multisystems Flashcards
rheumatoid arthritis definition
systemic inflammatory autoimmune disease - symmetrical polyarthrtitis
30-45 age onset F>M
rhematoid positive factors in 70% (more severe cases)
ESR and CRP (creatine-reactive proteins) positive during active RA
synovial fluid - cloudy, will clot, less viscous during active inflammation
RA pathophys
inflammation of synovium leads to effusion, pain, stiffness and limited ROM in the joint
chronic inflammation - immune cells break down articular cartilage
synovial overgrowth of granulation tissue (pannus) dissolves articulum
joint space narrows causing psuedo-laxity
tendon sheaths fray, tendons rupture leading to muscle imbalances
granulation tissue results in adhesions, fibrosis or fusion of the joint
x-ray findings RA
joint space narrowing unevenly (cartilage erosion) - secondary OA
bone erosion and peri-articular osteopenia
rheumatoid nodules and swelling
ARC 1987 criteria for classification of RA
need at least 4 of 7 criteria**
criteria 1 to 4 must have been present for 6 weeks**
- morning stiffness =/> 1hr
- soft-tissue swelling/fluid in at least 3 joints simultaneously
- at least 1 area swollen in wrist, MCP or PIP
- symmetrical arthritis
- rheumatoid nodules
- abnormal amounts of serum rheumatoid factor
- erosions or bony decalcification on x-ray wrist and hand
signs/symptoms RA
morning stiffness > 1 hr
generalized stiffness that eases with movement
extreme fatigue (increased resting energy expenditure)
rheumatoid cachexia - loss of lean body mass, muscle wasting
signs of systemic disease - loss of apetite/weight loss, fever, malaise
crepitus
deformity
joint pain
swelling
RA red flags (urgent referrals)
claudication pain pattern
systemic disease signs (fever, weight loss, malaise)
focal or diffuse weakness
history of significant trauma
hot, swollen joint
neurogenic pain (burning, numbness, paresthesia)
*Cord compression signs - neurological signs and cervical radiculopathy (spinal cord compression may come from inflammation in the cervical spine.) URGENT ER
Standardized assessment of joint inflammation (SAJI)
active joint (1 of the following must be present)
STOP - swelling, tenderness, over pressure
1. effusion - 2 thumb technique, 4 finger technique, palpation
2. joint line tenderness
3. stress pain - pain with passive overpressure
damaged joint (1 of the following must be present)
1. subluxation or deformity
2. bone on bone crepitus
3. loss of more than 20% of PROM
4. ligament instability
raynauds disease - triggered cold/stress vasomotor constriction of arteries
nerve compression
contraindications for RA (ACTIVE)
superficial heat - not on inflammed, hot, swollen joints (hot packs, LLLT, paraffin wax, hypdrotherapy)
deep heat - during acute inflammatory stage (ultrasound)
cold - in patients with raynauds disease
stretching
strengthening
lupus definition
autoimmune disorder causing production of antibodies
lupus signs/symptoms
systemic disease signs - fever, malaise, fatigue
skin abnormalities - malar rash (butterfly), discoid rash, photosensitivity
alopecia
oral or nasopharyngeal ulcers
pleuritic chest pain and SOB
pericarditis, hypertension, raynauds
headaches, seizures, psychosis
nonerosive arthritis - symmetrical in PERIPHERAL joints - (not hip or spine)
ANA positive - anti-nuclear bodies *hallmark lab values
SLE/lupus PT management
energy conservation techniques
avoid sun exposure UV light
breathing exercises
modalities for pain/effusion
ROM exercises
NO STRETCHING*
NO STRENGTHENING during acute flare ups
AS Ankylosing Spondylitis definition
seronegative spondyarthropathy chronic inflammatory of the axial spine
M>F age 15-30
HLA-B27 gene
c-reactive protein and ESR increased during active inflammation
insidious onset progressing from caudal to cephalad
AS signs/symptoms
insidious onset progressing from caudal to cephalad
morning stiffness 30-40 mins
nocturnal pain
low back, SIJ, glute pain and stiffness
loss of ROM spine, hips, shoulders
postural abnormalities
tenderness over enthesitis sites - insertion of muscle (plantar fascia, achilles, ischial tuberosity
systemic signs - fatigue, eye anterior uveitis
AS postural changes
increased kyphosis, reduced lumbar lordosis/cervical lordosis, eye upward gaze, fixed thoracic ribcage (restrictive disease), hip and knee flexion
