Kardiovaskulárny systém

Arterial circulation delivers oxygenated blood and essential nutrients to organs and tissues throughout the body. The distribution of blood volume required for various physiological functions is regulated by altering arterial diameter. This process involves vasodilation (widening of arteries) or vasoconstriction (narrowing of arteries), which help control blood flow to different tissues and organs based on their needs.  

At rest, the heart pumps around 4.5 to 5 litres of blood per minute, known as the cardiac output, providing the necessary oxygen and nutrients to sustain vital life processes throughout the body. During physical activity or exercise, the muscles require increased oxygen and energy to support their heightened metabolic activity. This necessitates increased blood circulation to deliver oxygen and nutrients and remove waste products from the muscles. In response to heightened demands, such as increased physical activity, the heart pumps more blood, and arterial dilation occurs, ensuring organs and tissues receive sufficient oxygen and nutrients to support their functions. The circulatory system distributes blood throughout the body according to specific needs. 

Initially, diminished circulatory capacity in individual organs may only manifest symptoms under high-stress conditions. Symptoms occur on physical exertion in the heart and skeletal muscles, whereas discomfort is felt following meals in the digestive system. As the disease progresses, symptoms like pain and dysfunction occur with less exertion or even at rest. The reduction in blood supply to the brain is not directly linked to "load." Still, it can be associated with a gradual loss of functions in various brain regions, leading to a range of symptoms, including dizziness, tinnitus, visual disturbances, speech impairments, and problems with balance and coordination. Complete blockage of the arteries supplying the brain can lead to a type of stroke. 

Atherosclerosis is the most common cause of peripheral artery occlusion. The narrowing of arteries associated with this condition typically leads to the gradual onset of signs and symptoms.  

One of the first symptoms a patient experiences is muscle aches. Physical exertion increases the need for oxygen and nutrients to the muscles, but the constricted blood vessels cannot provide an adequate arterial blood supply. The typical symptom of muscle hypoxia initially manifests as a 'pulling' and uncomfortable tension, followed by spasmodic pain. The pain compels the patient to stop and rest; during this period, circulation stabilises, leading to a cessation or reduction of the pain.  

Intermittent claudication is a typical symptom of lower limb arterial circulatory disturbance. After a certain distance, the patient is forced to stop and rest due to the pain. This behaviour is colloquially called 'window shopping,' where patients may pretend to browse store windows while resting, allowing their symptoms to diminish without drawing attention to their condition. The pain experienced during activity is typically distal and varies according to the segment of the affected blood vessel.  

The arterial pulse in the affected artery, and potentially in distal arteries, may be weakened or impalpable. In areas with poor circulation, the skin may appear pale, feel cold to the touch, and become thinner. Hair in areas with poor circulation may weaken and thin. Nails may be weaker and cracked. Skin affected by poor circulation is more susceptible to infections, and the nails are more prone to fungal infections. Poorly healing wounds, ulcers, and eventually complete tissue necrosis and gangrene can occur. The risk of these complications, including poorly healing wounds and gangrene, is increased in individuals with diabetes. 

Lower limb localisation
The abdominal aorta divides into two branches, the right and left common iliac arteries. The external iliac artery, the outer branch, supplies blood to the lower limb. In contrast, the internal iliac artery provides blood to the pelvis and external genitalia.  

Narrowing of the common iliac artery can cause lower limb pain, pain in the pelvis and lumbar spine, and erectile dysfunction in men. A narrowing in the abdominal aorta results in insufficient circulation in both common iliac arteries, with symptoms on both sides. 

Narrowing of the femoral artery in the leg can cause classic symptoms such as pain, cramping, and muscle weakness during physical activity. Hypoxic pain primarily manifests in the triceps surae muscle group during physical activity. The pulsation of the popliteal artery, as well as the other arteries in the leg, may be weakened or impalpable.  

The leg arteries, including the anterior and posterior tibial and fibular arteries, originate from the femoral artery at the knee level. These blood vessels supply arterial blood to the muscles acting on the leg and foot. Symptoms, typically including pain and cramping, usually manifest in the legs. The decrease in pulse can be felt in the back of the leg, between the first and second metatarsal bones (dorsalis pedis artery), and behind the inner ankle (posterior tibial artery). Symptoms in the upper limbs are much less common, and no functional stage classification exists.  

The pathological process is not confined to a single vessel; the entire arterial network may be variably affected. During physical activity, pain typically manifests in the areas most severely affected by vascular issues, potentially masking symptoms of milder circulatory problems. It should also be stressed that coronary and cerebral blood vessels can be affected, influencing activities such as daily exercise, sports, and leisure pursuits. 

