Geriatric Studies
Diabetes
Kineseology
Muscle Testing
Medical Illustrations
A. Clinical terminology: a chronic systemic disorder characterized by high blood glucose (hyperglycemia) and the disruption of metabolism of fats, proteins and carbohydrates.
1. Characteristics: The insulin produced for the body is either ineffective or lacks an effective quantity.
a. Risk factors: hereditary & environmental factors, ethnic origins, obesity, and history of gestational diabetes, medications, age and chronic pancreatitis
b. Inappropriately elevated blood glucose levels that could lead to end organ complications: nephropathy (kidney disease); retinopathy (loss of eye sight); neuropathy (nerve dysfunction - sensation); accelerate atherosclerosis;
c. No distinct etiology
d. No distinct curative therapy
e. A combination of disorders - endocrine, metabolic, carbohydrate metabolism, lipid metabolism
2. Insulin - hormone that helps your body use energy from sugar, starches & other foods; made in the pancreas; releases it to the blood stream to bind to sugar and create energy
3. Glucose - a form of sugar produced when the body digests food, sugars, starches you eat; this is your blood sugar; normal range is 70-120 mg/dL
B. Types
1. Insulin dependent (Type I); depends on insulin to control blood sugar level
a. Possible causes: genetic predisposition; viral infection of the pancreatic islet cells; autoantibody against beta cells
2. Non - insulin dependent (type II): no insulin to control blood sugar levels; may or may not need medication
a. Possible causes: genetics; diet (high calories); obesity; lack of exercise; insulin resistance (related to diet & exercise); primary diseases - pancreatitis, pancreatic cancer, Cushing�s disease, hyperlipidemia
3. Temporary types due to a medical condition, medications, and pregnancy
C. Signs and symptoms: Onset usually indicative of Hyperglycemia or diabetic ketoacidosis (see below)
D. Possible complications:
1. Hypoglycemia: low blood sugar (< 50mg/dL)
a. Cause: small or missed meal, error in insulin dosage, increase in exercise routine or without apparent cause.
b. Onset is sudden, may lead to insulin shock
c. Signs and symptoms: shakiness, increased heart rate, cool sweating, light headedness, dizziness, hunger, impaired vision, weak, fatigue, headache, mood swing or behavior changes, confusion, pallor, tingling sensation in the mouth, clumsy or jerky movements.
d. Emergent treatment: eat sugar�5-6 pieces of hard candy, � cup of orange juice, 3 glucose tablets, or milk then test blood sugar; 30 minutes after symptoms... eat a healthy snack
2. Hyperglycemia: high blood sugar (> 200 mg/dL)
a. Cause: larger meal than required, small amount of insulin, illness/infection, stress, antibiotics or decreased amount of exercise
b. Onset is gradual and may progress to a diabetic coma
c. Signs and symptoms: extreme thirst, frequent urination, dry skin, blurred vision, fatigue/lethargy, nauseated or abdominal pain, dizziness; increased appetite; ketones and glucose in the urine; weight loss; infection.
a. Emergent treatment: test blood sugar > 250 mg/dL then call physician; monitor patient until help arrives
3. Ketoacidosis
a. Cause: flu, cold or infections, hyperglycemia above; rarely from Type 2 and slow onset
b. Signs and symptoms:
(1) First symptoms- Thirst or dry mouth, frequent urination, high blood glucose level, ketones in the urine
(2) Second symptoms: Fatigue and tiredness, dry skin, nausea, vomiting or abdominal pain; difficulty breathing ( short, deep breaths) Fruity odor on breath, confusion and lack of attention
(3) Vomiting indicates seriousness and becoming life-threatening
b. Ketoacidosis from hyperglycemia may cause renal and cerebral impairment, usually in the elderly or mildly obese or diabetic coma or even death
4. Eyes: vision changes- blurred, Retinopathy (change in retina), may lead to blindness, especially in the age range of 20 �74 years old
5. Heart - chest pain, shortness of breath, hypertension (HTN), increase heart rate, increase cholesterol level, increase risk for CVA (cerebral vascular accident)
6. Kidney - protein in urine, increase blood pressure, hemodialysis once kidneys fail to function.
7. Neuropathy of the foot or hand: pain, numbness, and decrease-healing process, decrease clotting mechanism.
8. HTN and Diabetes go hand in hand: HTN twice as common in people with diabetes due to increase heart pumping.
E. Management:
1. Manage diet: regular meal schedule,
2. Medications
3. Maintain body weight
4. Regular exercise program
5. Avoid high fat food
6. Avoid concentrated sweet foods
7. Don�t smoke: vasoconstriction, decrease circulation to peripheral areas
8. Education
9. Foot Care: Very important because of neuropathy and increase risk for wound injury that could lead to an amputation.
a. Wash and dry well
b. Check feet daily for redness, blisters, swelling, callous, corns
c. Careful cutting nails; better to have a podiatrist do it especially when it�s hard and thick
d. Don�t use iodine, peroxide, etc. on wounds
e. Keep skin soft
f. Wear clean socks and comfortable shoes (1/2 size larger) break in new shoes slowly
g. Don�t use extremely hot water
D. Physical therapy ( See tables____: Diabetes Mellitus key points to remember and benefits and potential risks of exercise)
1. Precautions/contraindications:
a. Do not exercise patient with high levels of ketones in urine or high blood sugar level.
b. Inform PT and notify physician if patient presents any sign of hypoglycemia, hyperglycemia or ketoacidosis.
c. Ask patient about the nutritional intake prior to beginning treatment.
d. Be aware that the patient may not exercise intensely to reach the calculated heart rate.
e. No exercise for those with autonomic neuropathy.
f. No exercise for those with blood glucose of 300 mg/dL or higher due to possible increase in blood sugar level.
g. Physical agents of heat and cold must be used cautiously and sensation must be tested.
2. Interventions
a. Exercise for strengthening, weight maintenance, glucose transport and ROM.
b. Diabetic foot care education
c. Education of importance of physical fitness and diabetes.
d. Monitor glucose levels before and after treatment sessions.
IV. Genitourinary
A. Fluid and electrolyte balance:
1. Key component of cellular metabolism
2. Homeostasis is maintaining the body�s chemical and physical balance by body fluid that nourishes and supports the cell.
