COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

S.Y. 2016-2017

SEMINAR 1

MEDICAL BACKGROUND
ON
Peripheral Vascular Disease
(PVD)

SUBMITTED TO:
Sir Bernardo Tayaban Jr., PTRP
Sir Maverick Kaypee Colet, PTRP

SUBMITTED BY:

Agra, Crissa Julienne E.

BSPT-IV
 I. Introduction

Peripheral vascular disease (PVD) is any condition of the blood vessels that causes
partial or complete obstruction of flow of blood to or from the arteries or veins outside the
chest.

Peripheral vascular disease (PVD) is a general term used to describe any disorder that
interferes with arterial or venous blood flow of the extremities.

Peripheral vascular disease (PVD) includes disorders of the arterial, venous, and
lymphatic system. In clinical settings, the term PVD is usually used to describe peripheral
arterial disease. PVD is increasingly common and has the potential to cause loss of limbs
or, occasionally, life.

Peripheral vascular disease is common among older clients and diabetic clients. It is
characterized by disturbances of blood flow through the peripheral vessels. These
disturbances eventually damage tissues as a result of ischemia, excessive accumulation of
waste and fluids, or both. Damage can be result of any disorders that narrows, obstructs,
or injures blood vessels, thus impeding blood flow. Without intervention, damage may
progress to the point of tissue or organ death.

In PVD, blood vessels become narrowed and blood flow decreases. This can be due to
arteriosclerosis, or hardening of the arteries, or it can be caused by blood vessel
spasms. In arteriosclerosis, plaques build up in a vessel and limit the flow of blood and
oxygen to your organs and limbs. As plaque growth progresses, clots may develop and
completely block the artery. This can lead to organ damage and loss of fingers, toes, or
limbs, if left untreated.

PVD is also known as:

arteriosclerosis obliterans
arterial insufficiency of the legs
claudication
intermittent claudication

TYPES
Functional Peripheral Vascular Organic Peripheral Vascular Disease
Disease
Dont involve defects in blood Are caused by structural changes in
vessels structure. (The blood the blood vessels. Examples could
vessels arent physically damaged.) include inflammation and tissue
These diseases often have damage.
symptoms related to spasm that
may come and go.

TYPES
1. ATHEROSCLEROTIC PERIPHERAL Peripheral arterial occlusive
ARTERY DISEASE disease (PAOD) is a common
circulatory problem in which
narrowed arteries reduce blood
flow to the limbs.
Acute limb ischemia occurs when

2. BUERGER DISEASE
(THROMBOANGIITIS OBLITERANS)
3. VASOSPASTIC DISEASE OR RAYNAUD
SYNDROME
4. VENOUS INSUFFICIENCY DISEASE
5. DEEP VEIN THROMBOSIS
6. LYPMH EDEMA
there is a sudden lack of blood
flow to a limb. Acute limb
ischaemia is caused by
embolism or thrombosis, or rarely
by dissection or trauma.
Chronic limb ischemia (CLI) is a
severe obstruction of the arteries
which markedly reduces blood
flow to the extremities (hands,
feet and legs) and has progressed
to the point of severe pain and
even skin ulcers or sores. The
pain caused by CLI can wake up
an individual at night.
is a rare disease of the arteries and
veins in the arms and legs. In
Buerger's disease, the blood vessels
become inflamed, swell and can
become blocked with blood clots
(thrombi). This eventually damages
or destroys skin tissues and may
lead to infection and gangrene.
manifests as recurrent vasospasm of
the fingers and toes and usually
occurs in response to stress or cold
exposure
is a condition that occurs when
the venous wall and/or valves in the
leg veins are not working effectively,
making it difficult for blood to return
to the heart from the legs.
is a condition that occurs when
the venous wall and/or valves in the
leg veins are not working effectively,
making it difficult for blood to return
to the heart from the legs.
lymphoedema, or lymphatic
obstruction is a chronic (long-term)
condition in which excess fluid
(lymph) collects in tissues
causing edema (swelling).
Lymphedema can be very
debilitating. In short, lymphedema is
edema due to lymphatic fluid; a
blockage of the lymphatic system.
 II. Definition of terms

Raynauds disease
o a vasomotor disease of small arteries and arterioles that is most often
characterized by pallor and cyanosis of the fingers
Thrombosis
o The formation or presence of a blood clot in a blood vessel. The vessel
may be any vein or artery
Necrosis
o the death of most or all of the cells in an organ or tissue due to
disease, injury, or failure of the blood supply.
Embolism
o an obstruction in a blood vessel due to a blood clot or other foreign
matter that gets stuck while traveling through the bloodstream.
Atherosclerosis
o the most common form of arteriosclerosis, associated with damage to
the endothelial lining of the vessels and the formation of lipid deposits,
eventually leading to plaque formation.
Arteriosclerosis
o thickening, hardening, and loss of elasticity of arterial walls.
Thromboangiitis obliterans
o aka (Buergers disease)
o inflammation leads to arterial occlusion and tissue ischemia, especially
in young men who smoke.
Arterial Ulcer
o Arterial ulcers (see image below) are often located distally and on the
dorsum of the foot or toes

III. Epidemiology

Most common in older individuals and disproportionately affects black people.

PAOD develops earlier in men than in women, with the peak incidence during the 6 th
and 7th decades of age.
Asymptomatic peripheral arterial disease affects 17% of men and 20% of women 55
years old and greater.
Increases with age, with estimates of 1-2.5% of individuals aged 50-60 years having
PAOD, and increasing to 5-9% in those over 65 years.
Claudication is associated with a 10-year survival of 50%, which is reduced further
in persons who have critical limb ischemia
As the obesity rate increases, the rate of vascular ulcers also increases because of
the comorbidities that are associated with patients who are obese.
Venous ulcers are seen in 2.5% of patients admitted to long-term care facilities. This
rate is believed to be much higher than the overall population prevalence.
The majority present with occlusive disease in the femoral-popliteal vessels (80%),
and 40% demonstrate stenosis in the tibial-peroneal artery distribution. Nearly one-
third have disease in the aorta or iliac arteries
 In persons with PAOD, coronary artery disease is responsible for 63% of deaths,
while 9% occur secondary to cerebrovascular disease, and 8% are the result of
other cardiovascular events
very high in those elderly with diabetes compared with non-diabetic individuals of
the same age, diabetic persons with PAOD receive less intensive treatment than
those with coronary artery disease or cerebrovascular disease