Slowly developing and increasing arterial stenosis triggers a compensatory mechanism to increase blood volume in the undersupplied area. The insufficient supply of oxygen causes a shift in the metabolism of tissues, such as muscle tissue, from aerobic to anaerobic processes. In particular, type I (slow-twitch/red) fibres, normally reliant on oxidative metabolism for energy production, are forced to switch to anaerobic energy production due to insufficient oxygen. This switch leads to the acidification of the muscle tissue. The acidic metabolic products produced here have a vasodilating effect. Because narrowed arteries cannot dilate, the surrounding collateral blood vessels, which are initially nonfunctional, begin to dilate. Additionally, new blood vessels may form to bypass the narrowed section, thereby restoring blood supply to the affected area. This compensatory dilation and formation of new blood vessels are also utilised in movement therapy, as discussed later.

After taking a proper history, the following signs may be seen on the affected part of the body during the examination: the skin is pale, thin, dry, and cool to the touch. The hair is thinned and sparser than on the intact side. The nails are cracked, possibly showing signs of fungal infection. The skin between the toes can crack, and fungal infections can also appear. The colour of the skin in stages III and IV may be purple, brownish-discoloured, or completely black. Wounds and ulcers may appear on the foot or shin. The muscles are inactive due to pain provoked by movement, and atrophy quickly. 

Palpation of the Arterial Pulse
The pulsation of the arteries should be palpated on both sides simultaneously, if possible. This test is recommended for both upper and lower limbs, even if there are no symptoms in any limb. The question is whether the pulsation is tactile and equal on both sides. The absence of pulsation indicates that the obstruction or stenosis is more proximal to the tested point. It should be noted that the lack of pulsation does not necessarily imply a severe circulatory disturbance in the area of blood supply to the vessel. Collateral circulation can bypass the stenosis and provide an adequate blood supply, but these blood vessels are not palpable.  

The posterior tibial artery can be palpated just posterior to the medial malleolus.

The popliteal artery is located behind the knee and runs behind the knee pit. The pulse of the popliteal artery is difficult to feel as the artery is not superficial and does not cross a prominent bone.

Palpation of the arterial pulse in the upper limbs
The radial/ulnar artery is on the distal part of the forearm, above the wrist, on the radial/ulnar side. 

The brachial artery is palpable in the antecubital fossa of the elbow joint, approximately one finger's width medially from the midpoint. The elbow should be fully extended so the artery can be easily felt. 

The ankle–brachial index (ABI) is a diagnostic measure that compares the systolic blood pressureat the ankle with that in the arm. Normal systolic pressure in the lower limb is higher than in the arm. This test should be performed with the patient in the supine position. The normal range for the ABI ratio is between 0.91 and 1.3. Values below 0.9 may indicate vasoconstriction, and severe vasoconstriction is suspected when the ratio falls below 0.4, per the American Diabetes Association guideline. 

ABI: Ankle-arm index, PAD: peripheral arterial disease

In the second part of the test, the examiner has the patient sit up with their legs hanging off the exam bed. The time it takes for the arteries to refill with blood (when the leg regains colour and the pain subsides) indicates whether the arterial circulation is intact or reduced. With normal circulation, a hanging leg will not only regain its normal colour within 30 seconds but also become hyperemic (flushed). In patients with vascular conditions, the flushing response during testing might be slower to appear but more intense than in individuals without vascular issues.  

The test is considered double-positive if the pain does not resolve within 30 seconds of the patient being seated. In this case, even the effect of gravity on arterial circulation is not enough to correct the arterial blood shortage. The test has multiple variations. In some cases, the limb can be held in a more pronounced hip flexion, while in others, the patient can continuously perform ankle plantar and dorsiflexion with the lower limb raised. Increased hip joint flexion intensifies the impact of gravity, and the muscles, through their continuous movement, deplete available oxygen more rapidly, leading to the onset of symptoms.  

Functional tests
Walk test (walking distance): the test assesses how many meters the patient can walk without stopping due to ischemic pain in the lower limb. Based on Fontaine's scale, the absence of or minimal clinical symptoms such as tingling, numbness, and cold sensitivity define stage I. Stage IIa is intermittent claudication with a distance above 200 m, whereas stage IIb is below 200 m. Stage III accounts for rest pain, and grade IV comprises ulcers of gangrene and necrosis. Stages III and IV are referred to as critical limb ischaemia.  

