What is thrombocytopenia?
- What platelet levels indicate the different level of function and exercise?
- At what level is exercise contraindicated?
- What level is there risk of spontaneous bleed?
- What level requires a doctors approval for exercise?
THROMBOCYTOPENIA
Low platelet count (normal = 150-400,000/mcL)
- Increased risk of bruising or bleeding (report any unusual bruising or symptoms to MD)
If <50,000 MCL = avoid activities with contact or risk of falling
- RX = 40-60,0000 MCL
- -> low weights (1-2 lbs), stationary bike low resistance, walking or ADLs
- RX = 20-40,0000 MCL
- -> low intensity exercise, low weights (0-2 lbs), stationary bike no resistance or minimal, walking, and ADLS
If <20,000 MCL = Incr risk of spontaneous bleed unrelated to trauma
- RX = 10-20, 0000 MCL
- -> doctor approval, active ROM exercises, walking, ADLS (may need supervision)
If <10,000 MCL = spontaneous CNS, GI, or respiratory tract bleeding may also occur
- RX = <10, 000 MCL
- -> no exercise, only essential ADLs, prevent falls and injury
What is the diagnostic criteria for Rheumatoid Arthritis (RA)?
RA CRITERIA:
- morning stiffness >1hr (6 weeks)
- arthritis of ≥ 3 joints (6weeks)
- arthritis of hand joints
- symmetric arthritis (6weeks)
- rheumatoid nodules
- serum rheumatoid factor
- radiographic changes
- abnormal antibody HLA-DR4 (80% those w/ RA)
- -> also found in pts with interstitial lung disease, chronic hepatitis, idiopathic pulmonary fibrosis, normal aging adults, SLE
What is the pathophysiology of RA?
RHEUMATOID ARTHRITIS
MAIN FEATURE –> SYNOVITIS –> symmetrical pattern
- Synovium becomes swollen and cells proliferate, creating a dense cellular membrane (pannus) spreads over articular cartilage
- Eerodes underlying cartilage and bone
- W/ time –> pannus may extend to the opposite articular surface creating:
1) fibrous scar tissue
2) adhesions
3) bony ankylosing
LEADS TO:
- Immobility + consolidation (bones form a single unit) of a joint
- Bones can become osteopenic
- Ligaments/tendons become damaged or ruptured
- Surrounding mm deteriorate = joint instability + deformity prone
What is the difference between a Cam and a Pincer lesion with FAI?
FEMORAL ACETABULAR IMPINGEMENT
TYPES
Cam
- Decreased/absent waist of the jx of femoral neck and head
- W/ hip flex = abnormal femoral head drives into acetabulum
- Young men
Pincer
- Abnormal acetabulum provides excessive cover of femoral head
- Retroverted or deep acetabulum
- Impingement when femoral neck pushes against overarching acetabulum
- Women 30-40 years
Differentiate between bouchard and herbenens nodes
- What condition does this occur in?
Hand//
- PIP is Bouchard node,
- DIP is Hebernen’s node;
In OA –> osteophytic growth
What is Ankylosing Spondylitis (aka Marie-Strumpell disease)?
- What is the hallmark sign?
Ankylosing Spondylitis (aka Marie-Strumpell disease)
o stiffness/fusing of the spine by inflammation, disease of young adults
o Associated with genetic marker HLA B27
o Features: MSK-sacroiliitis, enthesitis, synovitis; other signs-eyes, bowels, lungs, heart
o The hallmark sign is sacroiliitis; may also feel deep, dull pain in buttock area d/t inflammation of SI joint; fusion can occur over time
o Enthesitis - inflammation of entheses leading to bony erosion and overgrowth (entheses = where tendons, ligs, and joint capsule attach to bone)
Common sites are spine, hip, peripheral regions; syndesmophytes (bony spurs on 2 sides of a joint) can also cause bony fusion and rigidity
o Synovitis - usually affects peripheral jts, commonly shoulders, hips, knees, ankles
What is the clinical criteria for diagnosing AS
CLINICAL CRITERIA
- LBP + stiffness for more than 3 months
- Improves with ex, worse with rest
- AM stiffness
- Altered posture/muscle imbalances = deformities/instability
- HFP, thoracic kyphosis, flattening of anterior chest wall, protrusion of abdomen, flattening of lumbar lordosis, slight hip flex
- Decreased strength = deconditioning
- Decreased L-spine ROM in sagittal + front planes = flexion posture d/t pain, tissue contractures, mm guarding, fusing
- Altered breathing mechanics = decr chest expansion compared to normal values –> diaphragmatic breathing pattern and decr vital capacity
- Fatigue d/t disease process
Give a brief overview of Ankylosing Spondylitis?
