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Buergers disease by dr .ravinder narwal

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  • I was diagnosed with Beurgers Disease 20th May 2013, I immediately stopped smoking, and I received an artery bypass in my left leg, I had gangerene in my foot and grow in toenails with all my toes, I avoided an amputation because I quit smoking, I'm exercising with a Cross Fit trainer and already gained use of my foot again, my toe nails are recovering and new ones are growing, I'm so happy I quit smoking, just regret the fact I almost had to loose a leg before stopping, I'm 29 white female live in Namibia, South West Africa. It can happen to anyone, stop smoking NOW!!!
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Buergers disease by dr .ravinder narwal

  2. 2. PERIPHERAL ARTERIAL DISEASE <ul><li>ANY CONDITION THAT CAUSES PARTIAL OR COMPLETE OBSTRUCTION OF THE FLOW OF BLOOD IN ARTERIES. </li></ul><ul><li>Infective :- </li></ul><ul><li>syphilitic </li></ul><ul><li>Non -syphilitic </li></ul><ul><li>Tuberculous </li></ul><ul><li>Non –infective :- </li></ul><ul><li>Collagen vascular disease </li></ul><ul><li>Wegner’s syndrome </li></ul><ul><li>Kwasaki syndrome </li></ul><ul><li>Buerger disease [ TAO ] </li></ul><ul><li>Raynauds disease </li></ul><ul><li>Takayasaku syndrome </li></ul>
  3. 3. BUERGERS DISEASE <ul><li>It is an inflammatory occlusive vascular disorder involving small and medium sized arteries and veins in the distal upper and lower extremities. </li></ul><ul><li>Cerebral , visceral and coronary vessels may also be affected. </li></ul><ul><li>Buergers disease was first reported by Felix von winiwarter in 1879 in Austria. </li></ul>
  4. 4. EPIDEMIOLOGY <ul><li>Buergers disease is more common in men than womens 3:1. </li></ul><ul><li>Most patients with buergers disease are aged 20 -45yrs. </li></ul><ul><li>It is more common in Israel , Japan , and India .The disease is most common on among south asian. </li></ul><ul><li>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. </li></ul>
  5. 5. ETIOLOGY <ul><li>Mechanism of TAO remains unknown . Several possible causes have been propose. </li></ul><ul><li>Tobacco use. </li></ul><ul><li>Inherited factors </li></ul><ul><li>Immune response </li></ul>
  6. 6. PREDISPOSING FACTORS <ul><li>Smoking [99.9 % ] </li></ul><ul><li>Hypertension </li></ul><ul><li>Diabetes </li></ul><ul><li>hyperlipidemia </li></ul>
  7. 11. Healthy Lungs <ul><li>You can see how the lung looks without the effects of inhalation of smoke. </li></ul><ul><li>Note black specks throughout indicative of carbon deposits from pollution. </li></ul>
  8. 12. Lung after smoking <ul><li>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. </li></ul>
  9. 13. PATHOLOGY <ul><li>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. </li></ul><ul><li>LATER- intra luminal inflammatory infiltrate changes </li></ul><ul><li>from predominantly polymorphonuclear to lymphocytic with occasionnal eosinophils. </li></ul><ul><li>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. </li></ul>
  10. 14. CLINICAL FEATURES <ul><li>Pain and weakness in leg and feet or arms and hands. </li></ul><ul><li>Swelling in feet and hands. </li></ul><ul><li>Fingers and toes that turn pale when exposed to cold . </li></ul><ul><li>Open sores on fingers and toes. </li></ul><ul><li>skin changes or ulcers on hands or feet. </li></ul><ul><li>The pain typically begins in the extremities , but may radiate to more central parts of the body. </li></ul><ul><li>Presence of distal extremity ischemia [ indicated by claudication ,pain at rest , ischemic ulcers or gangrene ] </li></ul><ul><li>Paresthesias [ numbness, tingling, burning ] of the hands and feet . </li></ul>
