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Characterized by a rapid constriction of the arterial blood vessels to the extremities and usually triggered by cold temperatures or stress, Raynaud disease can result in a spectrum of painful — even dangerous — symptoms. Those who have it experience a trigger-induced onset of cold hands or feet, pain, and in rare and severe forms, ulceration of the fingers.

While experts say clinicians have yet to find a cure for RD, PTs and others play an important role in educating patients about how to reduce attack frequency and severity.

Raynaud Times Two

There are two types of the disease: Raynaud disease (primary Raynaud) and Raynaud phenomenon (secondary Raynaud).

“Primary [RD] is having the vasomotor changes only; secondary [Raynaud phenomenon] is when Raynaud is associated with other conditions, such as rheumatoid arthritis and Sjogren’s syndrome,” says Peter Dorsher, MS, MD, consultant in physical medicine and rehabilitation at Mayo Clinic in Jacksonville, Fla.

More common among women and most likely to occur in adults between ages 20 and 40, the incidence of primary RD in the U.S. is thought to be from 3% to 4%. The frequency of secondary Raynaud phenomenon varies according to the disorder with which it is associated, and is thought to be almost universal in people who have scleroderma. It may occur in as many as 50% of people who regularly use vibrating equipment.

Symptoms of RD tend to occur at the tips of the fingers, toes, ears, or nose. Patients report physical changes in their extremities, with the fingers or other affected areas turning white, blue, and then red after exposure to cold air or stress.

The goals of treatment, according to Dorsher, are to reduce the number of attacks and severity of arterial spasm in the extremities, as well as to treat any underlying disease conditions. Certain medications that dilate the blood vessels can help, such as calcium channel blockers or alpha-blockers. But some medications can worsen the condition, including over-the-counter cold remedies, prescribed beta-blockers, and birth control pills.

Attack Management

Kim Kimpton, PT, who works for HealthMark in Denver, says a clear cause for RD has yet to be established; so physical therapy is aimed at trying to reduce the number and severity of those attacks, and prevent the tissue damage that can occur. “What PTs do is education, education, education,” she notes.

Noli Dioneda, PT-CLT, staff PT, department of rehabilitative services, Mayo Clinic in Jacksonville, Fla., says, “Symptoms associated with this disease that can be managed by physical therapy are that of cold sensitivities in hands and feet, joint pain and stiffness, and overall decrease in flexibility of their musculoskeletal system. There are several treatment modalities that can be of use by the treating therapist.”

But PTs should be cautious when using modalities because exposure to cold can be a triggering event. According to Dioneda, useful modalities include paraffin, infrared heat, and ultrasound, but even warm modalities that stimulate blood flow to the affected extremity must be used with caution because too much heat can damage fragile blood vessels. Biofeedback can be used to help train blood vessels to relax, reducing reactive vasospasm.

However, Dioneda observes, the single safest treatment approach that a PT can use for these patients is therapeutic exercise. “Passive and active stretching addresses the generalized stiffness seen in this patient population. Active range of motion exercises and mild strength training exercises without too much constraint on [the] joint muscle system [have] been proven beneficial in improving vasodilation of peripheral blood vessels in the extremities,” she says.

PT for Prevention

PTs often offer these practical tips to pass onto patients:
* Wear oven mitts or gel cycling gloves when using a vacuum cleaner to reduce the vibration effect
* Avoid carrying heavy shopping bags with narrow handles that restrict blood flow to fingers
* Dress in layers and always have available gloves, hats, earmuffs, and socks for cold weather
* On cold days and nights, have the car running with the heat on to warm up the steering wheel before you put your hands on it. Wear driving gloves.
* Consider using portable mechanical heat devices
* In warm climates, turn down the air conditioning
* Put on gloves, mitts, or use a towel to avoid direct contact with anything in the refrigerator or freezer. Use insulation around glasses or bottles.
* Wash dishes in warm water
* Exercise, don’t smoke, and limit caffeine
* Implement stress reduction strategies
* In the case of an attack, warm the extremity as quickly as possible either with warm water or by covering the affected area (for example, tucking the hands under the armpits)

Kimpton says that although niacin, a B3 vitamin, has been shown to have a relaxing effect on blood vessels, it should be prescribed by a physician because of potential dose-related side effects.

“PTs can’t cure Raynaud, but they can teach patients lifelong skills to prevent the episodes and cope with those when they do occur. That’s what PT is about in this particular disease,” Kimpton says.

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Lisette Hilton is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.

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