- Onset
- Meds
- Diagnosis
- PT goals
- Physical assessment
Quick overview:
- Onset before 40, low back pain, sacroiliitis, kyphotic deformitiy Csp, Tsp, dec lumbar lordosis, M>F
- Meds: NSAIDS, corticosteroids, cytotoxic, tumor necrosis factor
- Diagnosis – HLA-B27
- PT goals: trunk flexibility, endurance, increase resp function (relaxation)
- Physical Ax - posture (tragus to wall), lateral trunk flexion, trunk flexion (modified schobers), trunk extension (smythe test), trunk rotation, chest expansion, cervical mobility
What is the treatment for spondyloarthritis
- Medical
- Physical therapy
- Outcome measures
Spondyloarthritis Rx:
- Meds- DMARDs, NSAIDs, corticosteroids, biologics
- Physical Management- control/decrease inflammation, P management, reduce stiffness/increase ROM, posture correction, increase mm strength and endurance, increase cardio
- Rx: maintain joint mobility with exercise, stretching, heat, and postural instruction/re-education
Outcome measures
- BASFI (impact of disease on fxn in last week)
- BASDAI (how disease is managed)
What is Enteropathic spondylitis?
ENTEROPATHIC SPONDYLITIS
Related to:
Inflammatory conditions of the bowel (cause diarrhea):
- Ulcerative colitis (affects lower half of bowels)
- Crohn’s disease (affects whole digestive system = worse)
Incr bowel disease = incr arthritis
Can also affect = Spine, SI joint, limb joints
Exercise in OA and RA
- Contraindications and red flags
- Precautions
EXERCISE IN RA AND OA
RA = primarily affects MCP + PIP, rheumatoid cachexia (breakdown of muscle fibres), fatigue!!!
OA = affects weight bearing joints hip, spine, DIP, PIP, first CMC, first MTP
BOTH BENEFIT FROM - aerobic, resistance, and stretching/ROM = pool is great for both
- Follow ACSM general but based on individual pat presentation
CONTRAINDICATIONS/RED FLAGS
o Incr pain, fatigue or AM stiffness
o sudden pain at joint or joint deformity
o joint becomes red, swollen and hot after doing exercise (within 24 hrs)
o Decr muscle strength and function (local myositis)
o neurological SSx (CV involvement)
o SOB on mild exertion
PRECAUTIONS
o watch out for inappropriate exercise = can harm joints (RA = deforming forces)
o swollen joints at risk for capsular stretch and rupture
o OP bone at risk for #
o use machine and resistance bands rather than free weights
Differentiate between T1DM and T2DM
DIABETES TYPE I
o juvenile onset
o require insulin
o immune mediated attach of islet cells in pancreas
o decreased circulating insulin
o PRESENTATION:
= weight loss, incr urination, dehydration
DIABETES TYPE II
o adult onset
o don’t need insulin = b/c doesn’t respond to it
- causes insulin resistance in peripheral tissues (don’t respond to insulin)
o PRESENTATION:
- obese
- acanthosis nigricans (hyperpigmented skin in axilla, groin, back of neck)
- HTN
NORMAL GLUCOSE LEVELS
o fasting plasma glucose: 5.6 mmol/L, diabetes >7 mmol/L
o impaired fasting plasma glucose : >5.6 mmol to <7 mmol/
Differentiate between Hypo and Hyperglycemia;
- What are some of the long term effects of hyperglycemia?
HYPOGLYCEMIA
o dizzy, nausea, weak, sweating profusely (this rules out orthostatic hypotension)
o fatigue, irritability, confusion, fainting
HYPERGLYCEMIA
o blurred vision, fatigue, thirst, frequent urination, weakness, abnormal breathing, acetone breath
o LONG TERM EFFECTS
- damage to small blood vessels (retinopathy and diabetic nephropathy)
- damage to large blood vessels = abnormal glucose metabolism causes increased cholesterol levels = vessel wall damage = atherosclerosis and myocardial infarction, stroke, gangrene
- damage to peripheral nerves = diabetic neuropathy
What are the considerations for physical therapy for a diabetic patient?