B. Imbalance conditions
1. Dehydration: excessive decrease in body fluids; most commonly seen and most dangerous
a. Signs and symptoms: More output than intake; poor skin integrity and turgor, increase body temperature, headache, lethargy, confusion/disorientation, postural hypotension, vertigo, muscle cramps, diarrhea, vomiting, irritability, rapid pulse and respirations, and incoordination
b. Risk of hypovolemic shock
c. Causes: emesis, sweat, heat, diuretics, sodium deficiency
d. Management: hydration, decrease exercise capacity, offer water during treatment
e. PTA precaution: fatigue, fainting, monitor vital signs
2. Overhydration: excess body fluid
a. Signs and symptoms: swelling or edema in interstitial tissues; increase blood pressure and heart rate; shortness of breath with activity; lethargic; muscle cramps, twitches and stiffness; weight gain; headache, blurred vision
b. Causes: Excessive fluid intake; acute renal failure, congestive heart failure, cirrhosis
c. Management: diuretics; edema massage; elevation of extremities
3. Potassium imbalance: Normal serum level is 3.5 to 5.5 mEq/L
a. Hypokalemia: decreased potassium concentration in the blood stream
(1) Signs and symptoms: muscle fatigue and weakness; lower extremity cramps; slow reflex; postural hypotension; dizziness; arrhythmia; irritability, confusion; depression; respiratory distress; nausea; vomiting; diarrhea; lack of appetite
(2) Causes: Poor nutrition, decreased food intake, Cushing�s disease, diuretic medications, increased aldosterone level, kidney disease
(3) Management: potassium replacement drink or IV medication
(4) PTA implications: restore strength and function while monitor orthostatic hypotension and cardiopulmonary response to activity
b. Hyperkalemia: increased potassium concentration in the blood stream
(1) Signs and symptoms: muscle weakness; flaccid paralysis; bradycardia that could lead to cardiac arrest; arrhythmia; nausea, diarrhea. Abdominal cramps
(2) Causes: High potassium diet in renal failure patients, kidney failure, Addison�s disease, decreased aldosterone insulin deficiency, trauma to muscle
(3) Management: adjust diet, hemodialysis, electrolyte medication
(4) PTA implications: restore strength and function and monitor cardiopulmonary response to activity
4. Sodium imbalance: Normal serum level is 134-145 mEq/L
a. Hyponatremia: serum sodium level below 135 mEq/L in the blood stream
(1) Signs and symptoms: muscle weakness and twitching; hypotension; tachycardia; anxiety; headaches, restlessness; convulsions; cyanosis; cold, clammy and decreased skin tugor; circulatory collapse and shock
(2) Causes: Addison�s disease; Excessive fluid loss via sweating, vomiting, diarrhea or diuretic medication, increased body water;
(3) Management: replace sodium, cease fluid loss
(4) PTA implications: exercise and strength restoration
b. Hypernatremia: Serum sodium level above 145 mEq/L in the blood stream
(1) Signs and symptoms: weight gain, pitting edema, pulmonary edema, hypertension, tachycardia, agitation, restlessness, flushed skin, sticky mucous membranes, convulsions
(2) Cause: Cushing�s disease; salt water ingestion; decreased fluid intake, dehydration; diabetes insipidus; kidney disease; watery diarrhea
(3) Management: hydration methods; treat the medical conditions to lower the sodium levels to the normal range
(4) PTA implications: restore functional ability, monitor cardiopulmonary response to treatment
5. Calcium imbalance:
a. Hypocalcemia: Diminished calcium in the blood stream
(1) Signs and symptoms: Muscle cramps, tetany, spasms, parethesia (tingling and numbness), anxiety, irritability, twitching, arrhythmia, hypotension, convulsions
(2) Cause: Renal disease or renal failure, hypoparathyroidism, decreased GI absorption of calcium, decreased vitamin D
(3) Management: replace calcium
(4) PTA implications: muscle cramp management
b. Hypercalcemia: Excess calcium in the blood stream
(1) Signs and symptoms: Decreased muscle tone, weakness, bone pain, lethargy, drowsiness, headaches, confusion, irritability, heart block, weight loss, loss of appetite, nausea, cardiac arrest, hypertension, increase risk of fractures
(2) Cause: Hyperparathyroidism, bone atrophy, bone cancer,
(3) Management: treat medical conditions present; reduce the calcium level to normal range
(4) PTA implications: pain management, exercise, functional safety
6. Acid-base balance: keeping the pH of extracellular fluid in the body relatively constant; blood pH is 7.35 to 7.45;
a. Respiratory acidosis: CO2 retention, impaired alveolar ventilation
(1) Signs and symptoms: dyspnea, cyanosis, headache, restlessness, disorientation, sleepiness, decreased deep tendon reflex and coma
(2) Causes: hypoventilation, chronic pulmonary disease, Guilain Barre�, Myasthenia gravis, hypermetabolism, over-sedation of medication
(3) Management: maintain adequate levels of oxygen; treat the underlying cause, functional restoration
b. Respiratory alkalosis: low CO2, alveolar hyperventilation
(1) Signs and symptoms: tachypnea, anxiety, dizziness, parethesia, lack of concentration, blurred vision, muscle cramps, diaphoresis, weakness, tetany, twitching, arrhythmia, convulsions, dry mouth
(2) Causes: hypoxia, anxiety with hyperventilation, impaired lung expansion, CHF, pulmonary embolism, salicylate poisoning, stress, liver disease, CNS disease, scoliosis, sepsis, excessive exercise
(3) Management: resolve anxiety, relaxed breathing with functional activities
C. Urinary tract disorders
1. Infections
a. Urinary Tract Infection (UTI): infection of the urinary tract and bladder
(1) Signs and symptoms: pain, burning sensation with urination; urgency, frequency, dysuria; find blood in urine; back pain, fever and chills and malaise may be present.
(2) Cause: gram negative bacteria, stress
(3) Management: antibiotics, increase water intake, mobility, pelvic floor exercises
b. Cystitis: inflammation of the bladder and repeated bladder infections; may involve the kidneys and ureters; lower UTI
(1) Signs and symptoms: frequency, urgency, burning sensation during urination, pelvic pain, hematuria, fever, chills, malaise
(2) Cause: bacteria, calculi, tumors
(3) Management: antibiotics, pelvic floor exercises
c. Pyelonephritis ( pelvis nephritis): inflammation and infection of the renal pelvis & connective tissue of kidney
(1) Signs and symptoms: fever, chills, pain, nausea, frequency and burning with urination, malaise, headache, back pain; acute (bacterial infection) or chronic (tubulointerstitial disorder)
(2) Causes: bacteria, viral infection, calculi, pregnancy, tumors, mycosis
(3) Management: antibiotics, pelvic floor exercises
2. Obstructive disorders: blockage in flow process; bladder retention without emptying
a. Neurogenic bladder: abnormal activity of bladder or paralysis; involuntary retention of urine.
(1) Signs and symptoms: bladder distends, burning sensation with urination, fever with chills
(2) Causes: spinal cord or brain injury; neurological disease; diabetes; degenerative disease
(3) Management: straight catherization, foley, permanent suprapubic cystostomy, abdominal exercises
b. Kidney stones (renal calculi): crystallized minerals in renal pelvis made of calcium and uric acid
(1) Signs and symptoms: pain, unable to urinate
(2) Causes: Crystallization of calcium and minerals
(3) Management: medication for increase output and dissolving the stone, laser, high energy sound waves (lithotripsy), surgery,
5. Renal failure: kidneys unable to function
a. Acute: temporary or sudden loss of kidney function increasing the serum urea and creatinine
(1) Cause: toxic substances, infections, acute obstruction, trauma
b. Chronic: progressive kidney function loss to end-stage failure.