AS x-ray findings
sacroiliitis
syndesmophytes - bone growth inside ligaments “bamboo spine”
increased kyphosis
enthesitis - ITB insertion, plantar fascia insertion
arthritis - hip
AS contraindications
flexion based exercises
thermotherapy on active inflamed joints
Osteoporosis
metabolic bone disease causing reduced bone density & deterioration
typically post-menopausal women
primary osteoporosis - due to post menopause/senile age (70+)
secondary osteoporosis - due to another primary condition (hyperthyroidism) or treatment of another condition (corticosteroids)
Dexa T-score standard deviations
> -1 = normal
-1 to -2.5 = osteopenia
-2.5 = osteoporosis
-2.5 & history of at least 1 osteoporotic # = severe osteoporosis
Osteoporosis PT interventions
postural education - AVOID FLEXION (ant. wedge # common)
WB exercises - walking, squatting, jogging
osteomalacia (all)
metabolic bone disease resulting in softening of bones/decalcification
caused by: inadequate intestinal calcium absorption, increased renal excretion of phosphorus or vitamin D deficiency
signs/symptoms: pain, aching, fatigue, weight loss, weakness, increased thoracic kyphosis, LE bowing, high risk #’s
interventions: meds/nutrition, strength training, bone protection strategy
pagets disease (all)
metabolic bone disease with abnormal osteoblast/clast activity followed by disorganized remodeling
M>F, > 40 years old
signs/symptoms: pain, misshapen bones, #’s, arthritis
interventions: meds for pain/ regulating osteoclast activity
postural re-ed, strengthening, stretching, aerobic activity – low impact ex’s (caution with running hard, twisting, jogging)
osteomyelitis (all)
inflammation within bone caused by infection
most cases due to bacterial infection, infection through blood stream, open fracture or surgery
signs/symptoms: fever, tenderness/redness/warmth/swelling near site, loss of ROM in affected joints
interventions: antibiotics, surgery, ROM ex’s
skin function layers dermis vs. epidermis
protects against infections, UV rays and fluid loss
temp regulation
sensation
secretion of oils for lubrication
vitamin D synthesis + cosmetics
epidermis: most superficial, avascular, free nerve endings, 5 layers
dermis: deepest layer, contains blood vessels, lymphatics, nerve endings, collagen and elastin fibers and wound healing properties
burns classification 1st degree superficial
characteristics:
pink/red erythema, no blistering
dry
minimal edema
skin barrier to infection intact
mild pain»_space; SUNBURN
depth: damage to epidermis only
rate of healing: 2-3 days, no scarring
burns classification 2nd degree superficial partial thickness
characteristics:
bright pink or red (mottled)
intact blister
dry surface
moist weeping when blister removed
moderate edema
quick capillary refill
very painful - nerve endings damaged
sensitive to changes in temp, air exposure, light touch»_space; SCALD BURN
depth: damage to epidermis and into papillary dermis
rate of healing: 7-10 days, minimal scarring
burns classification 2nd degree deep partial thickness
characteristics:
red or waxy white
blisters broken
wet surface
marked edema
sluggish cap. refill
sensitive to pressure
insensitive to light touch/pinprick - nerve endings destroyed
» IMMERSION SCALD, FLAME BURN, COOKING OIL BURN
depth: damage to epidermis and into reticular dermis
rate of healing: 3-5 weeks, keloid/heterotrophic scar formation (may require grafting)
burns classification 3rd degree full thickness
characteristics:
white, charred, black or red
eschar formation
“parchment-like”
leathery
no blanching with pressure
marked edema
painless
severe infection risk
» FLAME BURN, CHEMICAL BURN
depth: damage to epidermis, dermis and partial into subcutaneous tissue
rate of healing: 3-5 weeks, keloid/heterotrophic scar formation (may require grafting)
burns classification 4th degree subdermal
characteristics:
charred skin
subcutaneous tissue visible
muscle damage
neurological involvement
large exit wound and small entry wound
always severe no matter size of area
» HIGH VOLTAGE ELETRICAL BURN
depth: epidermis, dermis, into subcutaneous tissue, bone, muscle, and large nerves
rate of healing: extensive, requires surgery, debridement, grafting, amputation
