Chapter 4 Circulatory System Conditions: Introduction Function of circulatory system:
Delivery of O2, nutrients Removal of CO2, wastes Maintenance of temperature Blood clotting Protection from pathogens Maintenance of pH balance
Chapter 4 Circulatory System: Introduction, cont.
Red blood cells (erythrocytes)
• • • • • Turnover: 2 million/sec All identical 98% of all blood cells Life span is 4 months or less; processed out by spleen No nucleus; lots of hemoglobin
Iron-based 250 million molecules/ cell Carries O2
• Biconcave discs: flexible to get through tiny capillaries
Chapter 4 Circulatory System: Introduction, cont.
White blood cells (leukocytes) (Fig. 4.1)
• Translucent • Different classes for different functions • Fight antigens, pathogens
Platelets (thrombocytes)
• Cell fragments • Make clots at sites of damage, areas where blood does not flow freely
Spin web of fibers from clotting factors in plasma
• Clots are melted by anticoagulants from liver
Chapter 4 Circulatory System: Introduction, cont. The heart
Left and right halves, divided by septum (Fig. 4.2)
• Left pumps to body (systemic circuit) • Right pumps to lungs (pulmonary circuit)
Top and bottom halves, divided by valves
• Atrial contraction • Ventricular contraction
Chapter 4 Circulatory System: Introduction, cont.
Blood vessels (60,000 miles)
Arteries
• Carrying blood away from heart • Thick smooth muscle layer
Arterioles
• Tiny arteries
Capillaries
• Squamous cell epithelial tubes; turnover of nutrients/wastes happens here
Venules
• Tiny veins
Veins
• Carry blood toward the heart • One-way valves to assist flow
Anemia
Insufficient O2-carrying capacity
Not enough functional RBCs Not enough hemoglobin in RBCs
Usually a symptom of some other disorder
Anemia, cont.
Types of anemia:
Idiopathic (of unknown origin) Nutritional
• • • • Iron deficiency Folic acid deficiency B12 deficiency (can lead to pernicious anemia) Other nutritional deficiencies
Protein, copper…
Anemia, cont.
Types of anemia, cont.
Hemorrhagic
• Blood loss from ulcers, endometriosis, fibroids, trauma, etc
Hemolytic
• Premature destruction of RBCs
Sickle cell (Fig. 4.3) , allergic reaction, malaria
Aplastic
• Bone marrow is suppressed
Cancer, autoimmune disease, renal failure, radiation, poisoning
Anemia, cont.
Secondary anemias
• • • • • Ulcers Kidney disease Hepatitis Acute infection Leukemia, lymphoma
Signs and symptoms:
• • • • • Pallor Dyspnea Palpitations Fatigue Intolerance to cold
Anemia, cont.
Massage?
Depends on the underlying cause Massage temporarily boosts RBC count
• • • • Idiopathic may respond well Nutritional will not see any improvement Rule out contraindicating disorders Watch for heart problems in extreme cases
Embolism, Thrombus
Embolism: traveling clot Thrombus: lodged clot (Fig. 4.4) Clots occur wherever platelets find a rough surface inside a blood vessel, or wherever blood does not flow freely
Embolism, Thrombus, cont.
Pulmonary Embolism:
Destination for any clots that form on the venous side of the systemic circuit (Fig. 4.5)
• 600,000/year, 60,000 deaths
Risk factors:
• DVT, Pregnancy, bed rest, surgery (especially for hip fracture), cardiovascular disease, birth control pills…
Signs and symptoms:
• Often silent until damage has occurred; then dyspnea, chest pain, coughing
Treatment:
• Anticoagulants, vacuum clots out of lung
Embolism, Thrombus, cont.
Arterial embolism:
Can land anywhere except the lungs: starts in arteries of systemic circuit, travels until vessels are too small to let it pass
• Usually a complication of atherosclerosis • Can be related to infection, valve damage, atrial fibrillation • Embolus can be clot, bone fragment, cluster of cells, air bubble…
Signs and symptoms:
• Kidney damage, stroke, heart attack, depending on destination
Treatment:
• Anticoagulants
Embolism, Thrombus, cont.
Massage?
Any emboli or thrombi systemically contraindicate massage Clients taking anticoagulants may bruise easily Work with health care team for clients in recovery
Hematoma
Bleeding between sheets of fascia
Smaller bruising is ecchymosis
Signs and symptoms:
Discoloration on skin for superficial bruises Pain, heat, gelid mass in large muscles for hematomas (subdural hematoma is a type of stroke, Chapter 3)
Hematoma, cont.
Treatment:
Small bruises: hydrotherapy, if anything Larger bleeds:
• Aspiration if possible • Gentle movement to stimulate “clean up” cells • May complicate to myositis ossificans
Massage?