  11. 16. DIAGNOSIS <ul><li>BLOOD TEST- can help to rule out scleroderma ,lupus ,blood clotting disorder and diabetes . </li></ul><ul><li>ANKLE BRACHIAL INDEX- index=ankle/brachial…..normal value >1 </li></ul><ul><li>PHOTO PHLE THESMOGRAPHY </li></ul><ul><li>LEG ELEVATION TEST </li></ul><ul><li>RUBBER DEPENDENCY TEST </li></ul><ul><li>ALLENS TEST </li></ul>
  12. 17. MEDICAL MANAGEMENT <ul><li>FOR TREATMENT OF SMOKING – </li></ul><ul><li>First line :- 5 A’S </li></ul><ul><li>A – ask </li></ul><ul><li>A –advice </li></ul><ul><li>A – asses </li></ul><ul><li>A – assist </li></ul><ul><li>A – arrange </li></ul><ul><li>2. Second line :- </li></ul><ul><li>ANTI – NICOTINE REPLACEMENT DRUG :- </li></ul><ul><li>Nasal spray of nicotine – 8 to 40 doses/ day </li></ul><ul><li>Bupropion- 150mg </li></ul><ul><li>Nasal lotion of nicotine. </li></ul>
  13. 18. <ul><li>NICOTINIE ACID DERIVATIE :- </li></ul><ul><li>Insitol nicotinate :- 1g ,3-4 times daily orally </li></ul><ul><li>Nicotinyl alcohol :- 25 -50mg ,4 times daily orally </li></ul><ul><li>3. Third line :- </li></ul><ul><li>Clonidine :- 0.15 -0.75mg/day </li></ul><ul><li>Refer to amputation. </li></ul>
  14. 19. <ul><li>Anti-platelat drug:- </li></ul><ul><li>Asprin – 75 to 325mg/day orally </li></ul><ul><li>Clopidrogrel -75mg/day orally </li></ul><ul><li>Ticlopidine – 500mg/day orally </li></ul><ul><li>Vasodilator drug :- </li></ul><ul><li>Cilastozol :- 100mg BD </li></ul><ul><li>Ca++ antagonist :- </li></ul><ul><li>Nifedipine :-10mg 3times daily orally. </li></ul><ul><li>Antihistamine :- </li></ul><ul><li>Cinnarizine – 75mg 3 times daily orally. </li></ul><ul><li>Vitamin E - 300 to 600 mg daily orally. </li></ul>
  15. 20. Surgical management <ul><li>Sympathectomy </li></ul><ul><li>Enarteratomy </li></ul><ul><li>Amputaion </li></ul><ul><li>PTCA </li></ul><ul><li>PABG </li></ul>
  16. 21. Complication of burgers disease <ul><li>Embolisation </li></ul><ul><li>Gangrene </li></ul><ul><li>Ulcer formation </li></ul><ul><li>Amputation </li></ul><ul><li>Muscle weakness atrophy </li></ul><ul><li>Sensory and motor impairment. </li></ul>
  17. 22. <ul><li>REHABLITATION </li></ul>
  18. 23. TEAM <ul><li>Medical director. </li></ul><ul><li>Medical co –director. </li></ul><ul><li>Cardio surgeon. </li></ul><ul><li>Cardiologist. </li></ul><ul><li>Cardio vascular pulmonary physiotherapist. </li></ul><ul><li>Physiotherapist. </li></ul><ul><li>Occupational therapist. </li></ul><ul><li>Psychologist. </li></ul><ul><li>Nurses. </li></ul>
  19. 24. PATIENTS PROBLEMS <ul><li>Stress ,anexity. </li></ul><ul><li>Education about the exercise ,protocol. </li></ul><ul><li>Psychological problem. </li></ul>
  20. 25. AIMS AND GOALS <ul><li>To improve patients physical condition ,mobility,functional condition. </li></ul><ul><li>Prevention of complication. </li></ul><ul><li>Prevention of sensory / motor impairment. </li></ul><ul><li>Prevention of skin. </li></ul><ul><li>Prevention of amputation </li></ul><ul><li>Prevention of risk factor [ smoking,diabetes,hyperlipidemia ] </li></ul>
  21. 26. PATIENT EDUCATION <ul><li>Stop smoking and amputation will be avoided. </li></ul><ul><li>Bedridden patients should be educated about the importance of protective heel pads or foam boot. </li></ul>