IV. Anatomy, Physiology, Kinesiology of Muscles

In the microscopic world of circulation, blood and lymph vessels permeate most tissues,
carrying oxygen and nutrients while removing carbon dioxide and wastes. Not all vessels
involved are the large tubes so often associated with the circulatory system.
Capillaries are woven throughout most of the tissues of the body, around muscle
fibers, through connective tissues, and below the basement membrane of the epithelium.
Since arteries and veins are too large and too thick to allow diffusion between the
bloodstream and surrounding tissues, a delicate network of blood and lymph capillaries
controls all chemical and gaseous exchange between blood, interstitial fluid, and lymph.
In the normal system, homeostatic mechanisms adjust blood flow across the
capillary walls to meet the needs of peripheral tissues.

Vascular
ARTERIAL
Arteries carry rich, oxygenated blood away from the heart, branching off into
sections with smaller diameters called arterioles, leading ultimately to capillaries.
The walls of arteries are generally thicker than those of veins because they have to
bear strong blood flow pressures generated by the heart.
Arteries are strong and durable, able to keep their cylindrical shape when stretched.
The movement of blood through arteries is dependent on heart function.
Arteries have the ability to change in diameter when the volume of blood passing
through them changes.
They can also change in diameter when the sympathetic division of the autonomic
nervous system (ANS) is
triggered, either contracting
(vasoconstriction) or relaxing
(vasodilation).Because they have
contractile abilities, arteries do
not need valves to effect blood
flow.
Arteries have three-layered walls
that give them strength and
elasticity.

VENOUS
Veins return oxygen-depleted
blood from tissues and organs to
the heart.
At the beginning of the venous
system, superficial blood
capillaries empty into venules that carry blood toward medium-sized veins (about
the size of muscular arteries).
 Superficial veins run above the fascia of the muscles. Deep veins run below the
fascia. Perforating veins run between the superficial and the deep, penetrating the
fascia to connect the superficial and deep vessels.
Veins also have three-layered walls but they do not need to be as muscular or
elastic as arteries because the blood pressure in veins is lower than in arteries.
Venous walls are so thin that they do not hold their shape well under stress,
collapsing or tearing when stretched.
The blood pressure in the medium-sized veins is so low that it cannot oppose the
force of gravity without structural assistance.
In the limbs, medium-sized veins contain valves that project from the inner walls of
the veins, pointing in the direction of blood flow.
Under normal conditions, the valves allow blood to flow in one direction, preventing
backflow of blood.
When the valves are working normally, any movement that compresses or pulls on
a vein will help to push blood toward the heart.

STRUCTURE AND FUNCTION OF THE BLOOD VESSELS

 VESSEL STRUCTURE FUNCTION
ARTERY Three-layered wall with Transport of blood
thick tunica media, which away from the
gives it the property of heart, maintenance
contractility and of blood pressure
elasticity
ARTERIOLE Three-layered wall, with Transport of blood
S much thinner layer and away from the
smaller lumen than in heart, help control
arteries blood pressure by
regulation of
peripheral
resistance through
vasoconstriction
and vasodilation
CAPILLARY Microscopic size with This walls permit
single layer of the exchange of
endothelium materials between
the blood and
interstitial fluid
VENULE Three-layered wall, with Transport of blood
very thin layer, which from capillary beds
gradually enlarge as they toward the heart
near the heart
VEIN Three-layered wall, with Transport of blood
thinner tunica media and from venules toward
larger lumen than in the heart
arteries. Include internal
valves to aid the
unidirectional flow of the
blood toward the heart

ENDOTHELIAL CELLS
Endothelial cells form a continuous lining for the entire vascular system called the
endothelium.
The endothelium is made up of approximately 60,000 miles of squamous epithelium
that lines the various-sized vessels.
Endothelium is a versatile, multifunctional tissue that plays an active role in
controlling vascular function.
This semipermeable membrane controls the transfer of molecules across the
vascular wall and has an essential role in homeostasis.
The endothelium also plays a role in the control of platelet adhesion and blood
clotting, modulation of blood flow and vascular resistance, metabolism of hormones,
regulation of immune and inflammatory reactions, and elaboration of factors that
influence the growth of other cell types, particularly vascular SMCs.
Structurally intact endothelial cells respond to various abnormal stimuli by adjusting
their usual functions and by expressing newly acquired functions.

VASCULAR SMOOTH MUSCLE CELLS

Vascular SMCs, which form the predominant cellular layer in the tunica media,
produce vasoconstriction and/or dilation of blood vessels.
A network of vasomotor nerves of the sympathetic component of the autonomic
nervous system supplies the smooth muscle in the blood vessels.
 These nerves and circulating hormones are responsible for vasoconstriction of the
vessel walls.
Because they do not enter the tunica media of the blood vessel, the nerves do not
synapse directly on the SMCs. Instead, they release the neurotransmitter,
norepinephrine, which diffuses into the media and acts on the nearby SMCs.
The resulting impulses are propagated along the SMCs through their gap junctions,
causing contraction of the entire muscle cell layer and thus reducing the radius of
the vessel lumen. This in turn increases the systemic circulation.

ARTERIES OF THE UPPER LIMB

AXILLARY As it runs through the axilla accompanied by cords of the

ARTERY brachial plexus, each axillary artery gives off branches to the
axilla, chest wall, and shoulder girdle.

Includes:
Thoracoacromial artery - which supplies the deltoid
muscle and pectoral region
lateral thoracic artery - which serves the lateral chest wall
and breast
subscapular artery - to the scapula, dorsal thorax wall, and
part of the latissimus dorsi muscle
anterior and posterior circumflex humeral arteries -
which wrap around the humeral neck and help supply the
shoulder joint and the deltoid muscle.

BRACHIAL The brachial artery runs down the medial aspect of the
ARTERY humerus and supplies the anterior flexor muscles of the arm.