6-minute walk test (6MWT): The 6MWT distance is a reliable measure of walking endurance in patients with PAD. A straight, flat corridor or walking area at least 30 meters long is needed for the test, and the patient must walk as far as possible within 6 minutes. The test result is the distance walked in six minutes, measured in meters. The most reliable diagnostic methods for peripheral artery disease include Doppler ultrasound, magnetic resonance imaging (MRI), and computer tomography (CT) scans. These tests offer the advantage of accurately determining the extent, height, and length of the stenosis (narrowing of blood vessels), providing precise diagnostic information for PAD. Furthermore, these diagnostic methods allow for the clear visualisation and tracing of the collateral network already developed within the vascular segment under investigation. This provides valuable insights into the patient's circulatory health.  

Stage I:
Discomfort and pain may develop with increased physical activity (the patient has no claudication or difficulty walking, and only imaging can confirm the disease). The primary goal at this stage is to prevent further deterioration of the condition. 

This may involve implementing lifestyle modifications, risk factor management, and, most importantly, performing regular physical activity. Engaging in regular large-muscle dynamic exercises can be highly beneficial for patients in Stage I of PAD. Although the intensity of this type of training is high, severe pain in the affected limb's muscles should be avoided during exercise. It is recommended that exercise routines be planned that specifically engage the muscles affected by PAD due to the compromised vascular segment. This type of training for patients with PAD is essentially equivalent to cardio-pulmonary endurance training, which can be conducted as continuous or interval training. The duration of the high-intensity phase in interval training is determined by the point at which the patient begins to experience uncomfortable muscle tension. Ideally, the exercise program should be performed at least twice a week, but aiming for 4–5 times a week is preferable for optimal benefits. In addition to regular exercise, providing lifestyle advice is crucial to the therapy. Patients with PAD should cease smoking. Evaluating and modifying dietary habits, particularly for overweight patients, should be an integral part of the treatment plan. 

A key component of exercise therapy is local anaerobic interval training below the ischemic pain threshold. This involves performing short bursts of high-intensity exercise, with the affected muscles experiencing reduced blood flow due to the stenosis (e.g., calf muscles in the case of femoral artery stenosis). 
The exercise intensity should be carefully determined beforehand by assessing the ischemic threshold. This is done by having the patient repeatedly perform a specific exercise until pain occurs in the working muscles. This pain signifies the ischemic pain threshold, representing 100% muscle work capacity (or 100% training load).
During the actual training, the intensity should be set at 90% of the maximum training load, ensuring that the exercise remains challenging but does not reach the pain threshold. This approach effectively stimulates the development of collateral circulation (new blood vessels) to bypass the blockage, thus improving blood flow and reducing symptoms. 

This test is performed in patients with a narrowing or blockage in the femoral artery. The patient should hold onto a stable surface for support and perform dynamic heel rises repeatedly. The ischemic threshold is determined by counting the repetitions completed before the onset of pain (this represents 100% training load). The patient should maintain a consistent pace of approximately 60 repetitions per minute. With each repetition, they must avoid using their arms for assistance and ensure full plantar flexion (pointing their toes downwards).  

We adapt the testing and training phases for patients with limited walking capacity (i.e., those able to walk less than 200 m) to accommodate their reduced exercise tolerance. These modified protocols are carried out in a seated position, thereby eliminating weight-bearing stress. If the iliac artery is affected, the patient performs knee extensions using only the leg's weight as resistance. When the femoral artery is impaired, the patient repeatedly performs ankle movements, simulating toe-walking. These adaptations allow the exercise programme to be tailored to each patient’s functional capacity, ensuring that training remains both safe and effective, even for individuals with significantly reduced mobility. 

The low-intensity phase of interval training can include exercises suited to co-morbidities or aimed at preventive care, such as improving posture and range of motion. Incorporating breathing exercises during these phases is crucial for enhancing arterial blood oxygenation, which is essential for health and adequate exercise. To maintain patient motivation, this stage can feature a variety of exercises, providing a change of pace from the high-intensity phase's repetitiveness. Additionally, the duration of rest periods should match or exceed that of the high-intensity intervals for adequate recovery.  

As the patient’s rehabilitation advances, interval training can expand to incorporate various activities such as gait training, cycling, or elliptical training. It is crucial to carefully monitor the intensity of these exercises to prevent muscle pain. An indicator of a patient's improvement in interval training is their ability to increase the duration of the active, or loaded, intervals in the training.

Stage III:
Rest pain or on minimal exertion. Also, the pain felt at night is frequent.
Aim: To improve the oxygen supply to resting tissues, slow down the progression of the disease, and prevent the need for limb amputation. In the third stage, the ischemic threshold is assessed using the Ratschow test, which identifies the point at which a raised lower limb and the onset of pain mark the threshold for ischemia, set at 100%. The training is set at 90% of the threshold value on the affected limb.   

