BUERGER’S DISEASEOR

THROMBOANGITIS OBLITERANS [TAO]

PRESENTED BY:

Dr. RAVINDER NARWAL

MPT- CARDIOLULMONARY

MPT- ORTHO

HIHT UNIVERSITY

PERIPHERAL ARTERIAL DISEASE

ANY CONDITION THAT CAUSES PARTIAL OR COMPLETE OBSTRUCTION OF THE FLOW OF BLOOD IN ARTERIES.

Infective :- syphilitic Non -syphilitic Tuberculous2. Non –infective :- Collagen vascular disease Wegner’s syndrome Kwasaki syndrome Buerger disease [ TAO ] Raynauds disease Takayasaku syndrome

BUERGERS DISEASE

It is an inflammatory occlusive vascular disorder involving small and medium sized arteries and veins in the distal upper and lower extremities.

Cerebral , visceral and coronary vessels may also be affected.

Buergers disease was first reported by Felix von winiwarter in 1879 in Austria.

EPIDEMIOLOGY

Buergers disease is more common in men than womens 3:1.

Most patients with buergers disease are aged 20 -45yrs.

It is more common in Israel , Japan , and India.The disease is most common on among south asian.

Death from buergers disease is rare , but in patients with the disease who continue to smoke ,43% require 1 or more amputation in 7.6year.

ETIOLOGY

Mechanism of TAO remains unknown. Several possible causes have been propose.

1. Tobacco use.

2. Inherited factors

3. Immune response

PREDISPOSING FACTORS

1. Smoking [99.9 % ]

2. Hypertension

3. Diabetes

4. hyperlipidemia

Smoking – To Die For!

This Powerpoint is hosted on www.worldofteaching.comPlease visit for 1000+ free powerpoints

Smoking – To Die For!

This Powerpoint is hosted on www.worldofteaching.comPlease visit for 1000+ free powerpoints

Healthy Lungs

You can see how the lung looks without the effects of inhalation of smoke.

Note black specks throughout indicative of carbon deposits from pollution.

Lung after smoking

Smokers lung with cancer.  White area on top is the cancer, this is what killed the person.  The blackened area is just the deposit of tars that all smokers paint into their lungs with every puff they take.

PATHOLOGY

Inflammatory changes occur in the arteries and veins , involving small and medium sized vessels by a necrotising panarteritis associated with prominent intra luminal thrombosis characterised by an intensive inflammatory cell infilterate consisting of neutrophils ,gaint cells and occasionally granulomas.

LATER- intra luminal inflammatory infiltrate changes from predominantly polymorphonuclear to

lymphocytic with occasionnal eosinophils. FINALLY- In the chronic stage, reconalisation of the

thrombus occurs, and the pathological changes than it produce are proliferation of endothelial cells , infilteration of intimal layer with lymphocytes , thickening of internal and external elastic tissue and the lumen may be occluded by the thrombus.

CLINICAL FEATURES

Pain and weakness in leg and feet or arms and hands. Swelling in feet and hands. Fingers and toes that turn pale when exposed to cold. Open sores on fingers and toes. skin changes or ulcers on hands or feet. The pain typically begins in the extremities , but may radiate to

more central parts of the body. Presence of distal extremity ischemia [ indicated by

claudication ,pain at rest , ischemic ulcers or gangrene ] Paresthesias [ numbness, tingling, burning ] of the hands and

feet .

DIAGNOSIS

BLOOD TEST- can help to rule out scleroderma ,lupus ,blood clotting disorder and diabetes .

ANKLE BRACHIAL INDEX- index=ankle/brachial…..normal value >1

PHOTO PHLE THESMOGRAPHY LEG ELEVATION TEST RUBBER DEPENDENCY TEST ALLENS TEST

MEDICAL MANAGEMENT

FOR TREATMENT OF SMOKING –1. First line :- 5 A’S A – ask A –advice A – asses A – assist A – arrange2. Second line :- ANTI – NICOTINE REPLACEMENT DRUG :- Nasal spray of nicotine – 8 to 40 doses/ day Bupropion- 150mg Nasal lotion of nicotine.