RADIAL The radial artery runs from the median line of the cubital
ARTERY fossa to the styloid process of the radius. It supplies the
lateral muscles of the forearm, the wrist, and the thumb and
index finger. At the root of the thumb, the radial artery
provides a convenient site for taking the radial pulse.

ULNAR ARTERY The ulnar artery supplies the medial aspect of the forearm,
fingers 35, and the medial aspect of the index finger.
Proximally, the ulnar artery gives off a short branch, the
common interosseous artery which runs between the
radius and ulna to serve the deep flexors and extensors of
the forearm.

PALMAR In the palm, branches of the radial and ulnar arteries

ARCHES anastomose to form the superficial and deep palmar
arches. The metacarpal arteries and digital arteries that
supply the fingers arise from these palmar arches.
 ARTERIES OF THE LOWER LIMB

INTERNAL These paired arteries run into the pelvis and distribute blood
ILIAC to the pelvic walls and viscera (bladder and rectum, plus the
ARTERIES uterus and vagina in the female and the prostate and ductus
deferens in the male).
Additionally they serve the gluteal muscles via the superior
and inferior gluteal arteries, adductor muscles of the
medial thigh via the obturator artery, and external
genitalia and perineum via the internal pudendal artery.

EXTERNAL These arteries supply the lower limbs

ILIAC As they course through the pelvis, they give off branches to
ARTEIRES the anterior abdominal wall. After passing under the inguinal
ligaments to enter the thigh, they become the femoral
arteries.
FEMORAL As each of these arteries passes down the anteromedial
ARTERIES thigh, it gives off several branches to the thigh muscles.
The largest of the deep branches is the deep artery of the
thigh (also called the deep femoral artery), which is the
main supply to the thigh muscles (hamstrings, quadriceps,
and adductors).
Proximal branches of the deep femoral artery, the lateral
and medial circumflex femoral arteries, encircle the neck
of the femur.

POPLITEAL This posterior vessel contributes to an arterial anastomosis

ARTERY that supplies the knee region and then splits into the anterior
and posterior tibial arteries of the leg.

ANTERIOR
TIBIAL ARTERY The anterior tibial artery runs through the anterior
compartment of the leg, supplying the extensor muscles
along the way. At the ankle, it becomes the dorsalis pedis
artery, which supplies the ankle and dorsum of the foot, and
gives off a branch, the arcuate artery, which issues the
dorsal metatarsal arteries to the metatarsus of the foot.
The superficial dorsalis pedis ends by penetrating into the
sole where it forms the medial part of the plantar arch.

This large artery courses through the posteromedial part of

POSTERIOR the leg and supplies the flexor muscles. Proximally, it gives
TIBIAL ARTERY off a large branch, the fibular (peroneal) artery, which
supplies the lateral fibularis muscles of the leg. On the
medial side of the foot, the posterior tibial artery divides into
lateral and medial plantar arteries that serve the plantar
surface of the foot. The lateral plantar artery forms the
lateral end of the plantar arch. Plantar metatarsal
arteries and digital arteries to the toes arise from the
plantar arch.
 VEINS OF THE BODY

SUPERIOR Vein carrying deoxygenated blood from the upper body (above the
VENA diaphragm) back to the right atrium.
CAVA
INFERIOR Vein carrying blood deoxygenated in the lower portion of the body
VENA (below the diaphragm) to the right atrium; it is the largest vein in the
CAVA organism.

INTERNAL Vein collecting blood from the encephalon and from one portion of the
JUGULAR face and neck; it is the largest vein in the neck.
VEIN
EXTERNAL Vein collecting blood from the arm and part of the neck and face; it
JUGULAR passes beneath the clavicle and receives the flow of the external
SUBCLAVIA jugular vein, among others.
N VEIN

AXILLARY Deep vein running through the hollow of the armpit and ending at the
VEIN subclavian vein; it receives the flow of the shoulder and thorax veins,
among others.

PULMONA Vein that returns blood to the heart after it has been oxygenated in
RY VEIN the lungs; unlike other veins, the pulmonary veins carry oxygen-rich
blood.

CEPHALIC Superficial vein of the outer arm emptying into the axillary vein; it
VEIN also receives blood from the superficial veins of the shoulder.
 BASILIC Large superficial vein of the inner surface of the arm; it connects to
VEIN the humeral vein in the armpit to form the axillary vein.

RENAL Large vein collecting blood from the kidney; it flows into the inferior
VEIN vena cava.

SUPERIOR Vein collecting blood from a section of the intestine (small intestine,
MESENTER right colon); it is one of the veins that flows into the portal vein.
IC VEIN

FEMORAL Vein collecting blood from the deep structures of the thighs and
VEIN receives blood from the great saphenous vein, among others.

GREAT Superficial vein collecting blood from the inner leg and thigh and
SAPHENOU receiving blood from certain veins of the foot; it is the longest vein in
S VEIN the body.

Blood Flow
 Fluids flow down pressure gradients from regions of higher pressures to
regions of lower pressures
Blood flows out of the heart when it contracts (region of highest pressure)
into the closed loop of blood vessels (region of lower pressure)
As blood moves through the cardiovascular system, a system of one way
valves in the heart and veins prevent the flow of blood reversing its direction
ensuring that blood flows in one direction only

Functions of the Cardiovascular System

The cardiovascular system has three major functions: transportation of materials,
protection from pathogens, and regulation of the bodys homeostasis.
Transportation:

The cardiovascular system transports blood to almost all of the bodys

tissues. The blood delivers essential nutrients and oxygen and removes
wastes and carbon dioxide to be processed or removed from the body.
Hormones are transported throughout the body via the bloods liquid plasma.

Protection:

The cardiovascular system protects the body through its white blood cells.
White blood cells clean up cellular debris and fight pathogens that have
entered the body. Platelets and red blood cells form scabs to seal wounds and
prevent pathogens from entering the body and liquids from leaking out. Blood
also carries antibodies that provide specific immunity to pathogens that the
body has previously been exposed to or has been vaccinated against.

