Rheumatoid arthritis
- A systemic inflamatory disease characterized by symmetrical polyarthritis
- Primarily a disease of the synovium
- Rheumatoid factors (RF) are antoboies found in the serum of 70% of pts with RA
- However, RA can still appear in RF negative patients
- Inflamation of the synovium leads to joint effusion, pain, stiffness, and decreased ROM
- Chondrocyte and osteoclasts lead to cartilage destruction and bone erosion.
- The joint space progressively narrows which leads to pseudolaxity
- In advanced RA the granulation tissue leads to adhesions, fibrosis, or bony ankylosis (fusion)causing increased immobility within the joint.
Lab tests
- Acute phase reactants INDICATES ACUTE INFLAMATION
- Increased Erythrocyte sedimentation rate (ESR)
- Increased C-reactive protein
Presence of antiboides
- Not present in all patients
- RF +ve is usually associated with a more severe or aggressive disease
Complete blood count
-RBC often decreased (anemia) in ~20% RA patients
Synovial fluid analysis
- Normal synovial fluid: Transparent, yellowish, absent of clots, and viscous
- Synovial from inflamed joint: Cloudy, will clot, less viscous
Radiographic findings
- Joint space
- Cartilage erosion: Narrowing joint space (unevenly)
Bone
- Erosion
- Peri-articular osteopenia
Soft tissue
- Rheumatoid nodules
- Swelling
Diagnostic criteria
Need atleast 4 of the 7 criteria
Criteria one to 4 must be present for atleast 6 weeks
1) Morning stiffness lasting atleast 1 hour
2) Soft tissue swellin g or fluid in atleast 3 joints simultaneously
3)At least one area swollen in the wrist, MCP, or PIP joint (DIP excluded)
4) Symmetrical arthritis
5) Rheumatoid nodules
6) Abnormal amounts of serum rheumatoid factor (RF)
7) Erosions or bony decalcification on radiographs of hand and wrist
Course of disease
- No cure
- Cycles of exacerbation and remissions
- Remission is defined as < 15 minutes of morning stiffness, and no joint tenderness or effusion for at least 3 months
S & S Systemic -Morning stiffness -Lasting >1 hour -Generalized stuffness -Progressively eases with movment -Severity and duration of morning stiffness are directly related to degree of disease -extreme fatigue *** -Increase resting energy expenditure -Due to chronic immune activation -Leads to rheumatoid "cachexia" -Weigh loss/appetite -Fever -Malaise
Systemic Lupus Erythemus (Selena Gomez)
Autoimmune disorder characterized by the production of autoantibodies
- Presents with episodes of relapse and remitting
- Presents as a butterfly rash
F>M
-During reproductive years (15-40)
Signs and symptoms
Sysytemic
-fever
-Malaise fatigue
skin
- Malar rash (butterfly rash)
- Discoid radsh
- Photosensitivity (light modalities are contraindicated)
Musculoskeletal
-Nonerosive arthritis
-Symmetrical
-Tenderness or effusion
Commonly in peripheral joints (except hip)
-spine and hips are usually not involved
Diagnosis SOAP BRAIN MD > 4 of 11 symptoms -Serosisits -oral ulcers\ -arthritis -photosensitivity -blood disorders -renal disorder -ANA positive (anti-nuclear antibody -immunological disorder -neurological disorder -mallar rash "butterfly rash" -discoid radsh
Ankylosing spondylitis
Chronic inflamatory disease of the axial skeleton
-May progress to complete spinal fusion
M>F
-Age of onset typically late adolescents/early adulthood (15-30 years old)
-Autoimmune disease thought to be due to a genetic predisposition (HLA-B27 gene assaociated with AS (90% carry this gene)
Onset
- Insidious onset
- pain and stiffness in low back and SIJ
- Pain is inflamatory
- worse in the morning