Locally avoid the area when acute and painful Later, work around edges within pain tolerance to stimulate reabsorption, more efficient healing
Leukemia
Cancer in bone marrow, affected WBC production
Two types of stem cells manufacture WBCs in bone marrow:
Myeloid Lymphocytic
Leukemia is genetic mutation in the production of these WBCs
Leukemia, cont.
Four main types (out of many)
Acute myelogenous leukemia (AML)
• Rapidly progressive, may be related to environmental factors
Chronic myelogenous leukemia (CML)
• Slow-growing, nonfunctioning WBCs interrupt immune system function, but do not disable it entirely
Acute lymphocytic leukemia (ALL)
• Rapidly progressive, affects young children more than other types; immune system function is disabled
Chronic lymphocytic leukemia (CLL)
• Slow-growing, mostly of B-cells; can be stable, best prognosis
Leukemia, cont.
Signs and symptoms (all related to bone marrow suppression)
Fatigue, low stamina, anemia (low RBCs) Bruising, bleeding (low platelets) Poor resistance to infection (low WBCs) Others:
• Night sweats, splenomegaly, weight loss, etc
Leukemia, cont.
Treatment:
Chemotherapy
• Need to identify which cells are mutated • Side effects exacerbate leukemia symptoms
Radiation, surgery Bone marrow transplant
Massage?
Be cautious of side effects of chemotherapy Work to improve sleep, eating, tolerance for treatment Work with health care team
Thrombophlebitis, Deep Vein Thrombosis
Inflammation of a vein, due to clot(s)
Usually in calves, thigh, pelvis Deep vs. superficial veins
Incidence:
250,000–2 million diagnoses/ year Complicates to pulmonary embolism in approximately 30% of cases
Thrombophlebitis, Deep Vein Thrombosis, cont.
Causes:
Physical trauma (kick, fall) Varicose veins (relatively low risk) Local infection Reduced circulation • Obstruction such as tight socks or knee brace • Prolonged immobility Pregnancy Blood diseases Surgery High-estrogen birth control pills Others: smoking, cardiovascular disease, paralysis…
Thrombophlebitis, Deep Vein Thrombosis, cont. Signs and symptoms:
Can show major signs of inflammation Can lead to signs on the skin from poor circulation DVT often silent
• Asymmetric temperature, texture in legs • Pitting edema: red flag! (Fig. 4.6)
Thrombophlebitis, Deep Vein Thrombosis, cont.
Diagnosis:
Ultrasound (fast, can be inaccurate) Venography (slow, can damage tissue)
Treatment:
Anticoagulants, support hose, vena cava filter
Massage?
Contraindicated because of risk of pulmonary embolism Can be extremely difficult to determine!
• “I have a deep ache in my calf– and by the way, I’m 7 months pregnant…”
Aneurysm
Bulge in wall of aorta (or heart)
Incidence:
Mostly men, >55 years 15,000 deaths/year Incidence has tripled in last 40 years
Aneurysm, cont.
Arteries lose elasticity, may bulge with chronic high pressure Usually at aorta or cerebral arteries
Can also occur at left ventricle
Causes:
• • • • Smoking Congenital weakness Inflammation Trauma
Aneurysm, cont.
Types of aneurysm (Fig. 4.7):
• • • • Saccular Fusiform Dissecting Berry (mostly in brain) (Fig. 4.8)
Signs and symptoms:
May not be painful May press on nearby tissue
• Headache (cerebral) • Hoarseness (thoracic) • Low back pain! (abdominal)
Aortic aneurysms usually occur with other cardiovascular diseases: get a thorough history!
Aneurysm, cont.
Treatment:
Surgical repair before a rupture
Massage?
If a client is diagnosed with a stable aortic aneurysm, bodywork should be noncirculatory! Survivors of aneurysm treatment may be good candidates;
• Compare to activities of daily living • Consult with health care team
Atherosclerosis
Subtype of arteriosclerosis (“hardening of the arteries”);
Damage to arteries from the accumulation and infiltration of plaques (Fig. 4.9) Coronary artery disease (CAD) is atherosclerosis, specifically of coronary artery (Fig. 4.10)
Incidence:
Very high in the United States; often completely silent
Atherosclerosis, cont.
Etiology, theory 1:
Endothelial damage occurs from chronic hypertension, smoking, carbon monoxide, other factors Monocytes arrive to clean up debris; move in and become fixed macrophages Macrophages take up LDL, become “foam cells” Foam cells infiltrate smooth muscle layer, cause proliferation: plaques Platelets arrive at sites of damage
• Release growth factor (more proliferation) • Form clots • Cause vascular spasm
Atherosclerosis, cont.
Etiology, theory 2:
LDL is deposited in subendothelial spaces
• • • • Oxidizes, becomes permanent Monocytes are attracted, become foam cells Plaques form Rough areas attract platelets, clots form, etc.