Regulation:

The cardiovascular system is instrumental in the bodys ability to maintain

homeostatic control of several internal conditions. Blood vessels help
maintain a stable body temperature by controlling the blood flow to the
surface of the skin. Blood vessels near the skins surface open during times of
overheating to allow hot blood to dump its heat into the bodys surroundings.
In the case of hypothermia, these blood vessels constrict to keep blood
flowing only to vital organs in the bodys core. Blood also helps balance the
bodys pH due to the presence of bicarbonate ions, which act as a buffer
solution. Finally, the albumins in blood plasma help to balance the osmotic
concentration of the bodys cells by maintaining an isotonic environment.

Hemostasis
Hemostasis or the clotting of blood and formation of scabs, is managed by the
platelets of the blood. Platelets normally remain inactive in the blood until they reach
damaged tissue or leak out of the blood vessels through a wound. Once active, platelets
change into a spiny ball shape and become very sticky in order to latch on to damaged
tissues. Platelets next release chemical clotting factors and begin to produce the protein
fibrin to act as structure for the blood clot.
Platelets also begin sticking together to form a platelet plug. The platelet plug will
serve as a temporary seal to keep blood in the vessel and foreign material out of the
vessel until the cells of the blood vessel can repair the damage to the vessel wall.
Lymphatic System
The lymphatic system parallels the cardiovascular system. The lymphatic system is
unique, in that it is a 1-way system that returns lymph fluid via vessels to the
cardiovascular system for eventual elimination of toxic byproducts by end organs, such as
the kidney, liver, colon, skin, and lungs.
The lymphatic system is a network of tissues and organs that help rid the body of
toxins, waste and other unwanted materials. The primary function of the lymphatic system
is to transport lymph, a fluid containing infection-fighting white blood cells, throughout the
body. The lymphatic system primarily consists of lymphatic vessels, which are similar to
the circulatory system's veins and capillaries. The vessels are connected to lymph nodes,
where the lymph is filtered. The tonsils, adenoids, spleen and thymus are all part of the
lymphatic system.
The lymphatic systems main functions are as follows:
Restoration of excess interstitial fluid and proteins to the blood.

Absorption of fats and fat-soluble vitamins from the digestive system and transport
of these elements to the venous circulation.

Defense against invading organisms.

Organ Function
LYMPH Contains nutrients, oxygen, hormones, and fatty acids, as
well as toxins and cellular waste products, that are
transported to and from cellular tissues
LYMPHATIC Transport lymph from peripheral tissues to the veins of the
VESSELS cardiovascular system
LYMPH NODES Monitors the composition of lymph, the location of
pathogen engulfment and eradication, the immunologic
response, and the regulation site
SPLEEN Monitors the composition of blood components, the
location of pathogen engulfment and eradication, the
immunologic response, and the regulation site
THYMUS Serves as the site of T-lymphocyte maturation,
development, and control

Lymph
Lymph is a fluid derived from blood plasma. It is pushed out through the capillary
wall by pressure exerted by the heart or by osmotic pressure at the cellular level.
Lymph contains nutrients, oxygen, and hormones, as well as toxins and cellular
waste products generated by the cells. As the interstitial fluid accumulates, it is picked up
and removed by lymphatic vessels that pass through lymph nodes, which return the fluid
to the venous system. As the lymph passes through the lymph nodes, lymphocytes and
monocytes enter it.
Lymphatic vessels
Lymphatic capillaries are blind-ended tubes with thin
endothelial walls (only a single cell in thickness). They are arranged in an
overlapping pattern, so that pressure from the
surrounding capillary forces at these cells allows fluid to enter
the capillary.
The lymphatic capillaries coalesce to form larger
meshlike networks of tubes that are located deeper in
the body; these are known as lymphatic vessels.
Lymph nodes
Lymph nodes are bean-shaped structures that are widely distributed throughout the
lymphatic pathway, providing a filtration mechanism for the lymph before it rejoins the
blood stream.
The average human body contains approximately
600-700 of them, predominantly concentrated in the neck,
axillae, groin, thoracic mediastinum, and mesenteries of
the GI tract. Lymph nodes constitute a main line of
defense by hosting 2 types of immunoprotective cell lines,
T lymphocytes and B lymphocytes.
Thymus
The thymus is a bilobed lymphoid organ located in
the superior mediastinum of the thorax, posterior to the
sternum. After puberty, it begins to decrease in size; it is small and fatty in adults after
degeneration.
Spleen
The spleen, the largest lymphatic organ, is a convex lymphoid structure located
below the diaphragm and behind the stomach.
It is surrounded by a connective tissue capsule that extends inward to divide the
organ into lobules consisting of cells, small blood vessels, and 2 types of tissue known as
red and white pulp.
Tonsils
Tonsils are aggregates of lymph node tissue located under the epithelial lining of the
oral and pharyngeal areas. The main areas are the palatine tonsils (on the sides of the
oropharynx), the pharyngeal tonsils (on the roof of the nasopharynx; also known as
adenoids), and the lingual tonsils (on the base of the posterior surface of the tongue).
Diseases of the lymphatic system
1. Lymphedema
results when the lymphatic system cannot adequately drain lymph, resulting
in an accumulation of fluid that causes swelling. It may be either primary or
secondary.

Primary lymphedema
 o is an inherited condition that occurs as a result of impaired or missing
lymphatic vessels; it may be present at birth, may develop with the onset of
puberty, or may occur in adulthood, with no apparent causes
Secondary lymphedema
o is basically acquired regional lymphatic insufficiency, which may occur as a
consequence of any trauma, infection, or surgical procedure that disrupts the
lymphatic vessels or results in the loss of lymph nodes

2. Lymphoma

Lymphoma is a medical term used for a group of cancers that originate in the
lymphatic system. Lymphomas usually begin with malignant transformation
of the lymphocytes in lymph nodes or bunches of lymphatic tissue in organs
like the stomach or intestines. Hodgkin lymphoma and non-Hodgkin
lymphoma are the 2 major categories of lymphoma, characterized by
enlargement of lymph nodes, usually present in the neck

3. Lymphadenopathy

Lymphadenopathy is a lymphatic disorder in which the lymph nodes become

swollen or enlarged as a consequence of an infection. For example, swollen
lymph nodes in the neck may occur as a result of a throat infection or sinus
infection. [3]

4. Lymphadenitis

Lymphadenitis is an inflammation of the lymph node that is due to a bacterial

infection of the tissue in the node, which causes swelling, reddening, and
tenderness of the skin overlying the lymph node. [3]

5. Filariasis

Filariasis is a lymphatic system disorder that results from a parasitic infection

that causes lymphatic insufficiency.