- stiffness and pain lasting atleast 30-40 minutes
- Sleep disturbed by pain(nocturnal back pain)
Progression
- Variable course: Mild self-limiting disease to severe with complete spinal fusion
- priods of exacerbation and remission
- progree from caudal to cephalic (bottom up)
Ppostural changes as disease progresses
- Increased thoracic kyphosis
- Decreased lumbar lordosis
- eye upward gaze d/t c-spine flexion deformity
- Fixed thoracic cage
- Hip and knee flexion to maintin upright posture and may lead to contractures
Most common areas for enthetits
- Plantar fascia
- Base of 5th metatarsal
- achilles tendon
S & S Systemic -Fatigue -Eye involvment (anterior uveitis) -cardiovascular and pulmonary involvment
Radiograsphoc findings
- Sacroilitis
- syndemophytes ( bamboo spine or railroad track)
- Thoracic kyphosis
- Enthesitis Plantar fascia and ITB insertions
- Arthritis (hip)
Physical assessment
- BASMI
1) cervical rotation
2) Trigus to wall
3) Modified Schober (10 cm above PSIS & 5 cm below PSIS, ask pt to flex forwaard and measure the difference)
4) finger to floor lateral flexion
5) Intermalleolar distance
Osteoperosis
- A metabolic bone disease that presents with decreased bone mass (density) and microarchiteal deteroriation (quality)
- F>M, typically post menopause
-Primrary osteoperosis
Type 1: Post menopausal (women 50-75)
Type 2:Senile (men and women over 70)
Secondary osteoperosis: Msy be due to another primrary condition or treatment
Risk factors Non-modifiable -Age -Gender (F>M) -Race (caucassion and asian decent) -Menopause -Fam Hx -small skeletal frame -Amenorrhea (absence of menstursation)
Modifiable
- Sedentary lifestyle (inadequate loading)
- Diet (deficient in calcium and vitamin D)
- Smoking
- Caffeine
- Alcohol abuse
- ammenhorea
T scores >-1 SD is normal -1 to -2.5 is osteopenia <-2.5 SD is osteoperosis <-2.5 and one osteoperotic fracture is severe osteoperosis
Can lead to:
- Bone fractures
- Compression fractures
- Postural changes
- Back pain
- Decrease mobility
Interventions focus on weight bearing exercises
osteomalacia
- A metabolic bone disease which results in softenng of bones due to decalcification
- May be due to inadeqaute intestinal absorption of calcium, increase renal excretion of phosphorus, or vitamin D deficiency
Pagets disease (Osteitis Deformans)
- A metabolic bone disease involving abnormal osteoclast and osteoblast activity followed by disorganized remodelling
- leads to enlarged and mishappenbones
- Bone may appear large but lack strructural integrity and strength
Characteristics
-Misshapen bones, pain, fractures, and arthritis
osteomyelitis
- inflamattion within a bone caused by an infection
- May be infected through the blood stream, open fraccture, or surgery
- Most cases d/t bacterial infection
Osteogenesis Imperfecta (brittle bone disease)
- Genetic bone disorder characterized by fragile bones
- M=F
- Affect type I collagen
- Bone mineralization often not affeccted
Characteristics
- Short stature
- frequent fractures
- scoliosis
- Ligament laxity
Intervention goals: Minimiuze fractures, enhance independent function, and promote general health
Precautions when treating people with OI
- Never push or pull on a limb
- When suspected fractureminimize handling of the affected limb
- handle babies with extra care
- Place one hand under buttock and legs, & other under the shoulder, neck and head
- Do not lift from underpits
- Do not lift by ankles to change a diaper
- encourage babies to explore independent movment
- Support in tummy time and side lying to develop muscles.