(1) Cause: diabetes mellitus, prolonged acute urinary tract obstruction and infection, systemic lupus erythematosus, uncontrolled hypertension, hereditary defects of the kidneys, glomerular disorders
(2) Signs and symptoms: fatigue, decreased alertness, inability to concentrate, dizziness, headaches, anxiety, pain/restlessness in legs, peripheral and pulmonary edema, muscle weakness, muscle tremors, Osteomalacia, osteoporosis, anemia, functional losses, orthostatic hypotension, dry skin, pallor, pruritus, brittle/thin fingernails, metallic taste in mouth, nosebleeds, ecchymosis, heart failure, hypertension, dyspnea with activity, memory loss, low endurance, anorexia, impotence, nausea, vomiting
c. Treatment:
(1) Hemodialysis or peritoneal dialysis: artificial kidney; filter blood of toxic substances; maintain fluid, electrolyte and acid-base balance; weigh patient before and after dialysis while monitor blood pressure during dialysis
a. Signs and symptoms: nausea, vomiting, drowsiness, change in blood pressure, headaches, seizures, fatigue and generalized weakness, decreased alertness and concentration
(2) Physical therapy: monitor vital signs, ROM, increase strength, function and endurance, provide sufficient rest periods, family/ caregiver instructions
(3) Avoid taking blood pressure on the shunt site
(4) Kidney transplantation
6. Urinary incontinence: inability to retain urine; weak bladder or weak sphincter control
a. Four categories:
(1) Functional/Total incontinence: lose urine at all times irregardless of position associated with inability or unwillingness due to:
� Impaired cognition like dementia or depression
� Impaired physical functioning like spinal cord injury or stroke
� Environmental barriers
(2) Stress incontinence: loss of urine during activities due to:
� increase in the intra-abdominal pressure liked sneezing and coughing
� weak pelvic floor muscles and sphincter like pregnancy or pudendal nerve damage
(3) Urge incontinence: loss of urine by an unexpected strong urge to void or after bladder fullness; inability to reach the toilet in time due to:
� Detrusor instability like from a stroke
� Hypersensitive bladder
(4) Overflow incontinence: uncontrolled continuous leakage of urine secondary to retention of an overdistended bladder or incomplete emptying due to:
� Anatomic obstruction like fecal impaction
� Acontractile bladder like diabetes, or medication
� Neurogenic bladder like brain tumors or multiple sclerosis
b. Management:
(1) Dietary control: monitor foods and fluids that aggravate the bladder and incontinence such as caffeine, juices; control the fluid intake
(2) Medical management:
� Drug therapy for stress, urge and overflow incontinence, e.g. estrogen with phenylepropanolamine
� Treat reversible problems
� Evaluate and control medications for other medical conditions that may aggravate incontinence, e.g. diuretics for CHF
� Catheterization for overflow incontinence or nonresposvie to other treatment regimens but a high risk of UTI
� Surgery to remove obstruction or cystocele, bladder neck suspension
(3) Bladder training: training to respond to a voiding schedule
� Voiding diary involving a routine of regular intervals and taking the person to the toilet
� May include intermittent catheterization
c. Physical therapy goals, outcomes, and interventions for stress and urge incontinence as established and delegated by the Physical therapist:
(1) Assessment
� Symptoms and history of incontinence such as onset, duration, urgency, frequency, timing of episodes and causative factors
� Strength of pelvic floor muscles
� Functional mobility and environmental factors
(2) Instructional Pelvic floor muscle strengthening exercises (pubococcygeus muscle) for stress incontinence
� Kegel Exercises: active muscle contraction and strengthening: Type 1 involves holding contractions to a goal of 10 second holds and 10 second rests between contractions; Type 2 involves holding short contractions during the flow of urine, 10-80 times per day. Avoidance of squeezing buttocks or contracting abdominals or bearing down is important.
� Functional electrical stimulation for muscle re-education; patient unable to initiate contractions.
� Biofeedback: pressure recordings to reinforce contractions and relaxations
� Progressive strengthening: Weighted vaginal cones or pelvic floor exerciser for home exercise program.
� Incorporating Kegel exercise into functional activities such as coughing, sneezing, lifting, positional changes, etc.
(3) Behavioral training
� Voiding diary: record keeping of daily activities of voiding and nutritional intake
� Education: explanation of anatomy, physiology, causes of muscle weakness, incontinence, avoidance of Valsalva maneuver, exercise program
(4) Functional mobility training as needed to ensure independence and safety for sit-to �stand transitions, ambulation and toilet transfers.
(5) Environmental and home modifications: raised toilet seat, portable commode, toilet rails, lighting, etc.
(6) Maintenance of skin condition
� Instruct appropriate skin care and toileting schedule
� Skin protection with adult diapers and underpads
(7) Provide psychological support for the impact of the emotional and social consequences of incontinence.
V. Immune system and infectious disorders
A. Allergy: hypersensitivity of immune system to relatively harmless environmental antigens
1. Signs and symptoms: rash, watery eyes, utricaria, sneezing, edema, shortness of breath,
2. Etiology: response to antigen-antibody reaction to trigger histamine to inflammatory response to anaphylactic shock
3. Management: antihistamine medication; avoid triggers
4. PTA precautions: knowledge of allergic triggers
D. Center for Disease Control (CDC) Guidelines for Isolation Precautions
1. Standard Precautions: protective asepsis (see table 5.1)
a. Purpose: prevent transmission and spreading of the infectious disease and control nosocomial infection
b. Major features:
(1) Universal Precautions: blood, blood products and body fluid precautions.
(2) Body substance Isolation: decrease risk of transmission from moist body substances
2. Transmission-based precautions: for patients with known or suspected infections of highly transmissible or epidemiological pathogens such as airborne, droplet and contact precautions (see table 5.2)
F. Physical therapy Infection control:
1. Purpose: to eliminate infectious organisms or bacteria
2. Sterilization: total destruction of all microorganisms by exposure to chemical and physical agents
a. Autoclaving: heat at 250-270� F with water pressure
b. Boiling water at 212� F
c. Ionizing radiation
d. Dry heat
e. Gaseous
3. Disinfection: reduce the number of microorganisms; typically used on surfaces or equipment
a. Ultraviolet light: used for air and surface disinfection
b. Filtration: water or air purification
c. Physical cleaning with ultrasonic means or washing with antimicrobial products
d. Chemical cleaning with chlorination, iodines, phenols, quaternary ammonia compounds, formaldehyde
e. Hydrotherapy disinfection: drain and clean tank, scrub pumps and equipment with a germicidal detergent e.g. Chlorazene, rinse well
4. Antisepsis: inhibits or destroys microorganisms living on the skin or living tissue
a. Antiseptic solutions e.g. Povidone-iodine (Betadine)
b. Quaternary ammonia compounds e.g. Zephiran
c. Mercurial
d. Germicidal soaps e.g. pHisoHex
e. Antibacterial additives to hydrotherapy equipment
VI. Hemophilia
A. Clinical characteristics/ management
1. Pathophysiology: Bleeding disorder
a. Inherited sex-linked recessive disorder of blood coagulation affecting males; females are the carriers
b. Hemophilia A ( clotting factor VIII deficiency); Hemophilia B (clotting factor IX deficiency)
c. Percentage of clotting factor determines the severity
d. Synovial joints prone for hemarthrosis ( bleeding in the joints) causing swelling, warmth, pain, decreased ROM, leading to cartilage destruction
e. Hemorrhage into muscles of forearm flexors, gastrocnemius, soleus, iliopsoas producing pain and decreased movement
f. Bleeding can be spontaneous or from trauma
2. Medical management
a. Blood replacement therapy- infusion
b. NSAIDs, except aspirin for pain control
c. Rest, ice, elevation, functional splinting, no weightbearing during acute bleeding
d. No cure
3. Complications:
a. Joint contractures and joint inflammation
b. Muscle weakness around the affected joints
c. Leg-length discrepancies
d. Postural scoliosis
e. Decreased aerobic endurance
f. Gait deviations
g. ADL difficulties
B. Physical therapy goals, outcomes and interventions as established and delegated by the PT
1. Assessment performed by the physical therapist upon initial evaluation
a. Clinical signs and symptoms of acute bleeding episodes- parathesia, stiffness, pain, swelling, decreased ROM, tenderness, heat
b. Goniometry measurements
c. Joint deformities- valgus and varus
d. Muscle strength
e. Functional mobility skills, gait
f. Pain level
g. ADL assessment
2. Acute stage interventions:
a. PRICE: Protect, rest, ice, compression, elevation
b. Maintain position, prevent any further deformity
3. Sub-acute stage intervention after hemostasis:
a. Factor replacement therapy first.