signs of inhalation injury
facial burns, singed eyebrows and nasal hairs, harsh cough, hoarse voice, carbonaceous sputum, abnormal breath sounds (wheezing/stridor), respiratory distress, hypoxemia
complications: CO2 poisoning, tracheal damage, upper airway obstruction, pulmonary edema, pneumonia
heterotrophic scar
excessive scar formation that raises above level of adjacent skin
3 R’s (raised, red, and rigid)
keloid scar
heterotrophic scar that extends beyond the boundary of original wound
burns PT interventions
positioning - elongated position or functional, minimize edema, prevent contractures, preserve function (airplane splint, hamburger hands)
splinting
AROM - start on admission for all joints even affected, coordinate with pain meds, stop 3-5 days after graft for joints above/below
PROM - if pt not alert or unable to follow commands, on children, if unable to achieve AROM, stress is gentle gradual and sustained
resistance ex’s - beware abnormal thermoregulation, monitor vitals
conditioning ex’s - monitor vitals, walking, cycling, rowing, stair climbing
ambulation - begin as early as possible, stop after LE grafting, TED stockings, elastic wraps to minimize edema in standing
pressure dressings and massage for scar management - once wound has healed, pressure 25mmHg worn 23 hours/day** 12-18 months, washed daily
diabetes mellitus
metabolic disorders characterized by hyperglycemia due to defective insulin action or secretion
beta cells in pancreas produces insulin
insulin regulates blood glucose levels by promoting glucose uptake by the liver, adipose cells, and skeletal muscle cells for storage as glycogen
diabetes mellitus
metabolic disorders characterized by hyperglycemia due to defective insulin action or secretion
beta cells in pancreas produces insulin
insulin regulates blood glucose levels by promoting glucose uptake by the liver, adipose cells, and skeletal muscle cells for storage as glycogen
type 1 DM
pancreas fails to produce sufficient or any insulin
“insulin-dependent or juvenile diabetes”
typical onset childhood
auto-immune abnormality that damages islet cells of the pancreas
type 2 DM
pancreas fails to produce sufficient insulin, as well as resistance to insulin
“adult-onset diabetes”
causes: OBESITY - BMI > 30, poor diet, abdominal fat, sedentary lifestyle
hyperglycemia
blood glucose > 11mmol/L
increased thirst
frequent hunger
increased urination
delayed healing
ketoacidosis - fruity breath smell > life threatening
don’t exercise > 16mmol/L
GIVE insulin
hypoglycemia
drop in blood glucose <3.9mmol/L, high insulin levels increase glucose uptake and drop BP
increased physical activity, not eating on time, meds that increase insulin
sweating
nausea
tremors
warmth
anxiety
palpitations
hunger
headaches
confusion
weakness
seizures
coma
insulin injections should be taken > 1 hour before exercise
check blood glucose before/after exercise
avoid exercise at night*, preferably after meal
15:15 rule: if +/< 5.5mmol/L ingest 15-30g carbs - ** wait 15 mins retest
peripheral neuropathy DM
insidious onset, affects sensory and motor neurons
“glove and stocking” distribution
numbness, tingling, burning
charcot foot - weakened bones may #, reduced sensation = foot deformity
autonomic neuropathy DM
impaired function of peripheral nerves in ANS
blunted HR and BP response to activity
high resting HR
impaired peripheral vasodilation, impaired sweating, poor thermoregulation
increased risk post-exercise hypotension/orthostatic hypotension
diabetic retinopathy
avoid activities that cause sudden increase in BP
valsalva maneuver, heavy lifting, strenuous UE ex’s, head down postures
effects of exercise on DM
increased insulin sensitivity
reduced insulin resistance
increased insulin uptake
improved blood glucose control
reduced risk diabetic complications
exercise parameters DM
aerobic: 3-7 days/week
intensity: 50-80% VO2R or 12-16 RPE
20-60 mins
large muscle groups
resistance: 2-3 days/week with 48 hours break
2-3 sets of 8-12 reps at 60-80% of 1RM
contraindications for diabetic retinopathy
BMI normal
18.5-25
BMI moderately obese (class 1)
30-35
> 30 = obese
BMI overweight
25-30
obesity exercise parameters
F: =/> 5 days/wk
I: moderate (40-60% HRR), vigorous (50-75% HRR)