RX
- regular exercise = very important
- talk to MD about insulin levels for exercise
- have snack before (have raisins/juice available to boost sugar levels if necessary)
- monitor blood sugar levels pre, during, and post exercise
- avoid exercise at night = person may go to sleep and slip into a hypoglemic coma and die
- PT always monitor pt for SSx hyper or hypoglemia
What is fibromyalgia?
- Signs and symptoms
- Diagnositc criteria for fibromyalgia
- Treatment (medical and physical)
Fibromyalgia = chronic pain syndrome affecting mm and soft tissue (non-articular rheumatism); Etiology: unknown
S&S’s -headaches, sensitivity to stimuli, fatigue, myalgia (mm pain), generalized aching, sleep disturbances
11 of 18 points: Occiput (suboccipital insertions), low cervical (ant aspects of intertransverse spaces at C5-C7), Traps (mid-pt of upper border), Supraspinatus (at origin), Second rib (lateral to 2nd costochondral junction), lateral epicondyle, gulteal, greater trochanter, knee (at medial fat pad proximal to joint line)
Rx: anti-inflamm, mm relaxants, pain meds, psycholgical support, nutrition
PT Rx: energy conservation, aquatic therapy
What is Systemic Lupus Erthematosus?
Systemic Lupus Erthematosus
- Can involve kidney, CNS, cardiac, pulmonary; on skin may find BUTTERFLY rash, localized erythema and edema, alopecia (loss of hair), photosensitivity, mucosal ulcers, Raynaud’s (fingers are cold sensitive), effusion in joints; Associated with positive serum “antinuclear antibodies” (ANA)
- Typically presents with the articular feature: EFFUSIONS
- Will have the skin change of PHOTOSENSITIVITY
What is schleroderma?
Scleroderma - a relatively rare autoimmune disease affecting the blood vessels and connective tissue. It is characterized by fibrous degeneration of the connective tissue of the skin, lungs, and internal organs.
Autoimmunity provokes massive fibrotic tissue response which may lead to joint contractures, pulmonary fibrosis, GI dysmotility (esp esophagus)
o Produces tight, drawn skin
What is cellulitis?
Cellulitis: inflammation of cellular or CT in or close to the skin; characterized by fever, hot, red skin and edema
Differentiate between dermatomyositis and polymyositis
Dermatomyositis and polymyositis = inflam connective tissue disorders characterized by proximal limb girdle weakness, often w/o P.
- Dermatomyositis- affects both skin and mm; is also assocd. w/ a photosensitive skin rash, purplish erythematous eruption over face (esp upper eyelids), hands, forearms
- Polymyositis- mm only
What is Graves disease?
- Signs and symptoms
- Medical Mx
GRAVES’ DISEASE – hyperthyroidism, F>M
- autoantibodies stimulate the thyroid (TSH receptor), T3 and T4 (these inhibit the secretion of TSH) will be high
S/S
- fever, wt loss, exercise intolerance, goiters, bulging eyes (exophthalmos), tachycardia, decrd fertility
RX
- betablockers for HR, anti-thyroid drug therapy, radioactive Iodine, Sx removal of thyroid
What is Hashimotos disease?
- Signs and symptoms
- Medical Mx
HASHIMOTO THYROIDITIS – hypothyroidism, F>M
- autoimmune destruction of thyroid gland, T3 and T4 are low, TSH is high
S/S
- wt gain, cold intolerance, round puffy face, bradycardia, constipation, depression
RX
- thyroid hormone replacement
What is Addisons disease?
- Signs and symptoms
- Medical Mx
ADDISON’S
- autoimmune process against the adrenal cortex, fatal if not treated, great prognosis if treated
S/S
- weakness, fatigue, anorexia, hyponatremia, hypoglycemia, hyperpigmentation
RX
- replace missing adrenal hormone with aldosterone and cortisol
What is Cushings disease?
- Signs and symptoms
- Medical Mx
CUSHING’S DISEASE
- chronic glucocorticoid (cortisol) excess
- can also get from cancer of adrenal gland
S/S
- moon face, central obesity, abdominal striations
RX
- surgical if caused by tumor (tumor in pituitary or adrenal gland)
