CASE REPORT
Asse ssm e nt a nd physica l t he r a py t r e a t m e nt for pe r iphe r a l a r t e r y occlusive
dise a se of t he uppe r lim b: a ca se st udy
D a nie lle Apa r e cida Gom e s Pe r e ir aI; M a r ce lle Xa vie r Cust ódioI; Joã o Pa u lo Fe r r e ir a de Ca r va lhoI; Andr é M a u r ício Bor ge s de Ca r va lh oI I; I ná cio Te ix e ir a da Cunha- FilhoI I I IPhysical therapist, Centro Universit€rio de Belo Horizonte (UNI-BH), Belo Horizonte, MG, Brazil. IIAngiologist, UNI-BH, Belo Horizonte, MG, Brazil.
IIIPhD. Physical therapist, UNI-BH, Belo Horizonte, MG, Brazil.
Correspondence
J Vasc Bras. 2008;7(1):72-5.
ABSTRACT
The aim of this paper was to present a case study proposing a protocol for assessment and rehabilitation of a patient with upper limb intermittent claudication. Case description: 50-year-old woman with obstruction of the left brachial artery secondary to catheterization performed 4 months ago. Monophasic sound was observed during continuous Doppler ultrasound assessment of both the radial and ulnar arteries. During the arm crank test, ischemic pain started at 2 minutes and 30 seconds of cranking, while maximal pain was reached at 9 minutes and 26 seconds. The patient was treated by arm cranking exercises performed three times a week for 8 weeks. After the treatment, arm crank time increased: ischemic pain onset was at 5 minutes and 7 seconds and maximal pain was reached at 18 minutes. The patient reported disappearance of cyanosis and improvement in performance of daily activities. The assessment protocol comprehended both subjective (validated Brazilian Portuguese version of SF-36 questionnaire) and objective (arm crank) measurements and was well tolerated, besides being able to detect changes in the patient’s functional capacity.
Changes detected at pain onset and at maximal pain may have occurred spontaneously, but it cannot be ruled out that this intervention can be potentially beneficial for individuals with upper limb claudication. The results observed in this case study warrant further studies involving larger sample size.
Ke yw or ds: Arterial occlusive disease, physical therapy, upper limb.
O obj et ivo dest e art igo é apresent ar um est udo de caso em que se propõe um prot ocolo de avaliação e int ervenção para um a pacient e com claudicação de m em bro superior. Descrição do caso: m ulher de 50 anos com 4 m eses de evolução de quadro de obst rução de art éria braquial esquerda pós- cat et erism o. Na avaliação com Doppler cont ínuo, observou- se presença de som m onofásico em art érias radial e ulnar. No t est e do cicloergôm et ro, a dor isquêm ica iniciou aos 2 m inut os e 30 segundos e at ingiu o pont o m áxim o aos 9 m inut os e 26 segundos. Foi realizado t rat am ent o em cicloergôm et ro t rês vezes por sem ana durant e 8 sem anas. Após o t rat am ent o, o t em po de t est e em cicloergôm et ro aum ent ou: dor inicial aos 5 m inut os e 7 segundos e m áxim a aos 18 m inut os. A pacient e relat ou desaparecim ent o da cianose e m elhora na realização de at ividades de vida diária. O prot ocolo de avaliação propost o envolvendo m edidas obj et ivas ( cicloergôm et ro) e subj et ivas ( quest ionário SF- 36 t raduzido e validado em port uguês) foi bem t olerado, t endo sido capaz de det ect ar alt erações no est ado funcional da pacient e. As alt erações det ect adas no t em po de surgim ent o de dor inicial e de dor m áxim a podem t er acont ecido de m odo espont âneo, m as não se pode descart ar que a int ervenção possa, pot encialm ent e, ser benéfica para indivíduos com
claudicação de m em bros superiores. Os result ados observados nest e est udo de caso avalizam fut uros est udos envolvendo m aior núm ero de part icipant es.
Pa la vr a s- cha ve : Art eriopat ia oclusiva, fisiot erapia, m em bros superiores.
I nt r oduct ion
Peripheral occlusive art erial disease ( POAD) is charact erized by im proper lim b perfusion, usually due t o at herosclerot ic process.1 The m ain signs and sym pt om s are pain, reduct ion in cut aneous
t em perat ure, absence or reduct ion in affect ed lim b pulses, cyanosis, hypoperfusion, ulcerat ions and int erm it t ent claudicat ion, t he lat t er being t he m ost frequent ly observed in lower lim bs.1 I n t he upper
lim bs, t he claudicat ing sym pt om m ay occur especially when t he act ivit y is perform ed wit h elevat ed arm s.2 - 4 POAD in t he upper lim bs has lower incidence and is m ore frequent ly associat ed wit h
iat rogenesis secondary t o cat het erizat ion.2 , 3
Form s of t reat m ent for POAD are surgical int ervent ion, drug t herapy and physical t herapy rehabilit at ion program as alt ernat ives for reduct ion in claudicat ing sym pt om s, im provem ent in funct ional capacit y, prevent ion of vascular occlusion progression and cardiovascular com plicat ions.5
However, t here are no specific prot ocols for t he funct ional assessm ent of upper lim b claudicat ion, not even specific prot ocols for rehabilit at ion of t hese pat ient s, probably due t o low
incidence/ prevalence of upper lim b claudicat ion. Despit e presence of claudicat ion and funct ional lim it at ion observed in t hat condit ion, assessm ent and t reat m ent prot ocols have not been
syst em at ized. Therefore, t his art icle aim s at present ing a case st udy t hat proposes an assessm ent and int ervent ion prot ocol for a pat ient wit h upper lim b claudicat ion.