b. Isometric exercise, aquatic therapy
c. Pain management physical modalities: TENS, Ice, massage,
d. Active assistive exercise to active to isokinetic and open chain resistive exercises.
e. Precaution or avoidance of closed chain exercise due to excessive compressive force through the joint
f. Contracture management techniques
g. Functional mobility and gait training- Assistive devices, orthoses, etc.
4. Chronic stage intervention:
a. Daily home exercise program for strength, functional activities, joint ROM
b. Outpatient therapy sessions as needed
c. Appropriate recreational activities, caution with contact sports
d. Emotional support for patient and family
VII. Oncology
A. Cancer: broad group of diseases characterized by uncontrolled growth and spread of abnormal cells
1. Terminology
a. Neoplasm (tumor): new mass of cells, abnormal growth
b. Benign tumor: harmless growth, stay together & surrounded by a capsule; not life-threatening but may disrupt organs, localized
(1) Lipoma: adipose or fat bump
c. Malignant tumor: cells break away & travel through blood and lymph vessels to other body parts; life-threatening; rapid growth leading to metastasis
(1) Malignant from epithelial tissues: carcinomas
� Melanoma : melanocytes (pigment producing cells of skin)
(2) Malignant from connective tissue: sarcomas
� Osteosarcoma:� malignant tumor of bone tissue
(3) Malignant in the lymphatic system: Lymphoma
(4) Malignant in the bone marrow or blood system:
� Myeloma and leukemia:
(5) Miscellaneous: doesn�t fit the categories (neuroblastoma, skin, lung, and stomach)
d. Metastasis: �spreading� of the cancer cells from one organ to another; cells grow rapidly and replace organ with undifferentiated tissues; spread through the lymphatic system or blood stream
2. Characteristics: may affect any body organ
a. Etiology: Unknown but associated with risk factors:
(1) Genetics (e.g. hereditary)
(2) Carcinogens: chemical (e.g. smoking), radiation (e.g. sun exposure), viral (e.g. AIDS)
(3) Age (e.g. elderly)
(4) Dietary (e.g. obesity)
(5) Environmental (e.g. geographic location)
(6) Psychological (e.g. stress)
(7) Ethnicity
(8) Life-style behavior
b. Early warning signs:
(1) Unusual bleeding or discharge
(2) Sores that don�t heal
(3) A lump or thickening any where in the body
(4) Persistent cough or hoarseness
(5) Chronic indigestion or difficulty swallowing
(6) A change in mole or wart size and appearance.
(7) Change in bowel or bladder function
(8) Unusual weight loss
(9) Fatigue
c. Pathogenesis: Early detection important: primary tumors before
metastasis to secondary tumors has begun is the most treatable
(1) Detection methods: Self-examination(breast, testicular, skin lesions); Diagnostics:(radiography � CT, MRI, US); Biopsy of known neoplasm; Blood test
(2) Classification (staging): describes extent and prognosis of disease; influences treatment regimen
(3) Second leading cause of death in the U.S.
(4) Prognosis: higher success rates linked to early detection and treatment; aggressive treatment regimens; and quality of life outlook.
3. Medical interventions: curative and/or palliative
a. Surgery
(1) Curative- removes tumor or cancerous organ or cancerous tissues
(2) Palliative- relieve pain or obstruction
(3) Post-surgical treatment of chemotherapy or radiation or both
(4) Possible loss of function and weakness and edema
b. Chemotherapy � use cytotoxic compounds (anti-neoplastic drugs) to destroy any cancerous cells left and immune system
(1) Drugs given orally, subcutaneously, intramuscularly, intravenously, intrathecally (spinal)
(2) Intermittent dosages allow for bone marrow recovery
(3) Used in metastatic disease
c. Radiation therapy� ionizing or particle radiation to destroy dividing cells with or without chemotherapy
(1) Preoperatively used to shrink tumor and prevent metastasis
(2) Used for more localized lesions
d. Laser � intense beam of light; could be in combination with radiation and chemotherapy
e. Biotherapy (formerly immunotherapy)� increase body�s defense to fight cancer
(1) Vaccines now researched
(2) Interferon treatments
(3) Stem cell transplantation (bone marrow or umbilical cord stem blood cells)
(4) Monoclonal antibodies from B-lymphocytes
(5) Hormonal therapy for certain cancers
f. Local and systemic side effects of cancer therapy
(1) Surgery: Infection, increased pain, loss of function, deformity, and disfigurement
(2) Radiation therapy: radiation sickness, burns, immunosuppression, fibrosis, edema, diarrhea, delayed wound healing, hair loss, and CNS effects
(3) Chemotherapy: Gastrointestinal effects-anorexia, nausea, vomiting, diarrhea, ulcers, hemorrhage, bone marrow suppression, skin rashes, neuropathies, hair loss, sterilization, phlebitis
(4) Biotherapy: Fever, chills, nausea, vomiting, anorexia, fatigue, fluid retention, and CNS effects
(5) Hormonal therapy: nausea, vomiting, hypertension, steroid-induced diabetes, myopathy, weight gain, altered mental status, hot flashes, sweating, impotence, decreased libido
4. Hospice: care for the terminally ill patient and family
a. Right to live and die with dignity
b. 6 months or less to live
c. Interdisciplinary focus
d. Palliative care at home or in a hospice facility
e. Make death more acceptable and peaceful
f. Provision of supportive services: emotional, physical, social, spiritual, and financial
B. Physical therapy Assessment performed by the PT on the initial evaluation
1. Detailed systems assessment dependent upon cancer history.
2. Assess pain
a. Cancer pain syndrome: cancer-related pain is a common experience, e.g. nerve or nerve root compression, ischemic response to blockage of blood supply, bone pain. Sympathetic signs and symptoms may accompany moderate to severe pain, e.g. tachycardia, hypertension, tachypnea, nausea, vomiting
b. Pain at site distal to initial tumor site may suggest metastasis.
c. Iatrogenic pain may result from surgery, radiation or chemotherapy.