6. Splenomegaly

Splenomegaly, or enlarged spleen, is a lymphatic system disorder that

develops as a result of a viral infection, such as mononucleosis.

7. Tonsillitis

Tonsillitis is caused by an infection of the tonsils (the lymphoid tissues

present in the back of the oral cavity). The tonsils help filter out bacteria;
when infected, they become swollen and inflamed, leading to sore throat,
fever, and difficulty and pain while swallowing.

INTEGUMENTARY SYSTEM
 is an organ system consisting of the skin, hair, nails, and exocrine glands. The skin
is only a few millimeters thick yet is by far the largest organ in the body. The average
persons skin weighs 10 pounds and has a surface area of almost 20 square feet. Skin
forms the bodys outer covering and forms a barrier to protect the body from chemicals,
disease, UV light, and physical damage. Hair and nails extend from the skin to reinforce
the skin and protect it from environmental.
Also referred to as an organ, the integumentary system is the most often seen and
touched by a physical therapist of all the body systems. The integumentary system has a
functional relationship to many other body systems.
The derivatives of the integument:
Hair:
functions include protection & sensing light touch.
Hair is composed of columns of dead, keratinized cells bound together by
extracellular proteins.
Hair has two main sections: The shaft- superficial portion that extends out of
the skin and the root- portion that penetrates into the dermis. Surrounding
the root of the hair is the hair follicle. At the base of the hair follicle is an
onion-shaped structure called the bulb Papilla of the hair and the matrix
within the bulb produce new hair.

Nails:

participate in the grasp & handling of small things.

Nails are plates of tightly packed, hard, keratinized epidermal cells.

The nail consists of:

nail root: the portion of the nail under the skin,
nail body: the visible pink portion of the nail, the white crescent at the base of
the nail is the lunula, the hyponychium secures the nail to the finger, the cuticle
or eponychium is a narrow band around the proximal edge of the nail and
free edge: the white end that may extend past the finger.

Glands:

participate in regulating body temperature.

There are three main types of glands associated with the integument:
Sebaceous - Oil glands. Located in the dermis, and secrete sebum.
Sudoriferous - Sweat glands.
Divided into two main types:

o Eccrine - Most common, main function is regulation of body temperature by

evaporation, and

o Apocrine - Responsible for cold sweat associated with stress.

Ceruminous Lie in subcutaneous tissue below the dermis, secrete cerumen (ear
wax) into ear canal or sebaceous glands.

Functions of the skin:

 Thermoregulation
o Evaporation of sweat & Regulation of blood flow to the dermis.
Cutaneous sensation - Sensations like touch, pressure, vibration, pain,
warmth or coolness.
Vitamin D production
o UV sunlight & precursor molecule in skin make vitamin D.
Protection
o The sin acts as a physical barrier.
Absorption & secretion
o The skin is involved in the absorption of water-soluble molecules and
excretion of water and sweat.
Wound healing
o When a minor burn or abrasion occurs basal cells of the epidermis break
away from the basement membrane and migrate across the wound. They
migrate as a sheet, when the sides meet the growth stops and this is called
contact inhibition.
In deep wound healing
o A clot forms in the wound, blood flow increases and many cells move to the
wound. The clot becomes a scab; granulation tissue fills the wound and
intense growth of epithelial cells beneath the scab. The scab falls off and the
skin returns to normal thickness.

Layers of Skin:

1. Epidermis
The Epidermis is the thinner more superficial layer of the skin.
The epidermis is made up of 4 cell types:
Keratinocytes
o Produce keratin protein a fibrous protein that helps protect the epidermis
Melanocytes
o produces the brown pigment melanin
Langerhan Cells
o participate in immune response and
Merkel cells
o Participates in the sense of touch.

There are five distinct sub-layers of the Epidermis:

1. Stratum corneum
- the outermost layer, made of 25-30 layers of dead flat keratinocytes.
Lamellar granules provide water repellent action and are continuously
shed & replaced.
2. Stratum lucidum
- Only found in the fingertips, palms of hands, & soles of feet. This layer is
made up of 3-5 layers of flat dead keratinocytes.
3. Stratum granulosum
- made up of 3-5 layers of keratinocytes, site of keratin formation,
keratohyalin gives the granular appearance.
4. Stratum spinosum
- appears covered in thorn like spikes, provide strength & flexibility to the
skin.
5. Stratum basale
 - The deepest layer, made up of a single layer of cuboidal or columnar cells.
Cells produced here are constantly divide & move up to apical surface.

2. Dermis:
-is the deeper, thicker layer composed of connective tissue, blood vessels, nerves,
glands and hair follicles.
The epidermis contains 3 cell types:

o Adipocytes,
o Macrophages and
o Fibroblasts.

There are two main divisions of the dermal layer:

o Papillary region - The superficial layer of the dermis, made up of loose

areolar connective tissue with elastic fibers.
o Dermal papillae - Fingerlike structures invade the epidermis, contain
capillaries or Meissner corpuscles which respond to touch.

Reticular region of the Dermis Made up of dense irregular connective &

adipose tissue, contains sweat lands, sebaceous (oil) glands, & blood vessels.

WOUND PHYSIOLOGY
Normal Wound Healing
In the human body, an elegant sequence of events takes place to ensure that
when injury occurs, wounds will heal. Within the endogenous fluids of the body, every
cell and chemical mediator is programmed and ready to act when needed. When
conditions are normal, the body is equipped to heal itself.
PHASES OF HEALING
1. Inflammation (Phase I)
The normal immune system reaction to injury.
The central activity in wound healing.
Temporary repair initiated by coagulation (clotting factors, platelets) and
short-term decreased blood flow.
Necrosis occurs after cells have been injured or destroyed.
The spread of pathogens is slowed: debris and bacteria are attacked by a
host of cells. If the wound is acute, some periwound edema, erythema, and
drainage can be expected. If fluid accumulates at the injury site it is called
pus.
Oxygen is delivered via increased blood flow to keep the phagocytic cells
alive and functioning.
Permanent repair is facilitated by creating a clean wound, setting the stage
for the next phase of healing; signals are generated that re-epithelialization
can begin.