Ca se de scr ipt ion
A 51- year - old fem ale pat ient wit h POAD in t he left upper lim b, secondary t o brachial art ery obst ruct ion aft er cat het erizat ion had developed t his condit ion 4 m ont hs ago, when t he
cat het erizat ion was perform ed, wit h progressive worsening of sym pt om s, culm inat ing in work leave due t o t he claudicat ing sym pt om t hat im posed funct ional rest rict ions on her.
classificat ion adapt ed for upper lim bs: occurrence of ischem ic pain during physical effort4) ,
parest hesia and loss of left upper lim b st rengt h. The pat ient was hypert ensive, cont rolled by drug t herapy, and had hist ory of coagulat ion disorder. She was using Diovan® ( 80 m g) qd, Angipress® ( 25 m g) qd and acet ylsalicylic acid ( 500 m g) qd.
On physical exam inat ion, her left upper lim b was cyanot ic, t here was low cut aneous t em perat ure and absence of radial pulse on palpat ion. On ult rasound evaluat ion ( cont inuous Doppler) , t here was presence of m onophasic flow in t he radial and ulnar art eries.
Te st s
- Cycle e r gom e t e r of t he uppe r lim bs ( CEUL) .Test of progressive effort st art ed wit h a 15- wat t load, wit h 5- wat t increm ent s at every 3 m inut es unt il reaching 12 m inut es, and 10 wat t s aft er 12 m inut es unt il reaching m axim al ischem ic pain. Tim e of pain onset and t im e during which t he pat ient was able t o m aint ain act ivit y were recorded. Aft er t he t est , t he t im e needed t o st op pain in t he left upper lim b was recorded and classified as recovery t im e.6
- Qua lit y of life e va lu a t ion . The SF- 36 quest ionnaire was used in it s t ranslat ed version int o
Port uguese and validat ed by Ciconelli et al.7 The SF- 36 is a generic, m ult idim ensional inst rum ent t o
evaluat e qualit y of life, com posed of 36 it em s evaluat ing eight dom ains: funct ional capacit y, physical aspect , pain, general healt h st at us, vit alit y, social and em ot ional aspect s and m ent al healt h. I t has a score ranging from 0 t o 100, 0 being t he worst general healt h st at us and 100 being t he best st at us.7
This case st udy is in accordance wit h Resolut ion 196, published on 10/ 10/ 96 by t he Nat ional Healt h Counsel. All t est s were applied before and aft er int ervent ion wit h t he pat ient 's inform ed consent . Physical t herapy t reat m ent had frequency of t hree t im es a week and last ed for 8 weeks, consist ing of an out pat ient program wit h m uscle st ret ching of t he scaphoid waist , brachial biceps and wrist flexors, and condit ioning in CEUL unt il reaching m axim al pain. The t raining st art ed wit h 15 wat t s, gradually progressing t o 35 wat t s. The pat ient had t o com plet e 20 m inut es of t raining in t he bicycle, independent of rest ing periods. A hom e program was also perform ed, in which t he pat ient should insist in her daily act ivit ies unt il reaching m axim al pain. Only t hen t he pat ient should int errupt any act ivit y, t hus relieving t he sym pt om . As soon as t he pain allowed, t he act ivit y should be resum ed.
Re sult s
There were no differences bet ween hem odynam ic variables obt ained by CEUL in t est s before and aft er t he t reat m ent . However, final load increased from 30 t o 50 wat t s, represent ing a 66%
D iscussion
This st udy aim ed at present ing an assessm ent and t reat m ent prot ocol for upper lim b claudicat ion. Bot h t he assessm ent process and t reat m ent proposed proved t o be feasible and well t olerat ed by t he pat ient . The assessm ent prot ocol was able t o det ect funct ional and qualit y of life changes during t he period in which t he pat ient was under t reat m ent .
There were no subst ant ial changes in hem odynam ic variables, since use of bet a- blocker leads t o at t enuat ed response of frequency and blood pressure. Proport ion of im provem ent observed in t he CEUL t est was clinically relevant . Perhaps t his can be explained by t ask specificit y, i.e., by sim ilarit y bet ween how condit ioning was perform ed in t he t reat m ent and how t he t est was perform ed.
