Exercise therapy and physiotherapy

Disorders of mobility and motion are common in patients with vascular anomalies, especially when localized to the extremities. In the long term, however, restrictions in the functionality of the musculoskeletal system are often not caused by the disease of the vascular anomaly itself but by secondary, acquired phenomena such as excessively long immobilization or excessively aggressive invasive or surgical therapy attempts.

The primary joint problems or musculoskeletal problems associated with vascular malformations can and must be treated at an early stage in an interdisciplinary manner with the involvement of appropriate orthopedic expertise. This is possible and successful in most cases.

Pain that is often untreated or inadequately treated, with secondary, pain-related immobility for far too long, are causes of permanent functional limitations. Long-term immobility leads to shortening of tendons and muscles, shortening of capsuloligamentary structures around joints and reduction of bone mass and stability. Sometimes this is hardly amenable to conservative therapy.

Other secondary causes of musculoskeletal dysfunction are often inadequate, sometimes clearly too radical, incorrectly applied or performed invasive surgical therapies, in particular open partial resection operations that are mostly unnecessary or not correctly performed.
Often the affected extremity is also excessively underused without pain or symptoms for fear of “breaking something” or, for example, triggering a bleed. In most cases, this fear is not justified in patients with vascular anomalies.

This false tendency to overprotect and not use the affected limb is often reinforced by the well-intentioned advice of doctors or medical staff who, in cases of doubt (relevant experience is sometimes not available for these rare diseases), recommend excessive protection “for safety's sake”. Not only is this  not evidence-based, but it is simply wrong.

Sufficient exercise is indicated for most patients with vascular anomalies.

Consistent movement and also constant use of affected body regions, in practice mostly the legs or arms, is helpful in many ways:

• Prevention of loss of function, immobility atrophy and ultimately contractures.
• Reduction of tissue pressure and reduction of edema by removal of interstitial edema fluid via the muscle pump.
• “Pumping” of venous malformation areas by exercise reduces LIC and small blood clots, thus also reducing the occurrence of painful thrombophlebitis.
• The patient’s self-esteem increases with the possibility of leading a normal life

The application of exercise therapy, which is still a young discipline with relatively few scientifically proven publications, is in principle a very effective treatment method from the expert's point of view for the reasons mentioned above.
It usually consists of an initial history-taking and examination phase, during which therapists will familiarize themselves with a patient’s specific disease pattern.

In a subsequent instruction phase, the patient is instructed in specific movement therapy patterns and elements as well as in self-applied exercises.

Intensive physiotherapeutic treatment is particularly important and valuable for faster recovery and also for maintaining musculoskeletal functions, especially after lengthy acute phases of illness or after major invasive procedures (whether interventional or open surgery).

Contraindications for exercise are merely an open wound, existing tissue ischemia or acute bacterial inflammation (erysipelas).

There is little risk of relevant, major bleeding in patients with slow-flow malformations (venous or lymphatic malformations) because these dysplastic vessels are not under pressure. In these patients, any bleeding (e.g., from a direct open injury) can easily be stopped by simple external compression. A relevant risk of bleeding only exists in patients with fast-flow malformations (e.g., arteriovenous malformations) and co-existing open wounds or ulcerations or in the case of an open injury.

In this situation professional well-managed physiotherapy not only helps to prevent further damage, but also gives the patient confidence and helps to prevent incorrect movement and relieving postures from being practiced.

In view of the rather rare clinical picture of vascular anomalies, it certainly makes sense to establish a close relationship and coordinated communication between the patient, therapist and attending specialists.