Atherosclerosis, cont.
Nonmodifiable risk factors:
Heredity, genetics Gender Age Kidney disorders C-reactive protein (sign of long-term inflammation)
Atherosclerosis, cont.
Modifiable risk factors:
Smoking High cholesterol Uncontrolled hypertension Sedentary lifestyle Obesity Uncontrolled diabetes
Others:
Stress, depression
Atherosclerosis, cont.
Signs and symptoms:
NONE, until 75%–80% occlusion Poor delivery of O2 to heart leads to fatigue, poor stamina, shortness of breath
Complications (circular relationship with causes):
Hypertension Aneurysm Arrhythmia Angina pectoris Thrombus, embolism
• Heart attack, stroke
Atherosclerosis, cont.
Diagnosis:
Angiogram, CT scan
Treatment:
Changing exercise, eating to reduce cholesterol, reverse plaques as much as possible Medication to reduce cholesterol Smooth muscle relaxants, aspirin (anticoagulant) Surgery:
• Bypass surgery • Balloon angioplasty • Catheter atherectomy
Atherosclerosis, cont.
Massage?
Base decision on resilience of client
• Compare to activities of daily living:
“Does your doctor recommend that you get aerobic exercise?” (This indicates that it is safe to elevate heart rate)
• If client takes medications, adjust bodywork to accommodate
Hypertension
High blood pressure
Incidence:
1:4 adults 1:2 adults over 60 Men > women till age 65, then men = women African Americans > other races
Hypertension, cont.
Chronic high pressure in arteries damages tunica intima, opens the door to atherosclerosis, other forms of cardiovascular disease (see animation)
Essential hypertension (not due to other pathologic condition) Secondary hypertension (side effect of other problem; clears up when problem is resolved)
Hypertension, cont.
Blood pressure readings:
(average of 2+ readings taken at different appointments)
Category Optimal Systolic <120 Diastolic <80
Pre-hypertension
Hypertension
120–139 140–159
160+
80–89 90–99
100+
Stage 1
Stage 2
Hypertension, cont.
Signs and symptoms: “The silent killer”
• Shortness of breath after mild exercise; headache, swollen ankles, excessive sweating, anxiety
Complications:
Edema Atherosclerosis Stroke Heart failure Aneurysm Kidney disease Vision problems
Hypertension, cont.
Treatment:
Dietary Approaches to Stop Hypertension (DASH diet): as effective as many drugs; no side effects Exercise, weight loss Medication (can have unpleasant side effects)
• Diuretics • Vasodilators • Beta-blockers
Fewer than 1/3 people successfully manages hypertension
Hypertension, cont.
Massage?
If managed with diet and exercise, massage is probably safe and appropriate If managed with medication, may require some accommodations Avoid deep abdominal work (vaso-vagus reaction) Watch for signs of circulatory overload (bogginess, edema after session)
Raynaud’s Syndrome
Vasoconstriction in extremities Incidence
Primary Raynaud’s is mostly in women 14–40 years of age Secondary Raynaud’s linked to autoimmune disorders, also mostly women 5%–10% of general population? (Estimates vary)
Raynaud’s Syndrome, cont.
Primary: Raynaud’s disease
Unconnected to underlying pathologic condition, slow onset Stress, cold, mechanical irritation leads to extreme vasoconstriction in hands, feet (sometimes tongue, ears)
Secondary: Raynaud’s phenomenon
Connected to other pathologic condition, fast onset, more severe
• Arterial diseases (diabetes, atherosclerosis) • Connective tissue diseases (scleroderma, lupus, rheumatoid arthritis) • Reaction to drugs • Neurovascular compression (carpal tunnel syndrome)
Raynaud’s Syndrome, cont.
Signs and symptoms:
Usually bilateral Skin turns white/gray, then blue, then red as blood returns (Fig. 4.12) 1 minute–several hours Cell death may occur
Raynaud’s Syndrome, cont.
Treatment:
Depends on whether it is primary or secondary
• Noninvasive: quitting smoking; hydrotherapy, changing work habits (frozen foods, percussive movements); biofeedback, etc. • Medical: vasodilators, norepinephrine antagonists
Massage?
Primary is safer than secondary
• Get information on underlying pathologic conditions
Watch for tissue damage Can improve local circulation and improve sympathetic/parasympathetic balance
Varicose Veins
Distended superficial veins with valve damage
• Mostly legs • Also at esophagus, anus, scrotum
Incidence:
1:10 people Mostly women Mostly after age 50
Varicose Veins, cont.
Causes:
Wear and tear, gravity Mechanical obstruction
• Too-tight knee socks, brace, pregnancy
Congenitally weak veins
Superficial veins more vulnerable
Not surrounded by supporting muscle
• Greater and lesser saphenous
Varicose Veins, cont.