The therapy employed in Fontaine stage III operates with the influence of gravity on the blood vessels. During the training, the patient is lying on their back. The initial phase of the training commences with breathing exercises that help oxygenate arterial blood. During the second phase, high-intensity movements are performed with the healthier and less affected lower limb. This improves the circulation in the affected lower limb using the consensual effect. The following phase enhances vasodilation; during the therapy session, the therapist lifts the affected limb to a level where the patient feels discomfort at 90% of their pain threshold but not exceeding it. After holding it in this position for a period, the therapist then lowers the same limb, allowing it to hang freely off the edge of the bed. The duration for which the leg hangs freely off the bed is at least as long as the time it was lifted or until visible reddening of the leg occurs. This method involves repeating these three steps—lifting the limb, holding it at 90% of the pain threshold, and then letting it hang freely off the bed—for 15–20 minutes. 

Mechanism of action: This therapeutic technique utilises the force of gravity to affect the flow of blood through the arteries. Lifting the lower limb makes the peripheral arterial circulation more demanding due to gravity while enhancing venous drainage. Lowering the limbs allows gravity to promote increased arterial inflow into the peripheral arteries, thereby improving blood supply. 

It is noted that vascular stenosis with severe functional limitation is less common in the upper limbs, implying that the described technique primarily applies to the lower limbs. In the case of the upper limbs, assessing functional capacity is not conducted in the same manner as for the lower limbs, meaning that the Fontaine classification is inapplicable. Instead, the ‘fist clenching test’ can be used to evaluate the ischemic threshold in the upper limbs. During the test, the patient raises both arms slightly above shoulder height, with elbows bent and forearms in a vertical position. In this position, the patient is required to clench their fists and subsequently relax their hands. The combination of gravity and the muscles’ increased oxygen demand from fist clenching makes arterial circulation more challenging in the upper limbs during the test. The affected hand turns white, grip strength weakens, and pain becomes apparent. The number of repetitions or the elapsed time during these symptoms can determine the ischemic threshold. After lowering the arms, the hand gradually regains its normal colour, and the time it takes to do so can also indicate arterial circulation. During the training, the ‘fist clenching test’ can be repeated up to 90% of the threshold, or fast wrist movements with low resistance (e.g., using a hand dumbbell) can be incorporated.  

Stage IV:
It is characterised by complete arterial blockage, leading to tissue death. When the affected area is no longer responsive to exercise therapy, this indicates a severe condition in which circulation and function cannot be improved by these means. In such cases, amputation of the limb may be necessary. Physiotherapy should be integrated into post-amputation rehabilitation. The rehabilitation goals, such as preventing joint contractures, preparing the stump for prosthesis use, teaching prosthesis utilisation, and training position and location changes, are consistent with rehabilitation strategies employed after surgical treatment of traumatic amputations. However, it is crucial to note that patients who have undergone amputations due to vascular diseases, especially those with underlying circulatory problems, necessitate continuous medical care and treatment as circulatory patients.  

Raynaud’s syndrome, also known as Raynaud's phenomenon, is a medical condition in which the spasm of small arteries causes episodes of reduced blood flow to end arterioles. These episodes are typically triggered by exposure to cold temperatures or vibrations and usually resolve on their own after varying lengths without medical intervention. 

This condition most commonly affects the hands and feet, but can also manifest in areas such as the earlobes and nose. Many people have experienced similar symptoms, especially in response to cold weather.  

The syndrome is six times more prevalent in women than in men, typically manifesting at a young age, usually between 15 and 30 years old. Cold exposure is considered the most significant environmental factor contributing to the syndrome, while vibration is regarded as the most significant occupational factor. Smoking is also recognised as an essential risk factor for all types of vascular diseases, including Raynaud's syndrome. Additionally, having a family history of Raynaud's syndrome increases the likelihood of developing the condition.  

Various rheumatological diseases, including rheumatoid arthritis and Sjögren's syndrome, can trigger secondary or consequential Raynaud's syndrome. Symptoms may also manifest in individuals with lupus and scleroderma. 

There is no specific physiotherapy treatment for the disease. Eliminating risk factors such as vibration and protecting against cold (e.g., wearing gloves and socks) are essential preventive measures to reduce severe symptoms and tissue damage resulting from prolonged hypoxia. Medications are seldom needed, but in cases where they are necessary, vasodilators, typically calcium channel blockers, can help prevent the onset of symptoms.