Time frame: day of injury to approximately day 10.

Rate of inflammatory process is affected by the size of the wound, blood
supply, available nutrients, and the extrinsic environment.
 If this phase is interrupted or delayed, chronic inflammation can result,
lasting from months to years (see section titled Abnormal

2. Proliferation (Phase II)

New tissue fills in the wound as fibroblasts secrete collagen.
Skin integrity is restored by re-epithelialization and/or contraction (see
discussion below).
Angiogenesis occurs: new blood vessel growth from endothelial cells, fragile
capillary buds grow into the wound bed; new reddish, slightly bumpy tissue is
called granulation tissue.
Epithelial cells differentiate into type I collagen. Collagen synthesis occurs but
the resulting new scar tissue is fragile and must be protected; trauma during
this phase may return the wound to the inflammatory process.
Time frame: day 3 of injury to approximately day 20.
Rate of proliferation is affected by the size of the wound, blood supply,
available nutrients, and the extrinsic environment.
If this phase is interrupted or delayed, the result may be a chronic wound.

3. Maturation/remodeling (Phase III)

Maturation or remodeling of new tissue begins while granulation tissue is
forming during the prior (proliferative) phase.
Epithelial cells continue to differentiate into Type I collagen.
New skin has tensile strength that is 15% of normal. Scar tissue is rebuilding
but at best reaches 80% of original tensile strength.
Underlying granulation tissue is replaced by less vascular tissue.
In deep wounds, dermal appendages are rarely repaired (hair follicles,
sebaceous and sweat glands, nerves) but instead are replaced by fibrous
tissue.
Over time the scar tissue matures, changing from red to pink to white and
from raised and rigid to flat and flexible.
Time frame: approximately day 9 of injury up to 2 years.
Rate of maturation/remodeling is affected by the size of the wound, blood
supply, available nutrients, and the extrinsic environment.

The Role of Oxygen in Wound Healing

Clinical studies have shown that keeping patients warm and giving them
supplemental oxygen decreases the rate of infection and shortens hospital stay.
Improvement of oxygen levels in wound tissue alone may trigger wound healing.
Adequate oxygen levels will also enhance the effectiveness of growth factors and a
host of other cells that require oxygenation to maintain their function.
The delivery of exogenous oxygen will be discussed later in the chapter under the
section on Intervention. The nutritional status of the individual, as discussed below, will
also have an impact on oxygenation since hemoglobin, iron, vitamin B12, and folic acid
are needed to enable red blood cells to carry oxygen to healing tissues.
The Role of Moisture in Wound Healing
In the past, the goal of wound care was to create and maintain a dry wound, packed
with dry dressings, dried by heat lamps, and exposed to the air. Modern wound
management is based on the concept of creating and maintaining a moist wound
environment to facilitate wound healing.
 More than 50 years ago, research confirmed that a dry wound creates an
environment that is hostile to wound healing.
A dry wound allows the formation of wound scab and eschar, which inhibit migration
of epithelial cells, provide food for pathogens, and affect blood flow to the wound bed.
A dry wound also allows cooling of the wound surface; without a protective barrier, the
surface temperature of the wound is decreased and healing is slowed. Adhesion of
gauze or other dry dressings to the wound bed causes trauma to the wound bed and
pain to the individual upon removal. Bacteria enter a dry wound more readily because
of the lack of a protective barrier. As the wound dries, the rich
The Role of Nutrition in Wound Healing
It is well established that nutritional status can have a significant impact on wound
healing. Adequate protein intake is required for collagen synthesis, as well as the
formation of new blood vessels and muscle tissue. Literature abounds with information
about important nutritional issues such as the role of specific nutrients in wound
healing, how poor nutritional status can delay wound healing, the use of special
pharmacological interventions, and appropriate routes for nutritional support (enteral
versus parenteral. The nutritional status of special populations such as
children with special healthcare needs must be addressed by interdisciplinary
interaction. Pediatric patients in long-term care, recovering from surgery, or with
wounds, burns, or trauma are at risk for pressure ulcers. As with adults, adequate
protein intake is essential for healing to occur on time.
Nutrients that must be present for a wound to heal include iron, vitamin B12 and
folic acid (essential so that red blood cells can deliver oxygen to tissues), vitamin C and
zinc (essential for tissue repair), vitamin A (essential to stimulate collagen cross-
linking), and arginine (enhances healing and immune function).35,36 High protein
intake provides the amino acids required to build new tissue.
Protein and calorie needs will vary depending on the size of the wound and the
medical condition of the patient. What are yet to be established are guidelines about
energy levels, or nutrient needs required to heal a wound. In response to the available
information and the need for more research, nutrition and metabolic support of acutely
and chronically ill patients is emerging as an important branch of medicine methods
Wound Characteristics
The characteristics of wounds may be defined as dry, wet, or granulating. Wounds
can also be defined by their etiology, such as diabetic, vascular, or traumatic.
Wound characteristics can provide valuable information needed to make sound
clinical judgments about treatment
The following are characteristics that throughout the phases of wound
healing:
Location: where on the body
Size: depth, width, and length
Shape: irregular versus distinct
Edges: condition and shape of wound edges, evidence of premature healing
Tunneling, undermining, sinus tracts: presence and depth
Base: characteristics of the wound base compared to sides and edges
Necrosis, eschar, slough: amount, color, texture, adherence to wound bed
Exudate: amount, color, odor
 Granulation tissue: presence or absence, amount, location
Epithelialization: presence or absence, premature or on schedule
Exposed structures: color and condition of bone, tendon, ligament
Periwound area: edema, induration, maceration
Pain: although not a visible characteristic, it is measurable and significant to
the intervention
Quantity of bacteria: amount present in a wound. This is referred to as the
bio-burden.