3. Lung, breast, prostate, thyroid and lymphatic cancers commonly metastasize to bone. Pathological fractures, pain and muscle spasms may result.
4. Paraneoplastic syndromes: signs and symptoms are produced at a site distant from the tumor or its metastasized sites, from ectopic hormone production by tumor cells or metabolic abnormalities from secretion of tumor vasoactive products.
a. Cushing�s syndrome can result from small cell cancer of the lung.
b. Symptoms can result from cancer stimulation of antibody production, e.g. anorexia, malaise, diarrhea, weight loss, fever, progressive muscle weakness (Type II atrophy), diminished DTRs, myositis, joint pain.
c. Neurological syndromes can include cerebellar degeneration, peripheral neuropathy, myasthenia gravis, etc.
5. Assess for side effects of cancer treatment.
a. With immunosuppressed patient monitor vital signs, physiological responses to exercise carefully; may see elevated HR and BP, dyspnea, pallor, sweating, and fatigue. Patient is easily fatigued with minimal exertion.
b. Muscle atrophy and weakness: secondary to high doses of steroids in many chemotherapy protocols; weakness may result from disuse, or tumor compression/invasion.
c. ROM deficits: Particularly with high dose radiation around the joints.
d. Hematological disruptions:
(1) White blood cell suppression (leukopenia); increased susceptibility to infection.
(2) Platelet suppression (thrombocytopenia): increased bleeding.
(3) Red blood cell suppression (anemia): diminished aerobic capacity.
C. Physical therapy goals, outcomes, and interventions as established and delegated by the PT.
1. Educate patient and family about the disease process, rehabilitation goals, process, and expected outcomes.
2. Identify and support patient and family.
a. Assist in coping mechanisms.
b. Assist through the grieving process.
3. Provide proper positioning to prevent or correct deformities, maintain skin integrity; provide for overall patient comfort.
4. Edema control: elevate extremities, active ROM, massage; post-operative compression (elastic bandages, pressure garments).
5. Pain control.
a. TENS stimulation: may not control deep cancer pain; effective for post-operative pain.
b. Massage
6. Maintain or correct loss of range of motion: active-assisted/stretching, active ROM exercises.
7. maintain or correct loss of muscle mass and strength.
a. Isometric and light weight isotonic strengthening exercises safe for most patients with cancer.
b. Patients with significant bony metastasis, or osteoporosis. Low platelet counts (<20-25,000):
(1) AROM exercise only; no resistive exercise
(2) Weight bearing may be restricted; provide appropriate
ambulatory aids, orthoses.
(3) High risk of vertebral compression and other fractures with metastatic disease. Use light exercise only.
8. Maintain or increase activity tolerance and cardiovascular endurance, e.g. cycle ergometry, ambulation, energy conservation techniques.
a. Following prolonged bedrest or inactivity: careful assessment, gradual exercise and activity progression; submaximal aerobic exercise is indicated.
b. Monitor fatigue levels. Use activity pacing, carefully balance activity and rest periods; use short sessions throughout the day. Teach energy conservation techniques.
c. Precaution with patients who are anemic: may experience decrease aerobic capacity.
d. Precaution with certain types of chemotherapy (e.g. Adriamycin): may experience cardiac side effects.
e. Precaution with severe bony metastases, weakness: light aerobic exercise (cyclic, swimming) may be indicated.
9. Maintain or increase independence in:
a. Activities of daily living (ADLs) e.g. self-care.
b. Functional mobility skills, e.g. bed mobility, transfers, ambulation.
c. Coordination, balance, and safety.
10. Specific considerations for exercise programs.
a. Post mastectomy
(1) Focus is on restoration of pain-free full ROM of the shoulder, prevention/reduction of edema, restoration of function.
(2) Early post-operative exercise is stressed: some protocols as early as day one.
b. Post-bone marrow transplant
(1) Experience prolonged hospitalization and inactivity: average is 30 days; prolonged chemotherapy and radiotherapy, strict isolation.
(2) Focus is on restoration of function, overcoming the effects of deconditioning.
(3) Exercise is contraindicated in patients with platelet counts 20,000 or less; use caution with counts 20-30,000.
11. Physical agents (see also chapter ___)
a. Thermal agents (hot packs, paraffin baths, fluidotherapy, infrared lamps) and deep heating agents (ultrasound, diathermy).
(1) Do not use directly over tumor.
(2) Do not use over dysvascular tissue: tissue exposed to radiation therapy.
(3) Do not use with individuals with decreased sensitivity to temperature or pain in affected area.
(4) Do not use in areas of increased bleeding or hemorrhage, typically the result of corticosteroid therapy.
(5) Do not use with acute injury, inflammation, and open wounds.
b. Cryotherapy
(1) Do not use with patients with insensitivity to cold, or delayed wound healing.
(2) Do not use over dysvascular tissue: Tissue exposed to radiation therapy.
c. Hydrotherapy with agitation
(1) Do not use over dysvascular tissue: tissue exposed to radiation therapy.
(2) Do not use with individuals with decreased sensitivity to temperature or pain in affected area.
(3) Do not use in areas of increased bleeding or hemorrhage or open wounds.
(4) Risk of cross infection is high with immunosuppressed patients.
VIII. Peripheral Vascular Disease (PVD)
A. Characteristics: disease of the vascular (blood vessel) system affecting arteries, veins and lymphatics.
1. Results in chronic systemic problems
2. Decreased blood flow to and from the blood vessels to the extremities
3. Factors affecting PVD:
a. Smoking: constricts blood vessels
b. Diabetes
c. Hypertension
d. Hyperlipidemia (high cholesterol; high fat diet)
B. Arterial disorders
1. Acute arterial occlusive disease: sudden cessation of blood flow to the extremity, requiring emergency surgery
a. Arterial thrombosis: blockage in the artery due to plaques, clot or foreign body associated with a pre-existing atherosclerotic condition
b. Arterial embolism: a thrombus that breaks away and lodges elsewhere in the body causing an ischemic episode.
c. Signs & symptoms: sudden onset of pain, decreased pedal pulses, discoloration, hair loss, skin temperature changes, pallor, parathesia, lack of sensation
d. Ischemic conditions may lead to gangrene (tissue hypoxia or anoxia), decreased motor function and paralysis
e. High risk for arterial ulcer development
2. Chronic arterial insufficiency: see cardiac chapter on atherosclerosis
a. Intermittent claudication: leg pain during exercise due to inadequate blood supplies to the legs; may occur in the palms of the hands.