Signs and symptoms:
Lumpy, bluish, off-track distensions on legs (Figs. 4.13, 4.14) May be itchy or painful
Complications:
Skin irritation, eczema Night cramps Possible blood clots
Varicose Veins, cont.
Treatment:
Support hose, avoid standing for long periods, exercise and stretch leg muscles, elevate legs Surgery:
• Vein stripping, mini-stripping • Sclerosing chemicals • Lasers
Massage?
Local caution: damaged tissue close to surface Use broad, flat hands (light effleurage) “Spider veins” (telangiectasias) are safe
Heart Attack
Damage to cardiac muscle from ischemia: blocked coronary artery
Also called MI, myocardial infarction (Fig. 4.15)
Incidence:
#1 cause of death in the United States: 500,000/year (1:5) 13 million heart attack/angina survivors alive in the United States 25% heart attack patients have no history of cardiovascular disease
Heart Attack, cont.
Etiology:
Fragment of debris (clot or plaque) travels along coronary artery until it gets stuck; ischemia kills off part of myocardium (infarct)
• Or, coronary artery goes into prolonged spasm, seen with drug reactions
Newer plaques are more dangerous; less stable Infarct leads to inefficient contractions, possible fibrillations
• Ventricular fibrillations often deadly
Heart Attack, cont.
Signs and symptoms:
Pressure, pain in chest Spreading pain (left shoulder, jaw, arm) Nausea, sweating, dizziness Angina pectoris: “chest pain”
• Can be stable or unstable; risk predictor
Sometimes:
• Shortness of breath, anxiety, weakness, abdominal pain
Heart Attack, cont.
Complications:
Atrial fibrillations Embolism (clots form inside heart during fibrillations, can travel to brain, lung, elsewhere) Aneurysm of ventricles Heart failure Circulatory shock
Heart Attack, cont.
Treatment:
Identify location of blockage, remove ASAP
• Thrombolytics • Angioplasty, if possible • Pacemaker, if necessary
Observation Lifestyle changes to support healthier heart
Massage?
Depends on resilience, activities of daily living of the heart attack survivor Consult with health care team if necessary
Heart Failure
Progressive loss of cardiac function
Incidence:
5 million currently; 400,000 diagnoses/year Expected to rise to 15–20 million within 5 years
• Better survival of other cardiovascular diseases
Heart Failure, cont.
Long-term work of pushing blood through resistant arteries leads to structural changes in myocardium (see animation)
Becomes bigger (not stronger) Beats faster (not more efficiently) Finally wears out, cannot keep up with needs
Causes:
Underlying cardiovascular disease
• History of atherosclerosis, multiple heart attacks, etc. • Valve damage, infection, congenital problems
Heart Failure, cont.
Signs and symptoms (types of heart failure):
Left-sided heart failure (Fig. 4.16)
• Related to atherosclerosis, etc. • Left ventricle cannot pump well against resistance in systemic circuit; fluid backs up into lungs, leading to pulmonary edema, shortness of breath, cough, risk of pneumonia
Right-sided heart failure (Fig. 4.17)
• Related to emphysema, lung problems • Right ventricle cannot pump well against resistance in pulmonary circuit; fluid backs up into body, pooling in legs • High risk of kidney failure
Biventricular heart failure
• Both simultaneously
Heart Failure, cont.
Treatment:
Early: rest, change in diet, modify physical activity to not overload heart Medications: beta-blockers, digitalis, diuretics, vasodilators Surgery:
• Repair valves, cardiomyoplasty, transplant
Massage?
Circulatory massage probably not appropriate Noncirculatory work is usually safe and welcome Work with health care team
Hemophilia
Genetic disorder: absence of plasma proteins for formation of blood clots Incidence:
Approximately 18,000 men in the United States X-linked anomaly: passed by mothers to sons
Hemophilia, cont.
When a clot forms, 12 proteins from liver work together to weave a net
Hemophilia A (80% of all cases): lack of clotting factor VIII Hemophilia B (15%): lack of clotting factor IX
• Also called “Christmas Disease”
Other types: quite rare, missing other clotting factors
Mild, moderate, severe: depending on how much factor is present; severe = <1% normal (this is 60% of patients)
Hemophilia, cont.
Signs and symptoms:
Appears in childhood
• Bleed longer than normal • Excessive bruising • Intramuscular hematomas, nosebleeds, hematuria, joint pain
Complications:
Bleeding into joints can lead to arthritis Infected blood products
Hemophilia, cont.
Treatment:
Used to be transfusions of whole blood Now self-administered doses of specific clotting factors
Massage?
Severe hemophilia contraindicates rigorous, mechanical, circulatory massage Other techniques are safe, welcome, and appropriate