T: 30-60 mins
T: aerobic physical activity involving large muscle groups
obesity modalities precaution
risk of overheating - precaution with thermomodalities
HIV
virus that attacks the immune system, T cells with CD4 receptors
transmitted by BLOOD, BREAST MILK, semen and vaginal secretions, CSF
not transmitted by: SALIVA, FECES, URINE, SWEAT, TEARS
HIV universal precautions
use gloves if coming into contact with blood,body fluids, mucous membranes, or non-intact skin
refrain from patient care if you have an open wound/skin lesion
AIDS
advanced HIV progression
CD4 count < 200
1+ of 26 indicator conditions present
interventions AIDS
Highly active antiretroviral therapy (HAART) lifelong commitment
PT = energy conservation, pain/symptom management
managing deconditioning, weakness, fatigue, ROM, aerobic, resistance
peripheral neuropathy pattern HIV/AIDS
distal to proximal
symmetrical
Fibromyalgia Syndrome
widespread chronic pain and increased pain response to pressure
F>M during reproductive years 15-40 age
Fibro s/s
chronic widespread pain
allodynia
headache
fatigue
sleep disturbance
cognitive dysfunction “fibro fog”
anxiety and/or depression
IBS
fibro tender points (ACR 1990)
widespread chronic pain > 3 months affecting all 4 quadrants
tender points: NOTHING BELOW KNEE!
occiput
low cervical
traps
supraspinatus
2nd rib at costochondral junction
lateral epicondyle
gluteal
greater trochanter
medial knee
Lymphedema (primary vs secondary)
abnormal accumulation of lymph in tissue spaces
primary: congenital malformation/insufficient development of lymph system
secondary: surgical dissection of lymph nodes, inflammation/infection, obstruction or fibrosis, chronic venous insufficiency
Lymphedema interventions
manual lymphatic drainage
compression - low stretch bandage, compression garments
elevation, AROM, stretching, low-intensity cardiopulm. + resistance ex’s
lymphedema CDT (complex decongestive therapy) program
phase 1: manual lyphatic drainage, multiple layer low-stretch compression bandaging 23hrs/day, exercise, skin and nail care, CDT 4-5x/wk @ 1hr
phase 2: self-manual lymphatic drainage 20 mins/day, compression garment during the day with multiple layer bandage low-stretch at night, exercise, skin and nail care
pregnancy related back pain
worse with static postures or as day progresses
relieved by rest/change of position
COG shifts upward and forward
increased lumbar and cervical lordosis
increased anterior tilt
scapular protraction and UE IR
genue recurvatum at knees
UPPER + LOWER CROSSED SYNDROME - tight hip flexors, extensors, suboccipital muscles and weak glutes and abs
pregnancy related back pain ex’s
traditional low back ex’s - core, post. pelvic tilt
pregnancy sleeping position
left side lying, flex knees, hips with pillow between knees
supine with pillow under R pelvis and knees
pregnancy precautions + contraindications
precautions: heat (ligament laxity), laser (local)
contraindications: deep heating - diathermy, electrical stimulation (local abdomen/low back), traction, ultrasound (local)
diastasis recti
abdominal separation at the linea alba > 2 finger widths or 2cm
diastasis recti s/s
low back pain
reduced functional activity
herniation if severe
crook lying + raise head/shoulders to reach towards knees (+) = fingers sink into gap between rectus muscles
diastasis recti interventions
> 2cm only head lift with pevlic tilt or TA activation without breath holding
transtibial amputation pros/cons
pros: increased potential for walking (own knee joint) with reduced energy expenditure
cons: not a weight bearing end and bony prominences have potential risk of skin breakdown
transfemoral amputation pros/cons
pros: greater healing in avascular amputees
cons: not a weight bearing end and less potential of ambulation with greater energy expenditure and external knee joint
rotationplasty
used to treat bone tumors in children
part of the limb is removed and the remaining lower limb is rotated and reattached so the ankle can act as the knee joint
positioning for transtibial amputation
prevent knee and hip flexion contractures
patient placed in prone with no pillow
stump board for sitting in wheelchair
positioning for transfemoral amputation
prevents hip flexion, hip ER and abduction contractures