(1) Etiology: Ischemia due to atherosclerosis;
(2) Signs and symptoms: pain with activity usually in the calf musculature, ache, cramping or feeling tired with ambulation; rest pain may occur; pallor and decreased pedal pulses
3. Arterial ulcers: �ischemic ulcers�; shallow to deep wounds, circular edges and pink in color
a. Etiology: Arteriosclerosis, atheroembolism
b. Signs and symptoms:
(1) Painful, especially with leg elevation
(2) Pulses poor or absent
(3) Claudication and resting pain
(4) Atrophic changes
(5) Non-healing trauma
4. Medical management: heparization to dissolve clot, surgery to remove blockage, treatment of underlying atherosclerosis, diet and life-style behavioral changes, medications for underlying medical conditions, wound care
5. Physical therapy goals, outcomes and interventions as established and delegated by the physical therapist:
a. Assessment of the arterial condition and ulcers as performed by the physical therapist at the initial evaluation
b. Restore functional mobility after prolonged bedrest
c. Measure patient for compression garments due to residual edema
d. Education of risk factors and disease process
e. Skin and wound care (see wound section)
f. Progressive ambulation program
g. Support risk factor modification
6. Raynaud�s disease or phenomena: intermittent episodes of small arteriole constriction of the extremities in response to cold temperature or strong emotions such as anxiety or excitement.
a. Etiology: Unknown but evidence of hypersensitivity of the digital arteries to cold (fingers more than toes), release of serotonin, and congenital disposition.
b. Signs and symptoms:
(1) Cold sensation in the digits
(2) Temporary pallor
(3) Cyanotic and often numb or painful
(4) Skin changes from blue to white to red
c. Medical management:
(1) Warming in water or environment temperature change
(2) Treat underlying stimuli or possible medical condition
(3) Prevent vasospasm with vasodilating medications
(4) Analgesics for pain
d. Physical therapy goals, outcomes and interventions as established and delegated by the PT.
(1) Monitor room temperature during treatment.
(2) Biofeedback for relaxation
(3) Stress management techniques
(4) Education on managing symptoms and skin care and cold protection
C. Venous disorders
1. Acute venous disease or thrombophlebitis: partial or complete occlusion of a vein by a thrombus with inflammation of the venous walls. Occurs in the deep veins or superficial veins of the lower extremity
a. Etiology: post-surgical procedure (Deep vein thrombosis); venous stasis, hypercoagulation, or injury to venous wall.
b. Signs and symptoms:
(1) asymptomatic or symptomatic
(2) Dull ache, tight feeling or pain in the calf musculature
(3) Slight to moderate edema with warmth and tenderness
(4) Prominent superficial vein
(5) Pain with weight bearing and ambulation relieved with rest and elevation
c. Medical management: heparization and bed rest until clot dissolves
d. Physical therapy goals, outcomes, and interventions as established and delegated by the PT.
(1) Prevent thrombosis formation by encouraging active muscle contractions of the lower extremity.
(2) Early brief ambulation periods.
(3) Coughing and deep breathing exercises
(4) Proper positioning- elevation
(5) After thrombophlebitis diagnosis: monitor for signs of cardiopulmonary conditions
(6) Observe for excessive bleeding after anticoagulation therapy (e.g.Coumadin)
2. Chronic Venous Insufficiency (CVI): also known as post-phlebitic syndrome; inadequate venous return over a prolonged period of time.
a. Etiology: usually follows an episode of DVT; trauma, varicose veins, and neoplastic obstruction of the pelvic veins.
b. Signs and symptoms:
(1) Chronic edema of the leg (pitting edema)
(2) Discoloration, thickening and coarseness to skin near the ankles
(3) High risk for venous stasis ulceration
(4) May develop cellulitis or dermatitis later in he disease process.
c. Medical management:
(1) Treat the underlying medical condition.
(2) Frequent leg elevation periods.
3. Venous ulcers (lower extremity only): shallow, irregular shaped wounds with white-creamy to fibrous slough covering a base of good granulating tissue.
a. Etiology: CVI, venous hypertension, malnutrition; immobility; trauma;
b. Signs and symptoms:
(1) Rarely painful, comfortable with elevation
(2) Normal arterial pulses
(3) Eczema or stasis dermatitis
(4) Edema
(5) Dark pigmentation (discoloration)
c. Wound management: See section on wound care
4. Physical therapy goals, outcomes and interventions as established and delegated by the PT.
a. Assessment of venous condition and ulcers as performed by the PT during the initial evaluation.
b. Edema reduction:
(1) Massage
(2) Compression garments- bandaging techniques in a spiral or figure 8 patterns with tighter tension distally.
(3) Intermittent compression pumps not to exceed current blood pressure reading.
c. Education of the disease process and functional precautions.
d. Whirlpool for up to 2 treatments for wound cleansing
e. Wound care for ulcers �see wound section
IX. Obstetrics and Gynecology
A. Pregnancy considerations
1. Average pregnancy weight gain: 20-30 lbs.
2. Childbirth education classes taught by physical therapy:
a. Relaxation training e.g. mental imagery, relaxation response
b. Breathing management: diaphragmatic, slow and deep; Lamaze method, avoid Valsalva maneuver
c. Provide information about pregnancy and childbirth.
3. Postural changes
a. Thoracic kyphosis with scapular protraction and shoulder internal rotation due to breast enlargement and post partum infant care
b. Cervical lordosis and forward head posture to compensate for the rounded shoulders
c. Increases lumbar lordosis to compensate for the shift in the center of gravity and the knees hyperextend
d. Center of gravity moves to a posterior position while weight shifts to the heels.
e. Posture changes do not correct spontaneously after childbirth.
4. Balance
a. Center of gravity shifts upward and forward due to the enlargement of the abdomen and breasts.
b. Ambulates with a wider base of support.
c. Difficulty with walking, stair climbing, lifting and reaching
d. Activities requiring rapid positional changes such as aerobic exercise or bike riding may be dangerous in the third trimester.
5. Ligamentous laxity secondary to hormonal influences, which may persist post-partum:
a. Joint hypermobility e.g. sacroiliac joint
b. Pain
c. Risk for injury to weight bearing joints of the lower extremities and pelvis.
6. Muscle weakness: Abdominal muscles stretch and pelvic floor muscle weaken as pregnancy progresses leading to stress incontinence.
7. Physical therapy goals, outcomes and intervention as established and delegated by the PT:
a. Assessment of posture, balance changes and musculoskeletal changes performed by the PT during the initial evaluation
b. Body mechanics training to prevent injury
c. Pelvic stabilization exercises e.g. pelvic tilts
d. Postural exercises to strengthen, stretch and train postural muscles
e. Safety strategies
f. Pelvic floor exercises e.g. Kegel exercise
g. Stretching to reduce muscle cramping
B. Physiological changes
1. Reproductive system
a. Uterus increase from 5 by 10 cm to 25 by 36 cm
b. Uterus increases in capacity and weight
c. The uterus becomes an abdominal organ once it leaves the pelvis.
2. Urinary system
a. Kidneys increase by about 1 cm
b. Increase risk of urinary infection due to the change in position of the ureters causing reflux and urinary stasis.
c. Increase pressure on the bladder causing frequent urination
3. Pulmonary system
a. Elevation of the diaphragm and widening of the rib cage
b. Hyperventilation throughout the pregnancy
c. Dyspnea with mild exercise
4. Cardiovascular system
a. Blood volume increases
b. Venous pressure on the lower extremities increases
c. Increase plasma volume
d. Increase pressure on the inferior vena cava therefore avoids supine positions.
e. Blood pressure decreases because of venous distensibility
f. Increased heart rate and cardiac output
g. Teach ankle pumps, wear loose clothing, elevate legs, and modify exercise routine with many rests.