  22. 27. STAGES <ul><li>STAGE – 1 :-- [ 1 to 4 wks ] </li></ul><ul><li>SKIN CARE –use powder b/w the toes . </li></ul><ul><li>Wash gently every day. </li></ul><ul><li>To increase air circulation through the toes,cotton may be used b/w toes. </li></ul><ul><li>Ulcer treatment – . positioning . proper shoe fitting . proper gait training </li></ul><ul><li>MOTOR WEAKNESS :- [1 TO 4WKS ] </li></ul><ul><li>Isometric exercise – quard. And hams. </li></ul><ul><li>AROM : Ankle pumps,heel slides,heel and toe raises in sitting with 15 to 20 reps,3 sets,2-3 times daily. </li></ul>
  23. 28. <ul><li>Endurance excercises /aerobic ex. </li></ul><ul><li>Make pt. to walk ½ miles . </li></ul><ul><li>GANGRENE :- </li></ul><ul><li>Laser </li></ul><ul><li>Uv –rays </li></ul><ul><li>IRR </li></ul><ul><li>Proper care of skin </li></ul><ul><li>TO INCREASE CIRCULATION :- </li></ul><ul><li>Iontophoresis </li></ul><ul><li>Heat modalities </li></ul><ul><li>NEW MODALITIES – to increase peripheral circulation. </li></ul><ul><li>Vasotron </li></ul><ul><li>Curator </li></ul><ul><li>Artiassist </li></ul><ul><li>Ectera </li></ul>
  24. 29. BUERGER’S EXERCISES <ul><li>Pt. in supine position ,legs elevated to 45 degree. </li></ul><ul><li>Observe time taken for blanching +2 min . </li></ul><ul><li>Made to sit in high sitting position + 3 min.[ hyperemia ] </li></ul><ul><li>Pt. is made to lying supine for 3 – 5 min. </li></ul><ul><li>This sequence is repeated 4 – 5 times / session , for 3 sessions a day. </li></ul>
  25. 30. Effects and uses <ul><li>Improvement in collateral circulation. </li></ul><ul><li>Better utilization of oxygen by muscle tissue. </li></ul><ul><li>Walking tech. improves. </li></ul><ul><li>Psychological confidence of the pt. can lead to increase in work performance. </li></ul>
  26. 31. Stage – 2 [ wks ] <ul><li>Isometric +strengthening ex. </li></ul><ul><li>Pt. is made to walk ½ - 1 miles. </li></ul><ul><li>Buergers ex. </li></ul><ul><li>STAGE :- 3 [ >8 wks ] </li></ul><ul><li>Pt. made to walk >1 miles </li></ul><ul><li>Cardiopulmonary endurance ex. [ tread mill , bicycle ] </li></ul><ul><li>Prevention of TAO. </li></ul><ul><li>Buergers disease ex. </li></ul>
  27. 32. PREVENTION <ul><li>Smoking cessation –avoidance of 2 nd hand smoke & use of tobacco products. </li></ul><ul><li>Dietary modification – </li></ul><ul><li>Reduced fat , cholesterol , sweets . </li></ul><ul><li>Increased amounts of fruits & veg. </li></ul><ul><li>Wt. reduction – maintains a healthy wt. </li></ul><ul><li>Moderation in alcohol intake. </li></ul><ul><li>Physical activity [brisk walking ] </li></ul><ul><li>Ex. plan of minimum 30 min daily. </li></ul>
  28. 33. REHABLITATION OF AMPUTATIONS <ul><li>PRE – OPERATIVE PERIOD </li></ul><ul><li>Physical assessment of Pt. : -- </li></ul><ul><li>Check MMT. </li></ul><ul><li>Joint mobility. </li></ul><ul><li>Cardio resp. function. </li></ul><ul><li>Functional abilities. </li></ul><ul><li>Ex. Management :-- </li></ul><ul><li>Strengtheing ex. </li></ul><ul><li>Mobilization. </li></ul><ul><li>Bed mobility [ bridging ,rolling ] </li></ul><ul><li>Transfers from bed to chair & back. </li></ul><ul><li>Stabilization for the trunk in sitting & standing. </li></ul>
  29. 34. POST – OPERATIVE PERIOD <ul><li>Aims of treatment :-- </li></ul><ul><li>To prevent complication [ deformities , oedema , phantom pain ] </li></ul><ul><li>To maintain :-- </li></ul><ul><li>Strength of whole body & muscles controlling the stump. </li></ul><ul><li>Mobility. </li></ul><ul><li>Balance & transfers </li></ul><ul><li>To re –educate walking. </li></ul><ul><li>To restore functional independence. </li></ul>
  30. 35. <ul><li>THANK YOU </li></ul>