syndrome, cont.Raynaud syndrome, cont.• Medications:

– Calcium channel blockers, ACE inhibitors for vasodilation

– Selective serotonin reuptake inhibitors for peripheral vasodilation


Raynaud syndrome, cont.Raynaud syndrome, cont.• Massage

– Risks: Raynaud syndrome can be a symptom of a serious underlying disorder that requires some adaptation of bodywork. Clients may use vasodilating drugs that also require some changes in bodywork strategies.

– Benefits: Primary Raynaud disease indicates massage as long as the skin is intact and any medications are accommodated.

– Options: Many Raynaud syndrome patients enjoy warm hydrotherapy or paraffin baths on the affected areas.


Varicose veinsVaricose veins

• Definition:

– Varix”= “twisted”

– Valves in superficial veins weaken; vein is stretched, distorted

• Usually in legs, can be elsewhere

– Women > men


Varicose veins, cont.Varicose veins, cont.• Etiology: what happens?

– In the leg:

• Small veins pick up blood from internal muscle capillaries

• Run on superficial aspect, feed into larger veins that perforate leg muscles

• Muscle contraction/ relaxation moves blood from superficial to deep, and up legs

– Damage to valves in superficial veins:

• Wear and tear

• Standing all day

• Mechanical obstruction

• Knee socks, brace, pregnancy

– Vein becomes enlarged, distorted


Varicose veins, cont.Varicose veins, cont.

• Complications:

– Varicose ulcers, dermatitis

– Leg cramps

– Blood clots (melt easily)

– Risk of DVT, especially with sudden onset or change in size



Types of varicose veins

• Esophageal varices:

– Large veins at distal end of esophagus

– Most common with liver disease or bulimia

– Risk of rupture, internal bleeding




• Hemorrhoids:

– Clusters of vascular tissue around the anus

• Veins, capillaries, small arterioles

– Can develop inside rectum or externally

– Associated with constipation, straining during bowel movements




• Telangiectasias:

– “Spider veins”

– Ankles, legs, face

– Usually harmless; can indicate underlying circulatory problem




• Varicoceles:

– Dilated venous structures that supply spermatic cord

– Can be painless

– Can interfere with fertility, testosterone production




– Lumpy, bluish wandering lines

– Protrude from skin

– Back, medial aspect of calf and thigh

– Itching, throbbing pain



• Treatment:

– Support hose, elastic bandages

– Avoid long periods on feet, rest with feet elevated

– Avoid constricting clothes

– Surgery:

• Vein stripping

• Ambulatory phlebectomy

– Other:

• Sclerosing injections

• Laser

• Radiofrequency



• Massage

– Risks: Very extreme veins with skin damage at least locally contraindicate anything but the lightest massage. Be aware that superficial veins have some connectors to deeper veins, which could lead to DVT.

– Benefits: Massage is unlikely to change v. veins, but flat, gliding pressure toward the heart is safe for this condition as long as the skin is intact and the risk of blood clots is minimal.

– Options: Mild v. veins can respond to hydrotherapy: alternating hot and cold.


Heart attackHeart attack• Definition:

– Damage to cardiac muscle from ischemia

• CAD

– Muscle tissue doesn’t repair; replaced by scar tissue

– Damaged area = “infarct”

• Heart attack = myocardial infarction

– 1.5 million heart attacks in US/year

– 500,000 deaths

– #1 COD for men and women


Heart attack, cont.Heart attack, cont.


– A portion of myocardium dies due to lack of O2

– Usually a blockage in coronary artery

• Could be clot, debris, that travels from elsewhere

• Prolonged coronary spasm (drug overdose)

– New plaques more likely to break off, rupture than old ones

– Cardiac cells die from ischemia

• Can’t contract with coordination



• Etiology, cont.

– Related conditions:

• Atrial, ventricular fibrillations (can be very dangerous)

• Arrhythmia

• Embolism

• Aneurysm

• Heart failure

• Shock




– Angina pectoris

• Stable

• Unstable

– Spreading pain

– Shortness of breath without chest pain

– Stomach, abdominal pain

• It is important to pay attention to early symptoms: heart attacks progressively destroy tissue; early intervention is life-saving.


Heart attack, cont.Heart attack, cont.• Treatment:

– Identify location of blockage, break it up ASAP

• Thrombolytics

• Percutaneous transluminal coronary angioplasty

• Oxygen, pain management

– Later care: anticoagulants, nitroglycerin, observation, evaluation

– Surgery if necessary

– Lifestyle changes


Heart attack, cont.Heart attack, cont.• Medications:

– Emergency care:

• Aspirin (anti-platelet)

• Analgesics

• Nitroglycerin

• Thrombolytics, anticoagulants

– After-care

• Nitroglycerin

• Anticoagulants, anti-platelet drugs

• Cholesterol management drugs

• Anti-hypertensives



• Massage

– Risks: The safety of bodywork in this context depends largely on the adaptive capacity of the client. If activity is limited due to pain or the risk of a repeat event, massage must likewise be limited in its demands on the body.

– Benefits: Gentle massage for pain and anxiety is helpful even for clients with a recent heart attack. A client with a history of heart problems but who is physically active can probably adapt to any changes that massage might bring about.


Heart failureHeart failure• Definition:

– Progressive loss of heart function

– Not cardiac arrest

– 5 million patients in the US

• 300,000 deaths/year

– Prevalence doubles with each decade


Heart failure, cont.Heart failure, cont.


– Heart pumps 2,000 gallons/day

– If resistance develops, heart compensates

• Heart grows (cardiomegaly)

• Ventricles become stiff, inelastic

– Stress-related hormones boost short-term function, damages in long-term

– Heart muscle may fibrillate → circulatory system collapse

– Heart failure usually related to other CV disease

– Can be related to congenital weakness with heart muscle or valves



Types of heart failure

• Left-sided heart failure:

– Left ventricle pushes against resistance in the aorta (atherosclerosis)

– Fluid backs up into lungs

• Causes shortness of breath, coughing, pneumonia risk




• Right-sided heart failure:

– AKA cor pulmonale

– Resistance on the right side (lungs: could be a complication of left-sided heart failure)

– Right ventricle is weakened; back-up of fluid accumulates in legs (if ambulatory), abdomen (if bed-ridden)




• Biventricular heart failure:

– Left and right sided failure simultaneously

– Tends not to respond to medication

– Patient may be a candidate for transplant surgery

– See animation and video at thePoint.lww.com/Werner5e




– Depends on which side of heart is dysfunctional

– Shortness of breath, low stamina, edema, chest pain, indigestion, arrhythmia, distended vessels in neck, cold sweaty skin…

– Usually slow onset



• Treatment:

– Depends on location, severity

– Rest, change in diet, modify physical activity

– Medications

– Surgery: repair damaged valves, mesh bag, transplant



• Medications:

– Anticoagulants

– Beta blockers, ACE inhibitors

– Digitalis

– Diuretics

– Statins for cholesterol management



• Massage

– Risks: Most people with heart failure have a history of other cardiovascular disease, and limitations on physical activities. Massage must likewise be adjusted to fit within those limitations. Be aware the medications to manage heart failure have side effects that must be accommodated for.

– Benefits: Gentle bodywork that invites (rather than imposes) change may help to reduce blood pressure, decrease stress.

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