The pat ient also report ed absence of pain during daily act ivit ies. However, such change in percept ion was not t ot ally det ect ed by t he SF- 36, since t he score for pain reached 62% , and not 100% . This suggest s t hat SF- 36 underst anding m ay not be sat isfact ory t o assess pat ient s wit h POAD, even if t he t est had been validat ed for t he Brazilian populat ion.7
com pensat ion for ischem ic dam age. Nevert heless, t his pat ient showed progressive worsening of clinical and funct ional st at us over a 4- m ont h period from obst ruct ion onset t o her referral for physical t herapy. The pat ient could not perform her usual daily act ivit ies due t o t he ischem ic
sym pt om , and t hus, sim ilarly t o t he t reat m ent used for lower lim b ischem ic sym pt om result ing from at herosclerot ic obst ruct ion, an int ervent ion t hrough scheduled physical act ivit y was proposed.
The pat ient was subm it t ed t o a supervised regim en of physical exercises, using an int ensit y t hat allowed reaching t he t hreshold for claudicat ing pain. The int ervent ion was m aint ained for 8 weeks, wit h frequency of t hree t im es a week. I n addit ion, t he pat ient was inst ruct ed t o perform her daily act ivit ies, despit e occurrence of sym pt om s. I n case of claudicat ing sym pt om during household chores, t he pat ient was inst ruct ed t o int errupt t hem unt il pain relief, and t hen resum ing her act ivit ies. This procedure is sim ilar t o t hat proposed during supervised exercises. Therefore, alt hough im provem ent in clinical and funct ional st at us of pat ient s wit h iat rogenic lesion of t he art erial bed m ore frequent ly occurs spont aneously, t he possibilit y t hat our proposal has cont ribut ed t o sym pt om m it igat ion and t o im provem ent in funct ional capacit y cannot be ruled out . However, it is necessary t o perform furt her st udies, including a cont rol group and a higher num ber of part icipant s t o det erm ine efficacy of proposed int ervent ion, since t he prot ocol dem onst rat es sensit ivit y for funct ional changes, whet her spont aneous or not .
Conclusion
The proposed assessm ent prot ocol, involving obj ect ive ( cycle ergom et er) and subj ect ive ( SF- 36) m easurem ent s, was well t olerat ed and able t o det ect changes in t he pat ient 's funct ional st at us. I t is possible t hat t he changes det ect ed by t he proposed prot ocol have occurred spont aneously.
Nevert heless, we should not rule out t hat t he int ervent ion m ight pot ent ially cont ribut e t o sym pt om m it igat ion and rest orat ion of funct ional capacit y. The result s found in t his case st udy warrant fut ure st udies including a higher num ber of part icipant s.
Re fe r e nce s
1. Maffei FHA, Last ória S, Yoshida WB, Rollo HA. Diagnóst ico clínico das doenças art eriais periféricas. I n: Maffei FHA, Last ória S, Yoshida WB, Rollo HA, edit ors. Doenças vasculares periféricas. Rio de Janeiro: Medsi, 2002. p. 287- 304.
2. Gornik HL, Beckm an JA. Peripheral art erial disease. Circulat ion. 2005; 111: e169- 72.
3. Nakano L, Wolosker N, Rosoki RA, Net t o BM, Puech- Leão P. Obj ect ive evaluat ion of upper lim b claudicat ion: use of isokinet ic dynam om et ry. Clinics. 2006; 61: 189- 96.
4. Guirov K, St oyanov K, Topalov I . New m et hod and device for assessm ent of funct ional capacit y of upper ext rem it y wit h chronic ischem ia. I nt Angiol. 1997; 16: 245- 9.
5. Schm ieder F, Com erot a AJ. I nt erm it t ent claudicat ion: m agnit ude of t he problem , pat ient evaluat ion, and t herapeut ic st rat egies. Am J Cardiol. 2001; 87: 3D- 13D.
6. Out ras condições clínicas que influenciam a prescrição do exercício. I n: Am erican College of Sport s Medicine. Diret rizes do ACSM para t est es de esforço e sua prescrição. Rio de Janeiro: Guanabara Koogan; 2000. p. 136- 42.
validação do quest ionário genérico de avaliação de qualidade de vida SF- 36 ( Brasil SF- 36). Rev Bras Reum at ol. 1999; 39: 143- 50.
Cor r e sponde nce :
Danielle Aparecida Gom es Pereira
Rua João Gualbert o Filho, 1260/ 604, Bairro Sagrada Fam ília CEP 31035- 570 - Belo Horizont e, MG
Tel.: ( 31) 3309.9137, ( 31) 9103.7415 Em ail: [email protected] .br
This st udy was present ed as post er at Congresso de Angiologia e Cirurgia Vascular, in Juiz de Fora ( MG, Brazil) , in June 2004.