Burns
- An oinjury to the tissues of the body caused by heat, cold, chemicals, electricity, friction or radiation
- M>F
- Skin
- Largest organ in the body ad ~ 15% of total body weight
- Functions include:
- protect against infections and UV rays
- Protect against fluid loss
- Temperaturre regulation (Excretion of sweat and electrolytes)
- Sensation (itch, pain, touch, temp, pressure)
- Secretion of oils to lubricate skin
- Vitamin d synthesis
- Cosmetic aoearence
2 distinct layers of skin
1) Epidermis
2) Dermis
1) Epidermis
- Outermost layer exposed to the environment
- Avascular
- Free nerve endings (afferent nerves)
- composed of 5 layers
2) Dermis
- Deepest layer
- 20-30x thicker then the epidermis
- Contains blood vessels, lymphatics, nerve endings, collagen, and elastinn fibers
- Encloses the epidermal appendages which include sweat glands, sebaceous glands, and hair follicles which are a source of epidermal cells (required for wound healing)
Classification of burn injuries Depth of injury -Superficial (1st degree) -Superficial partial thickness (2nd degree) -Deep partial thickness (2nd degree) -Full thickness (3rd degree) -Subdermal (4th degree)
1st degree superficial Characteristics: -Pink or red (erythema) -No blisters -Dry -Minimal edema -Skin barrier to infection intact -mild pain: i.e sun burn Depth of injury: Damage to epidermis only Rate of healing: 2-3 days, desquamation, no scarring
2nd degree: superficial partial thickness
Characteristics:
-Bright pink or red (mottled)
-Intact blister
-Dry surface
-Moist weeping when the blister is removed
-Moderate edema
-Quick capillary refill
-Very painful**
-Sensitive to changes in temperature, air exposure, and light touch
-EX: Scald burn
Depth of injury: Damage to epidermis and into the papillary dermis
Rate of healing: 7-10 days with minimal scarring
2nd degree: Deep partial thickness (Distinguishing feature is if there is still hair follicles present)
Charactrristics:
-Red or waxy white
-Broken blisters
-Wet surface
-Marked edema
-Sluggish capillary refill
-Sensitive to pressure
-insensitive to light touch or light pinprick
-EX: Immersion scald, cooking oil burn, or flame burn
Depth of injury: Damage to the epidermis and into the reticular dermis
Rate of healing: 3-5 weeks, scar formation (hypertrophic or keloid**), may require skin grafting
3rd degree: Full thickness -White, charred, black, or red -Eschar formation -"parchment like" -Leathery -No blanching with pressure (vascular system disrupted) -Marked Edema -painless** -Severe infection risk -EX: Flame burn, or chemical burn Depth of injury: Damage to the epidermis, dermis, and partially into the subcutaneous tissue Rate of healing : 3-5 weeks, scar formation (hypertrophic and keloid), May require skin grafting
4th degree: Subdermal:
Characterics
-Charred
-Subcutaneous tissue visible
-Muscle damage
-Neurological involvement
-Large exit wound and smaller entry wound
-Always considered severe regardless of surface area of damage
-EX: High voltage electrical burn
Depth of injury: Damage to the epidermis, dermis, and into the subcutaneous tissue, muscle, bone, and large nerves
Rate of healing: Extensive healing time, requires extensive surgery, debridement and grafting, may require amputation, extensive healing time
Know rule of 9s for adult and child: Page 374 in book
Metabolic complications:
- Increased metabolic activities following a burn
- Decreased energy stores (d/t decrease nitrogen stores, and protein as energy)
- Weight loss
- Muscle atrophy
- Increased evaporative heat loss
- Impaired thermoregulation
Pulmonary complication:
-Inhalation injury is the most common cause of mortality in a burn injury
Sign of an inhalation injury: facial burns, singed eyebrows and nasal hairs, harsh cough, hoarseness in voice, carbonaceous sputum, breath sounds (wheezing or stridor), respiratory distress, and hypoxemia
-Associated complications: Carbon monoxide poisoning, tracheal damage, and upper airway obstruction, pulmonary edema, pneumonia
Cardiovascular complications
- Increased capillary permeability leads to:
- Fluid loss
- Decrease cardiac output (at risk for hypovolemic shock)
- Capillary permeability returns to normal at 24 hours
- Fluid replacement therapy helps manage intravascular fluid loss