Wound Closure Primary Intention

1. Healing by primary intention
- Occurs when a surgeon closes a wound by bringing the edges together.
Approximating the edges can occur through the use of sutures, staples,
glue, skin grafts, or skin flaps. Wounds closed by primary intention still
pass through the phases of wound healing but on a smaller scale. The
major mechanism for healing wounds by primary intention is connective
tissue deposition.
- A wound closed by primary intention that later opens up again owing to
maceration or infection has opened by the process of dehiscence.
Following dehiscence, a wound is almost always allowed to close by
secondary intention.

2. Secondary Intention Healing by secondary intention

- Occurs when a wound is left to heal on its own. The mechanisms of
healing by secondary intention are contraction, re-epithelialization, or a
combination of both. Deeper wounds heal by replacing injured tissue with
scar tissue as collagen fills the wound bed. During the process of
contraction, existing tissue migrates, pulling the wound edges toward the
center of the wound.
- This process forms no new tissue. New tissue may be forming in the
wound simultaneously but not via contraction. Contraction occurs when
growth factors trigger myofibroblasts to pull the wound edges inward.
- Growth factors and myofibroblasts can be influenced positively or
negatively by physiological factors such as the amount of oxygen and
nutrients available, and by mechanical factors such as external
compression and the shape of the wound. with new skin, re-
epithelialization stops by contact inhibition.

Factors affecting the rate and type of closure by secondary intention include the
following: Wound shape: linear wounds (surgical) contract most rapidly; circular
wounds (pressure ulcers) contract most slowly.
Wound depth: all things equal, the shallower the wound, the quicker the
closure.
Superficial (loss of the epidermis): closes by re-epithelialization.
Partial-thickness (loss of the epidermis and dermis): closes primarily by re-
epithelialization with minimal contraction.
Full-thickness (loss of all layers of the epidermis, dermis, and deeper
structures): closes by contraction and scar formation; however, epithelial
 cells will migrate from the wound edges to assist in wound closure if the
environment is homeostatic.
Wound location: areas with least pressure, most perfusion (face) will close
more rapidly than areas with most pressure, least perfusion (sacrum, heel).
Wound etiology: least traumatic (surgery) will close more rapidly than most
traumatic (pressure ulcer, burn).

3. Tertiary Intention
- Also called delayed primary, this type of closure occurs when a wound is
allowed to heal by secondary intention and then is closed by primary
intention as the final treatment. The delay in primary closure is usually
owing to the presence of infection.

V. Etiology

Functional Peripheral Vascular Organic Peripheral Vascular Disease

Disease
emotional stress smoking
cold temperatures high blood pressure
operating vibrating machinery or diabetes
tools high cholesterol
drugs

1. Arterial
Atherosclerosis:
- the most common form of arteriosclerosis, associated with damage to the
endothelial lining of the vessels and the formation of lipid deposits,
eventually leading to plaque formation.
a) Embolic Occlusion lodging of an embolus, which may be a blood clot, fat
globule, gas bubble or foreign material in the bloodstream. This can cause a
blockage in a blood vessel.
b) Idiopathic relating to or denoting any disease or condition that arises
spontaneously or for which the cause is unknown.
Abnormal Sympathetic Nervous System (Cause of Raynauds Syndrome)

2. Venous
a) Insufficient Venous Return is a condition in which the veins
have problems sending blood from the legs back to the heart.
b) Venous Damage injury of the vein that causes insufficient flow
of blood to the heart
c) Blood clot in Veins when a blood clot forms in the vein that
causes pain, swelling or weakness.
3. Lymphatic
a) Decrease Lymphatic Circulation there is a decrease in the
return of lymph fluid back, causing increase in volume and
produces edema
 Arterial Venous Lymphatic

Risk Factors: Risk Factors: Risk Factors:

Smoking Aging Congestive Heart
Diabetes Sedentary Failure
Mellitus Lifestyle Renal Failure
Hypertension Obesity Obesity
Hyperlipidemia Pregnancy
Cold, Vibration, Heredity
Stress Varicose Veins
Obesity

VI. Pathophysiology/Pathology/Mechanism of injury

Peripheral vascular disease (PVD), also known as arteriosclerosis obliterans, is primarily

the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to
proteins with a fibrous intravascular covering. The atherosclerotic process may gradually
progress to complete occlusion of medium and large arteries. The disease typically is
segmental, with significant variation from patient to patient. Vascular disease may
manifest acutely when thrombi, emboli, or acute trauma compromises perfusion.
Thromboses are often of an atheromatous nature and occur in the lower extremities
more frequently than in the upper extremities. Multiple factors predispose patients for
thrombosis. These factors include sepsis, hypotension, low cardiac output aneurysms,
aortic dissection, bypass grafts, and underlying atherosclerotic narrowing of the arterial
lumen. Emboli, the most common cause of sudden ischemia, usually are of cardiac origin
(80%); they also can originate from proximal atheroma, tumor, or foreign objects. Emboli
tend to lodge at artery bifurcations or in areas where vessels abruptly narrow. The femoral
artery bifurcation is the most common site (43%), followed by the iliac arteries (18%), the
aorta (15%), and the popliteal arteries (15%). The site of occlusion, presence of collateral
circulation, and nature of the occlusion (thrombus or embolus) determine the severity of
the acute manifestation. Emboli tend to carry higher morbidity because the extremity has
not had time to develop collateral circulation. Whether caused by embolus or thrombus,
occlusion results in both proximal and distal thrombus formation due to flow stagnation.