5. Musculoskeletal
a. Abdominal muscles become stretched and weakened as pregnancy progresses
b. Decreased tensile strength in pelvic ligaments causing increased mobility of the structures supported by these ligaments.
c. Pelvic floor becomes stretches and weak and may lead to stress incontinence that may not spontaneously correct after childbirth.
d. Teach pelvic floor exercises, stretching and avoid Valsalva maneuver.
6. Thermoregulatory system
a. Increased basal metabolic rate
b. Increased heat production
c. Woman must dress cool and comfortable, increase fluid intake
C. Pregnancy � induced pathology and physical therapy interventions as established and delegated by the PT
1. Diastasis recti: lateral separation of the rectus abdominis at the midline of the linea alba;
a. Etiology: unknown
b. Signs and symptoms: a separation of 2 cm or more is significant; may have loss of abdominal wall support and associated back pain; Test in hook-lying position, tester�s hand perpendicular to rectus abdominis.
c. Management: Avoid abdominal exercise until separation is less than 2 cm; protective abdominal head lift exercise, pelvic tilts utilizing hands to support the abdominal wall.
2. Pelvic floor dysfunction
a. Muscle and soft tissue laxity:
(1) Cystocele: bladder drops below uterus, progresses to herniation through the anterior vaginal wall
(2) Rectocele: posterior vaginal wall and rectum bulge forward
(3) Uterine prolapse: protrusion of uterus
(4) Observe for urinary frequency and urgency; painful urination and defecation; low back and perineal pain with prolapse
b. Surgery for uterine prolapse
c. Pelvic floor disruption: Episiotomy or tears during childbirth
d. Management: Pelvic floor exercises (see urinary incontinence section); modalities such as superficial heat and cold prenatally and TENS post partum
3. Low back and pelvic pain
a. Etiology: postural changes, ligament laxity, decreased abdominal strength
b. Signs and symptoms: Increase pains as the day progresses and with prolong standing; less pain in physically fit women.
c. Management: rest or change position; Proper body mechanics; massage, superficial heat or cold, firm mattress
4. Sacroiliac dysfunction: posterior pelvic pain
a. Etiology: Unknown but suspected to be from ligament laxity and postural changes
b. Signs and symptoms: Stabbing pain from the posterior pelvic area deep into the buttocks and lateral L-5/S-1 with possible radiation to the posterior leg; Pain with prolong sitting, standing or walking, climbing stairs; no relief with rest and increases with activity; Possible to be accompanied with pubic symphysis discomfort
c. Management: External stabilization like belts or corsets; avoid single leg weight bearing; modify exercises and activities
5. Varicose veins: varicosities in the lower extremities or vulva area
a. Etiology: Increased uterine weight and venous distensibility
b. Signs and symptoms: pain or discomfort in the pubis or lower extremities; bulging veins with increased bluish color
c. Management: Elastic support stockings; elevate lower extremities; avoid crossing legs; modify exercise program to non-weight bearing positions
6. Preeclampsia: pregnancy induced hypertension that may lead to coma or death of the mother
a. Etiology: not clearly understood
b. Signs and symptoms: sudden onset of hypertension; sudden weight gain, headache; edema due to fluid retention; dizziness; vision problems
c. Management: modify diet; monitor blood pressure; carefully followed by the physician.
d. Medical Emergency: Blood pressure (BP) of 150/110 or higher or marked edema; immediate delivery of the fetus; Intravenous therapy of MgSO4 to prevent seizures
e. Post partum care: mild sedation to prevent seizures or convulsions, monitor BP; bed mobility, ambulation, exercises being cautious of seizure indications
7. Cesarean childbirth: fetus surgically delivered through an incision in the abdominal wall and uterus
a. Etiology: small birth canal; lengthy non-progressed labor; fetal or mother distress; complications; eclampsia
b. Signs and symptoms: vital signs changes; labor problems
c. Management (Post -operative): TENS for incisional pain with electrodes parallel to incision site; pulmonary exercises for breathing and coughing using pillow for support; same post partum exercises as natural childbirth; limit heavy lifting for 4-6 weeks; friction massage for incision
XI. Psychology/Psychiatry
A. Terminology
1. Anxiety: A response to environmental stressors, tension or conflicts with feelings of uneasiness, apprehension, worries.
a. Degree of anxiety is related to the person�s perception of the external threat and tolerance level.
b. Can be constructive and positive, stimulate the individual toward purposeful activity or pathological condition.
c. Sympathetic responses (fight or flight) accompany anxiety e.g. rapid HR, hyperventilation, dyspnea, dry mouth, GI symptoms (vomiting, diarrhea, nausea), loss of appetite, palpitations
2. Depression: altered mood change characterized by sadness, diminished interest, indecisiveness, dejection, and helplessness. Can become a chronic and relapsing disorder.
a. Clinical manifestations:
(1) Diminished interest in previous pleasures and daily activities; socially withdraws e.g. family and work
(2) Poor nutrition: weight loss or gain; lack of appetite or overeat
(3) Insomnia or hypersomnia; decreased energy
(4) Feelings of guilt, hopelessness, worthlessness, lack self- confidence
(5) Impaired concentration; inability to think
(6) Recurrent thoughts of suicide and death
b. Clinical management:
(1) Pharmacological: tricyclic or SSRI anti-depressant medications; Precautions: balance disturbance, postural hypotension, falls and fractures, increased heart rate, dysrhythmias, ataxia, seizures
(2) Cognitive therapy or counseling may help moderate to severe conditions; helpful to mild conditions
c. Physical therapy interventions: perform all treatment sessions with a positive attitude avoiding excessive cheerfulness; demonstrate consistent compassion and interest; acknowledge depression but provide hope and positive reinforcement; involve the patient in treatment decisions and provide successful treatment experiences.
d. Report to PT ,RN, or MD any thoughts or acts of suicide.
3. Coping and adaptation mechanisms: unconscious perception of the individual to resolve or conceal conflicts and anxieties to regain equilibrium
a. Compensation: counterbalance a weakness by behavior of a favorable or stronger trait.
b. Denial: A refusal to recognize or accept reality
c. Repression: refusal or inability to recall undesirable past thoughts or events due to hiding it in the unconscious.
d. Displacement: the transferring of an emotion, idea or wish to a less anxiety -producing substitute.
e. Reaction formation: a defensive reaction in which a behavior or attitude is exactly opposite of what is expected.
f. Projection: attributing of your own undesirable behavior or idea to another
g. Rationalization: the justification of behaviors, ideas, or feelings using acceptable reasons other than the real reason.
h. Regression: resorting to an earlier, more immature pattern of functioning
B. Pathologies/conditions
1. Anxiety disorders (anxiety neurosis): excessive anxiety not associated with realistically threatening specific situations
a. Panic attacks: acute, unexpected, intense anxiety or terror; may be uncontrollable, accompanied by sympathetic signs, loss of mental control, sense of impending death.
b. Phobias: an obsessive, irrational and intense fear that leads to avoidance behaviors
c. Obsessive-compulsive behavior: intense anxiety is manifested by persistent and repetitive stereotypic acts; behaviors interfere with social, occupational, and interpersonal functioning
2. Posttraumatic stress disorder (PTSD): exposure to an overwhelming traumatic event that presents a variety of stress-related symptoms
a. PTSD symptoms: Flashbacks or nightmares that produce re-experience of the traumatic event, psychic numbing with reduced responsiveness, detachment from reality, survival guilt, avoidance of event stimuli. Other symptoms include autonomic arousal, hyperalertness, irregular and disturbed sleep, irritability, impaired memory and concentration and depression.
b. PTSD can be acute- symptoms for <3 months or chronic- symptoms > 3 months; onset can be delayed by months or years.
c. Symptoms should be addressed and not ignored. A mental health evaluation is indicated.