Heterotrophic ossification -Unknown etiology -Higher incidence in pts with higher TBSA burns -Usually with full thickness burns -Most common areas include: -elbows, hips, and shoulders symptoms include: -Decreased ROM, point specific pain
Neuropathy Peripheral neuropathy (sites are brachial plexus, ulnar nerve and the common peroneal nerve) and polyneuropathy (Higher incidence in patients with larger TBSA burns)
Amputation
- Common in subdermal burns d/t lack of viable blood vessels, most common cause is electrical burns***
- Hypertrophic scar: Excessive scar that rises above the level of adjacent skin
- 3R’s (raised, red, and rigid)
Keloid scar
- Type of hypertrophic scar that extends beyond the boundaries of the original wound
- More common in people with dark skin pigmentation
Interventions Initial management: -Establish and maintain an airway -Prevent cyanosis, shock, and hemorrhage -establish baseline data (depth of injury) -fluid replacement -Clean patient and the wounds -examine injury -Prevent and manage any pulmonary complications
Wound care
- Inspect wound
- Clean wound
- Debridement of the wound
- Prevent infection
PT management
-Positioning and splinting (goal to minimize edema, prevent contracture, preserve function)
-Therapeutic exercise
-AROM
-Begins on day of admission, of all extre mities and trunk
-Cordinate with pain meds and dressing changes
-discontinue for joints above and below the skin graft for 3-5 days to allow graft to
adhere
-PROM
-Performed when patient not alert or able to follow commands
-Stress should be applied in a gentle, gradual, sustained fashion
-resistive
-Monitor vital signs initially (before, during, and after)
-proper hydration is critical
-Correct temp d/t thermal dysregulation
-Conditioning
-Walking, cycling, rowing, stair climbing, and other forms of aerobic exercise should be
encouraged
-Ambulation
-Begin ASAP
-Discontinue ambulation after LE graft until safe to resume
-Use elastic wraps or T.E.D stockings to minimize edema and stasis when upright, and to
protect new graft
-Scar management
pressure dressings
-Begin with elastic compression wraps until patients skin or scar can tolerate shearing
forces
-Pressure of 2mmHg is ideal (may need to start with <10mmHg)
-Pressure garments typically worn 23 hours a day (except when bathing) for ~12-18
months
-Garments should be washed daily.
-Massage
-Deep friction massage to loosen scar tissue and break up adhesions
-Appears to soften scar, increase pliability and improve texture
Diabetes Mellitus
- A group of metabolic disorders characterized by hyperglycemia due to defective insulin action &/or excretion
- Beta cells of the pancreas produce and secrete a hormone known as insulin which helps to regulate the blood glucose levels by producing glucose uptake into the liver, adipose cells, and skeletal muscle cells for storage as glycogen
Tyoe 1 DM
- Pancreas fails to produce sufficient (or any) insulin
- Also known as insulin-dependent or juvenile diabetes
- ~5-10% of DM cases
- Auto-immune abnormality that damages the islet cells of the pancreas
- Genetic predisposition and environment believed to be a developing factor
Type II DM
- Condition where the pancreas fails to produce sufficient insulin, as well as resistance to insulin action
- Adult-onset diabetes
- ~90-95% of cases
Etiology (risk factors)
- Secondary to many dysfunctions
- Obesity (BMI >30) one of main factors***
- High abdominal fat (waist to hip ratio)
- Poor diet
- Sedentary lifestyle
Hypoglycemia -Drop in blood glucose <3.9 S & S -Autonomic effects -Sweating -Nausea -Tremors Warmth -anxiety palpitations -hunger Neuroglycopenic effects -Headache -Blurred vision -Confusion -Weakness -fatigue -Difficulty speaking -seizures -Coma
Reduce risks of hypoglycemia with exercise
- Educate patient to self monitor S & S
- insulin injections taken >1 hour prior to exerc ise
- avoid injecting into an exercising area
- Check blood glucose levels before and after exercise
- Exercise at consistent time of the day
- Preferably after a meal
- Avoid exercise at night
- Keep glucose rich snacks or drinks close by
- If <5.5 mmol/L, injest 15-30 g of carbs
- 15:15 rule, ingest 15g carbs, wait 15 minutes and retest
Hyperglycemia
-Blood glucose >11 mmol/L
-Commonly due to a lack of insulin present