patient in prone 15-20 minutes with neutral leg position, no pillows
amputations transfer
postsurgical leading with unamputated limb towards good side
walkers provide greater stability, crutches provide greater mobility and help train balance in prep for prostethic
supine to sit - slightly raise residuum + roll to good side and rise to sit
amputee strengthening considerations
strengthening on amputation side contraindicated in post surgical phase
TF: strengthen hip ext, abd, and add for ambulation
TT: hip ext/abd/add, knee extensors/flexors for ambulation
residual limb examination
shape
normal = cylindrical, conical, bulbous end
abnormal = dog ears, skin folds, edematous
pain - sharp, sticking, or pressure at end of stump = improper fitting prosthesis
phantom limb sensation words
tingling, burning, itching, pressure, numbness or wetness
amputation prosthetic ambulation training
never use walker unless using before amputation, cane may be used
smooth, energy-efficient gait as possible
pressure sensitive areas for WB transtibial
patella
lateral tibial condyle
tibial tuberosity
tibial crest
anterior-distal end of tibia
fibular head
distal end of fibula
distal end of stump with surgical suture
medial femoral condyle
lateral femoral condyle
pressure sensitive areas for WB transfemoral
greater trochanter
ramus
anterior superior iliac spine
adductor tendon
distal end of femur
inguinal fossa
pubic tubercle
surgical suture
red flags for cancer
night pain
constant unrelenting pain
unexplained weight loss
loss of appetite
unusual lumps/growths
unwarranted fatigue
bone pain that is worse at night
cord signs
history of cancer
common side effects of chemotherapy for PT
fatigue, neuropathies (contraindication for modalities, balance impairments, motor deficits) , chemo fog, nausea, vomiting, increased bruising due to reduced platelets
cancer-related pain and cancer-related fatigue*
common side effects of radiation for PT
fatigue, myelosuppression, nausea, vomiting, local skin problems
cancer-related pain and cancer-related fatigue*
cancer referral red flag
motor changes - report to oncologist (neurotoxicity)
PT cancer interventions
decrease pain - TENS (not over malignancy), cold pack, gentle mvmt, ex’s
decrease stress in bones - education on risks and protection strategies, splinting/bracing, assistive devices
fatigue management - 5 P’s!* planning, pacing, prioritizing, positioning, proficiency
cancer special considerations
exercise, strengthening and mobs contraindicated in pts with bone metastasis due to high risk pathological #’s
minimize rotation with bone metastasis in vertebrae
no modalities in cancer area unless palliative
check sensation before modalities in case of peripheral neuropathy
no creams, oils, topicals, chlorine over irradiated skin until approved
alter, adapt, or delay treatments in blood counts are too low
hemophilia clinical symptoms
bruising from shots or lifting babies under arms/firmly holding
excessive bruising from minor traumas
delayed hemorrhage after minor injury
persistently bleeding cuts
hemarthrosis
spontaneous bleeding into joints, muscles, organs
hemarthrosis
bleeding into joint space, affects synovial joints
target joints = recurrently bleeding joints
knee most common, ankle, elbow, hip, shoulder, wrist
swelling, stiffness, pain and warmth
chronic inflammation from blood may cause joint erosion of cartilage
management of active bleed - Acute stage
pain meds - no aspirin/ibuprofen
RICE
pain-free movement
non/minimal WB (crutches)
splinting and support
management of active bleed - subacute stage
progressive weight-bearing, mvmt and ex’s
wean from splints and slings
management of active bleed - musle
RICE
progressive movement
appropriate WB
hemophilia post-bleed rehab
effects of exercise - increased strength, ROM, joint protection, clotting factor, and temperature
isometric ex’s
slow progression to strengthening ex’s when full pain-free ROM in joint
slow, progressive return to weight-bearing activites
proprioception ex’s
hemophilia rehab considerations
heat contraindicated during active bleed
joint mobs contraindicated always
no contact sports
no activities with high injury risk
heavy weight lifting and eccentric loading not recommended