NICOTINIE ACID DERIVATIE :-

Insitol nicotinate :- 1g ,3-4 times daily orally

Nicotinyl alcohol :- 25 -50mg ,4 times daily orally

3. Third line :- Clonidine :- 0.15 -0.75mg/day Refer to amputation.

Anti-platelat drug:- Asprin – 75 to 325mg/day orally Clopidrogrel -75mg/day orally Ticlopidine – 500mg/day orally Vasodilator drug :- Cilastozol :- 100mg BD Ca++ antagonist :- Nifedipine :-10mg 3times daily orally. Antihistamine :- Cinnarizine – 75mg 3 times daily orally. Vitamin E -300 to 600 mg daily orally.

Surgical management

Sympathectomy Enarteratomy Amputaion PTCA PABG

Complication of burgers disease

Embolisation Gangrene Ulcer formation Amputation Muscle weakness atrophy Sensory and motor impairment.

REHABLITATION

TEAM

Medical director. Medical co –director. Cardio surgeon. Cardiologist. Cardio vascular pulmonary physiotherapist. Physiotherapist. Occupational therapist. Psychologist. Nurses.

PATIENTS PROBLEMS

Stress ,anexity. Education about the exercise ,protocol. Psychological problem.

AIMS AND GOALS

To improve patients physical condition ,mobility,functional condition.

Prevention of complication. Prevention of sensory / motor impairment. Prevention of skin. Prevention of amputation Prevention of risk factor

[ smoking,diabetes,hyperlipidemia ]

PATIENT EDUCATION

Stop smoking and amputation will be avoided.

Bedridden patients should be educated about the importance of protective heel pads or foam boot.

STAGES

STAGE – 1 :-- [ 1 to 4 wks ] SKIN CARE –use powder b/w the toes . Wash gently every day. To increase air circulation through the toes,cotton may be used

b/w toes. Ulcer treatment – . positioning

. proper shoe fitting . proper gait training

MOTOR WEAKNESS :- [1 TO 4WKS ] Isometric exercise – quard. And hams. AROM : Ankle pumps,heel slides,heel and toe raises in sitting

with 15 to 20 reps,3 sets,2-3 times daily.

Endurance excercises /aerobic ex.Make pt. to walk ½ miles .GANGRENE :- Laser Uv –rays IRR Proper care of skinTO INCREASE CIRCULATION :- Iontophoresis Heat modalitiesNEW MODALITIES – to increase peripheral circulation. Vasotron Curator Artiassist Ectera

BUERGER’S EXERCISES

Pt. in supine position ,legs elevated to 45 degree.

Observe time taken for blanching +2 min. Made to sit in high sitting position + 3 min.

[ hyperemia ] Pt. is made to lying supine for 3 – 5 min. This sequence is repeated 4 – 5 times /

session , for 3 sessions a day.

Effects and uses

1. Improvement in collateral circulation.

2. Better utilization of oxygen by muscle tissue.

3. Walking tech. improves.

4. Psychological confidence of the pt. can lead to increase in work performance.

Stage – 2 [ wks ]

Isometric +strengthening ex. Pt. is made to walk ½ - 1 miles. Buergers ex.

STAGE :- 3 [ >8 wks ] Pt. made to walk >1 miles Cardiopulmonary endurance ex. [ tread mill ,

bicycle ] Prevention of TAO. Buergers disease ex.

PREVENTION

1. Smoking cessation –avoidance of 2nd hand smoke & use of tobacco products.

2. Dietary modification – Reduced fat , cholesterol , sweets . Increased amounts of fruits & veg.3. Wt. reduction – maintains a healthy wt.4. Moderation in alcohol intake.5. Physical activity [brisk walking ]6. Ex. plan of minimum 30 min daily.

REHABLITATION OF AMPUTATIONS

PRE – OPERATIVE PERIOD Physical assessment of Pt. : --1. Check MMT.2. Joint mobility.3. Cardio resp. function.4. Functional abilities. Ex. Management :--1. Strengtheing ex.2. Mobilization.3. Bed mobility [ bridging ,rolling ]4. Transfers from bed to chair & back.5. Stabilization for the trunk in sitting & standing.

POST – OPERATIVE PERIOD

1. Aims of treatment :-- To prevent complication [ deformities , oedema ,

phantom pain ]2. To maintain :-- Strength of whole body & muscles controlling the

stump. Mobility. Balance & transfers To re –educate walking. To restore functional independence.

THANK YOU