-Regular exercise, proper diet and medications can prevent hyperglycemia
S&S
-Polydipsia (increase thirst)
-Polyphagioa (frequent hunger)
-Polyuria (increase volume of urination)
-Fatigue
-Blurred vision
-Delayed healing
-If Blood glucose >16.7 stop and allow them to take insulin, if not may go into ketoacidosis
(Hallmark sign is a fruity breath smell) which is life threatening
Diabetic complications
- Cardiovascular disease (leading cause of death for ppl with DM)
- Peripheral neuropathy (glove and stocking pattern)
- autonomic neuropathy (blunted HR and BP response to activity), impaired sweating and thermal regulation
- diabetic retionopathy
PT management
- Education
- Diabetic foot care (inspect skin, check shoes, skin care, and see doctor)
Exercise
- Effect of exercise on DM
- Increase insulin sensitivity
- Decrease insulin resistance
- in=mprove insulin uptake
- improve blood glucose control
- Decrease risk of diabetic complications
Parameters -Serobic exercise -3-7 dyas/week -50-80% of VO2R (RPE 12-16) 20-60 minutes -Emphasis on large muscle groups
RResistance
- 2-3 days/week with 48 hours break between sessions
- 2-3 sets of 8-12 reps at 60-80 %1rm
- Vares for time
- Tailor exercise program according to co-morbidities and precautions
- nephropathy
Obesity
A medical condition characterized by excess body fat that may impair health
- WHO declares chronic condition
- Diagnosed by BMI
Very severely underweight=<15 severely underweight=16-16 underweight=16-18.5 normal=18.5-25 overweight=25-30 obese class I (moderate obese)=30-35 Obese class II (severe obese)=35-40 Class III (morbidity)=>40
Etiology:
- diet (caloric surplus)
- sedentary lifestyle
- meds (anti depressants, & oral contraceptives)
- genetics
- Secondary to other diseases
Associated health problems
- Cancer
- cardiovascular disease
- gall bladder dysfunction
- metabolic syndromes
- obstructive sleep apnea
- OA (knees most affected)
- Type II DM
Exercise parameters
F: >5 days/week
I: Mod (40-60% HRR) to vigorous (50-75% HRR)
T: 30-60 minutes
T: Primarily shoulder be aerobic PA involving large muscle groups
HIV/AIDS
- A virus which attacks the immune system, specifically T-cells with CD4 receptors
- progressively weakens the host immune system
- increase susceptibility to opportunistic infections and cancers
Epidemiology:
- Global pandemic
- Men who have sex with men (most common)
- injection drug users
- females
- people from HIV endemic countries
- aborigional people
Etiology:
- Mode of transmission
- unprotected sex
- shared needles or equipment
- mother to child transmission
- occupational exposure
- blood andblood products
- Body fluids infectious for HIV:
- blood, breast milk, inflammatory exudate, semen and vaginal secfretions
- Body fluids not infectious for HIV:
- Feces, urine, saliva, sweat, and tears
Universal precautions: Important ***
- Universal precautions used for all patients where there is risk to blood exposure
- Do not use unnecessary precautions
- Use gloves if you come into contact with blood, body fluids, mucous membranes, or non-intact skin
- Change gloves after each patient
- Refrain from all direct care if YOU have open wounds or skin lesions
Diagnosis: Blood antibody test -ELISA and western Blot CD4 count -<200 for HIV Viral load test -Detectable range 50-500,000/ml
AIDS
- Advanced HIV progression
- Must have CD4 count <200,mm3 and 1 or more of the 26 indicator conditions
Interventions
Medical management
-Highly Active antiretroviral Therapy (HAART)
-Interferes with the virus life cycle
-Decreases viral load (cant fully irradicate) and preserves CD4 count
-Requires high compliance
Side effects
-Mitochondrial toxicity
-buffalo hump, posterior cervical spine bump
-Mitochondrial myopathy
-cardiomyopathy
-Hepatic steatosis
-Peripheral neuropathy (distal to proximal and symmetrical)
-Skin rash
-GI symptoms (diarhea, nausea, abdominal pain)
-Dyslipidemia
-osteopenia/osteoperosis
PT management:
Education: Energy conservation, expectations about unpredictable complications of the disease, and pain management
-Symptom management (pain, dyspnea)
-Managing secondary complications (deconditioning, weakness, and fatigue)
-Exercise (AROM, strengthening, and aerobic)
Fibromyalgia Syndrome