3. Psychosomatic disorders (somatoform disorders): recurring clinical significant physical complaints that are related to emotional causes.
a. Characteristics:
(1) Cannot be explained by identifiable disease process or underlying pathology
(2) Not under voluntary control; provides a means of coping with anxiety and stress.
(3) Patient is frequently apathetic to symptoms.
b. Types:
(1) Conversion disorder (hysterical paralysis): conversion of a repressed emotional problem to a physiological form.
(2) Hypochondria: abnormal or heightened concerns about health or body functions with hypersensitivity to internal sensations; false beliefs about suffering from some disease or condition
c. Management:
(1) Physical symptoms are real: treat the patient as you would another with the same symptoms.
(2) Provide a calm, supportive environment.
(3) Identify primary gains (internal conflicts); assist with learning new methods of stress management.
(4) Identify secondary gains (additional advantages) but do not reinforce them.
(5) Provide encouragement and positive support for the total person.
4. Schizophrenia: a common and serious group of disorders characterized by loss of contact with reality (disruption in thought patterns); unknown etiology with evidence of a biochemical imbalance in the brain.
a. Symptoms:
(1) Disordered thinking: fragmented thoughts, errors in logic, delusions, poor judgment, and impaired memory.
(2) Disordered speech: may be coherent but unintelligible or rambling, or incomprehensible, mute.
(3) Disordered perception: delusions and hallucinations
(4) Inappropriateness of affect: withdrawal of interest from people and from society; loss of self-dignity, self-direction and self-confidence; disordered interpersonal relations.
(5) Functional disturbances: inability to function in daily life and occupation.
(6) Little to no insight in the problems and behaviors.
b. Paranoia: a type of schizophrenia characterized by logically consistent delusions of persecution and grandeur or jealousy and distrust; withdrawal of all emotional contact with others.
c. Catatonia: a type of schizophrenia characterized by mutism or stupor; negativism, rigidity, or excitement; unresponsiveness; catatonic posturing (remains fixed and unable to talk or move for prolong periods)
5. Bipolar disorder (manic-depressive illness): a disorder characterized by mood swings from mania to depression; a biochemical dysfunction
a. Often intense outbursts, high energy and hyperactivity, excessive euphoria, restlessness, unrealistic beliefs, distractibility, poor judgment, denial, racing thoughts
b. Followed by extreme depression � see symptoms of depression
c. Treatment- pharmacological and hospitalization for acute onset
e.g. lithium carbonate
6. Perseveration: the continued repetition of a movement, word, or expression often accompanied by a brain injury or stroke.
C. Grief Process: the emotional process/ response by which an individual deals with loss, e.g. death of a loved one, loss of a limb
1. Characterized by:
a. Somatic symptoms: throat and chest tightness, fatigue, sighing, hyperventilation, anorexia, insomnia, etc.
b. Psychological symptoms: sorrow, discomfort, regret, guilt anger, irritability, depression, etc.
c. Resolution may takes months or years.
2. Stages:
a. Shock and disbelief, inability or refusal to comprehend loss.
b. Increased awareness and anguish; crying, anger are common
c. Mourning
d. Resolution of loss
e. Idealization of lost person or function.
3. Management:
a. Provide support and understanding of the grief process.
b. Encourage expression of feelings, memories.
c. Respect privacy, cultural or religious beliefs.
D. Death and Dying
1. Physical symptoms: decreasing physical and mental functioning, gradual loss of consciousness
2. Stages (Kubler-Ross):
a. Denial: patients insist they are fine, joke about themselves and the condition, no interest in treatment
(1) Allow denial for it�s a protective compensatory mechanism necessary until the patient is ready to face the condition
(2) Provide opportunities for patient to discuss the condition, ask questions and inquire about the impending death.
b. Anger and resentment: patients become disruptive and transfers blame to others
(1) Be supportive and compassionate: allow patient to express anger, frustration and resentment
(2) Encourage and direct focus to coping strategies.
c. Bargaining: Patients bargain for time to complete life tasks; turn to religion or other individuals , makes promises in return for function.
(1) Provide accurate information, honest, truthful answers at all times.
d. Depression: patients acknowledge impending death, withdraw from life; demonstrate an overwhelming sense of loss, low motivation.
(1) Observe for suicidal ideation.
(2) Dispel fears and anxieties, especially loneliness and isolation.
(3) Assist in providing for comfort of the patient.
e. Acceptance and preparation for death: acceptance of their condition; relate more to the family, make plans for the future and provide closure to life.
3. Management:
a. Support patient and family during each stage.
b. Maintain hope without supporting unrealistic expectations.
E. Physical therapy goals, outcomes and interventions: motivating and encouraging patients, managing the human side of rehabilitation
1. Establish boundaries of your professional relationship: identify problems, expectations, purpose, roles and responsibilities.
2. Provide empathic and compassionate understanding: express a capacity to understand what your patient is experiencing from the patient�s perspective.
a. Recognize losses, allow opportunity to mourn the �old self�.
b. Ask only open-ended questions that reflect what the patient is feeling
(1) Empathetic response: �It sounds like you are worried about the weakness in your legs and are trying your best.�
(2) Non-empathetic response: � Don�t worry about the weakness, it happens;� �You�re just imaging it�s weaker.�
c. Sympathy is counterproductive and unappreciated; caregiver is closely affected by the patient�s behaviors; keep your feelings in order for patient can feel your personal conflict and feelings e.g. PTA cries with the patient
3. Goal setting is realistic, meaningful and involves the patient and family as established by the PT.
4. Pt sets realistic time frames for rehabilitation process; PTA should give continual feedback on program process as well as recognize symptoms, stages of the grief process or death and dying for PT to adjust program.
5. Recognize and reinforce healthy, positive, socially appropriate behaviors; allow patient to achieve success.
6. Recognize secondary gains and unacceptable behaviors; do not reinforce negative behavior and attitude.
7. Provide an environment conductive to the patient�s emotional state, learning and optimal function.
a. Provide a message of hope tempered with realism.
b. Keep patients and family fully informed.
c. Lay adequate guidelines or preparation for discharge or expected changes in the rehabilitation program.
d. Help to re-establish personal dignity and self-worth; acknowledge the whole person.
8. Help patients identify feelings, successful coping strategies, recognize successful conflict resolution, and rehabilitation gains.
a. Stress ability to overcome major obstacles.
b. Stress that recovery is unique and highly individual.