Venous:
High Pressure in the Vein

Low-flow states within the capillaries

Leukocyte Trapping
 Venous Obstruction Inefficient
or insufficient Backflow

Venous
Insufficiency

LYMPHATIC
 Lymphatic
Drainage
damage
(Decreased
Circulation)

Obstruction of
the Lymphatic
Drainage

Obstruction of
the Lymphatic
Drainage

interstitial
fluid
formation
exceeds the
rate of
lymphatic
return

Accumulation
of Protein-Lymphede
enriched ma
intrinsic fluid

Damage to
the Lymph
Nodes

Thickening of
Lymph Nodes
 ARTERIAL:

Fatty
VII. deposit
VII.
start Blood clot Occlusion or Necrosocclusion
arterial
VII.
streaking
VII.
the form around narrowing of of the blood flow
(vessels)
ulcer
blood
VII. vessel the plaque vessels
walls
VII.
VII.
VII. Decrease formation
blood supply tissue
VII.
Fatty
VII.
matter Production of of a
Decrease hypoxia
builds up
VII. platelets
oxygen thrombus
VII.
VII. supply
VII.
Formation of
Slightly
VII. blood flows
VII. a material
injured to with reduced
VII. vessel Plaque Ischemia
blood pressure
VII. (atheroscleros (complication)
walls
VII. is
VII.
VII.
Blood
VII. vessel Combination
attempts
VII. to of fats and
Necrosis Necrosis
VII.
heal itself (as other
VII. substances
normal
VII.
response)
VII.
VII. Other substances that
Release
VII. of floating through
Decrease
bloodstream start
chemicals
VII. that
make
sticking to the vessel oxygen Ischemia
VII. the wall walls
supply
stickier
VII. (Inflammatory cells,
protiens, and calcium)
VII.
Clinical Signs and Symptoms/ Physical Disabilities/ Impairments

Arterial Insufficiency and Ulceration

Clinical Presentation
o Wounds will most frequently be located on the LEs: lateral malleoli, dorsum of
feet, toes.
o When wounds are present on an ischemic limb, atherosclerotic occlusion of
the peripheral vasculature is almost always present.
o The majority of patients with arterial insufficiency also have diabetes.
o Trophic changes are present and include abnormal nail growth, decreased leg
and foot hair, and dry skin.
o Skin is cool on palpation.
o Wounds are painful and patient may also describe pain in the legs and/or feet
(see discussion below about intermittent claudication).
o Wound base is usually necrotic and pale, lacking granulation tissue.
o Skin around the wound may be black, mummified (dry gangrene).

Venous Insufficiency and Ulceration

 Clinical Presentation
o Swelling of unilateral or bilateral LEs relieved in the early stages by elevation
o Complaints of itching, fatigue, aching, heaviness in involved limb(s)
o Skin changes including hemosiderin staining and lipodermatosclerosis
o Fibrosis of the dermis
o Increase in skin temperature of lower legs
o Wounds:
Most frequently located on the LEs: proximal to the medial malleolus
although can occur anywhere (arterial wounds may also occur at this
location).
Not significantly painful; usually complaints of minor dull leg pain are
relieved with elevation. Granulation tissue is usually present in the
wound bed.
Tissue is wet from a typically large amount of draining exudate.
o Signs and symptoms of lymphedema may be present (it is common to see
the impact of chronic inflammation and fluid overload as triggers for the
onset of lymphedema).

Lymphedema

Clinical Presentation
o Swelling distal to or adjacent to the area where lymph system function has
been impaired
o Swelling usually not relieved by elevation
o Pitting edema in the early stages of disease, nonpitting edema in later
stages, as fibrotic changes occur Feelings of fatigue, heaviness, pressure, or
tightness in the affected region
o Numbness and tingling
o Discomfort varying from mild to intense
o Fibrotic changes of the dermis
o Dermal abnormalities such as cysts, fistulas, lymphorrhea, papillomas,
hyperkeratosis
o Increased susceptibility to infection, at first local to the affected region but
often becoming systemic
o Loss of mobility and ROM
o Impaired wound healing

Pressure Ulcers

Clinical Presentation
o The first clinical sign of pressure ulceration is blanchable erythema along
with increased skin temperature. If pressure is relieved, tissues may
recover in 24 hours. If pressure is unrelieved, nonblanchable erythema
occurs. Progression to a superficial abrasion, blister, or shallow crater
indicates involvement of the dermis.
o When full-thickness skin loss is apparent, the ulcer appears as a deep
crater. Bleeding is minimal, and tissues are indurated and warm. Eschar
formation marks full-thickness skin loss. Tunneling or undermining is often
present (the official staging classification for pressure ulcers will be
covered later in this chapter).
o The majority of all pressure ulcers develop over six primary bony areas
sacrum, coccyx, greater trochanter, ischial tuberosity, calcaneus (heel),
and lateral malleolus.
Neuropathy

Clinical Presentation
o Ulceration is usually located on the weight-bearing surfaces of the foot
o Usually anesthetic, round, over bony prominences but can be located
anywhere
o Sensory neuropathy, if present:
Patient unable to sense pain and pressure
Risk of skin breakdown without patient awareness
Mechanical, repetitive stresses are most common causative factors
of wounds
o Motor neuropathy, if present:
Loss of intrinsic muscles
Hammer-toe, claw-toe deformities adding to risk of breakdown
owing to poor weight distribution and rubbing from shoes
Foot drop
o Autonomic neuropathy, if present:
Decreased or absent sweat and oil production leading to dry,
inelastic skin
Increased susceptibility to skin breakdown and injury
Propensity for heavy callus formation

OTHER SYMPTOPMS:

1. Exertional pain
2. Noctumal pain
3. Ischemic rest pain
4. Claudication manifestation
5. Foot, calf, thigh, or buttock pain
6. Pain worse with exertion
7. Pain relief with several minutes rest
8. Pain relief with dependent position

OTHER SIGNS:

1. Decrease skin temperature

2. Shiny skin
3. Skin hairless over lower extremity
4. Dystrophy toenails
5. Distal extremity color change with position
6. Skin pallor when leg elevated
7. Skin rubor when leg dependent
8. Bilateral leg diminished pulses throughout
9. Slow wound healing in leg
10.Impotence

PHYSICAL DYSFUNCTION:
Pain experience ischemic pain (claudication) during physical activity as a result of a
mismatch between active muscle oxygen supply and demand.
Muscle Weakness loss of strength, muscle atrophy, and eventual loss of motor
function, particularly in the hands and feet occurs with progressive arterial vascular
disease
Integumentary Changes
 o Skin discoloration including pallor at rest or with exercise, or reactive
hyperemia can develop.
o Trophic Skin changes includes shiny, waxy, appearance and dryness of the
skin and loss of hair distal to the occlusion
o Skin Temperature is Decrease
o Ulceration may develop particularly at weight bearing areas or over bony
prominences
Deformity due to edema, there is now limitation of motion.