-A syndrome characterized by widespread chronic pain and increased pain response to pressure with no other cause (diagnosed by exclusion
fibro=connective tissue
myo=muscle
algia-pain
F>M Reproductive years (15-40 y.o)
Believed to be a result of genetic or environmental factors
‘S&S
- Chronic widespread pain
- Allodynia’
- Headache
- Fatigue
- Sleep disturbance
- Cognitive dysfunction “fibro fog”
- Anxiety &/or depression
- IBS
PT management:
- Education that fibro isn’t a death sentence or dangerous
- Cognitive behavioral therapy
- Exercise (aerobic has great evidence)
- sleep hygiene
Lymphedema
-An abnormal accumulation of lymph fluid in tissue spaces (interstitial spaces)
Type of lymphedema
- Primrary (affects F>M, and primarily LE, can see hyperkeratosis)
- Congenital malformation of the lymphatic system
- Insufficient development of the lymphatic system
- Seconday lymphedema
- Surgical dissection of lymph nodes
- Inflamation and infection (systemic infection or direct trauma to the lymph nodes
- Obstruction or fibrosis (Trauma, cancer, or radiation therapy)
- Chronic venous insufficiency
Clinical manifestation
Location
-Most often apparent in the distal extremities, esp dorsum of hand or feet (dependent edema)
Severity
- Quantitative (how much edema)
- Qualitative (pitting edema, brawny edema, weeping edema)
S & S -Increase size of limb -Sensory disturbances -Decrease ROM pSkin changes (Fibrosis, brown pigmentation)
Interventions
- Manual lymph drainage
- Compression (low stretch bandage in early phases, compression garments in later phases)
- Elevation
- Exercise (AROM, stretch, low intensity resistance, low intensity aerobic
- Skin and nail care
Complex decongestive Therapy program (CDT)
Phase I
-Manual lymph drainage
-Compression therapy (multiple layer compression bandage (low stretch)
-Exercise
-Skin and nail care
Phase II
- Self-manual lymph drainage by pt.
- Com pression therapy (compression garments during the day and multiple layer bandaging (low stretch at night)
- Exercise
- Skin care
- Shoulder and UE ROM
- Avoid excess tension on the incision or blanching of scar during shoulder ROM
- Avoid exercises with involved arm in a dependent position
- Progress graded exercise program slowly
- Gentle massage of scar and adhesions
- Aerobic exercise and functional activities
Womens health
Pregnancy related back pain
- May be d/t:
- Postural changes of pregnancy
- Hormonal influences (up to 3-5 months postpartum)
- Increase ligamentous laxity d/t relaxin
- Decrease abdominal m muscle function
Characteristics
- Worse with muscle fatigues
- Relieved with rest or change of position
- Physically fit women have less back pain with pregnancy
Postural changes
- COG shifts upwards & forward d/t enlarged breast and uterus
- Increase cervical and lumbar lordosis
- Increase anterior pelvic tilt
- Scapular protection and UE ER
- Suboccipital muscle tightness
- Genu recurvatum at the knees
Interventions
- Core exercises and posterior pelvic tilt\
- Proper body mechanics
- Posture instructions (supine sleep with pillow under knees and pillow under R buttock, side lie with knees flexed to 90 and pillow between knees
- Modalities
- Precautions : heat and laser
- Contraindications
- Deep heating agents (diathermy)
- Electrical stimulation (local)
- Traction (d/t ligament laxity)
- Ultrasound (local)
Diastasis recti
- Seperation of the rectus abdominus at the linea alba
- Seperation larger then 2 finger breadths
S & S
- Low back pain
- Decreased functional activity
- Herniation (severe case)
Exam for diastasis recti is not valid 0-3 days after delivery
INTERVENTIONS
- Only head lift or head lift with posterior pelvic tilt or TA activation without breath holding should be used until the separation is <2cm]
- Once less then 2cm more advanced exercises
Pelvic floor dysfunction -Inability to control pelvic floor muscles Classification -Prolapse -Urinary or fecaql incontinence -Pain and hypertonus
Risk factors ->30 y.o -Multiple deliveries -Forced pushing -Use of forceps -Vaccumm extraction -Oxytocin -Perineal tears -Birth weight >8 pounds Other causes -Excessive straining -0Chronic constipation -Obesity -Chronic cough -Smoking -Hysterectomy
Interventions -Patient education -Neuromuscular re-education -Pelvic floor exercises -Biofeedback Manual treatment and modalities (intrravaginal/rectal techniques)
