Clinical Patterns Flashcards
(147 cards)
1
Q
Explaint the numeric and the TMN cancer staging systems.
A
T - extent/size of tumour. T0 in situ. T1-4.
N - N0 no lymph nodes, N1-3
M - M0 no mets, M1 (distant mets present).
I - no lymph, no mets, <2cm
II - 2-5cm, maybe lymph, no mets
III - >5cm, yes lymph, no mets
IV - mets, all other details do not matter.
2
Q
List the involved PT treatment of symptoms of post-op tumour removal.
A
i) scar mobilization
ii) ROM
iii) post-op pain and fatigue
iv) deconditioning training
v) infection and wound healing.
3
Q
List the involved PT treatment of symptoms of chemotherapy.
A
i) desensitization techniques for peripheral neuropathy.
ii) TREATMENT-RELATED FATIGUE
iii) deconditioning
Note: mindful of possible presence of OP, renal failure or pulmonary fibrosis
4
Q
List the involved PT treatment of symptoms of radiation therapy. When is it safe to begin stretching and manual therapy post radiation?
A
i) Tissue fibrosis (contracture & ROM release)
ii) TREATMENT-RELATED FATIGUE
iii) deconditioning
Stretch 4**-6 weeks after last dose as it often becomes strongest 2-3 weeks after administration.
5
Q
By what mechanism does cancer treatment cause treatment-related fatigue?
A
Bone marrow suppression, reduced RBCs, reduced capacity to produce energy.
Increased HR and CV effort to meet O2 needs causes increased energy consumption - even at rest.
6
Q
Which blood test levels would be altered in patients with cancer?
A
i) Hb - pt anemic, cannot exercise if <8g/dL
ii) Neutrophils - reduced WBCs, increased infection risk,
iii) thrombocytopenia - low platelet, increased risk of bruising and bleeding, cannot exercise if <10,000MCL
7
Q
Describe the two types of lymphodema.
A
Primary: rare, inherited d/t problem with teh lymph vessels
Secondary: damage or obstruction of lymph vessels
8
Q
What are the risk factors for developing lymphodema?
A
i) radiation
ii) axillary dissection (breast cancer)
iii) infection
iv) older age
v) obesity
vi) post-op weight gain
9
Q
Describe the stages of lymphodema.
A
0 - transport reduced, not yet visible, c/o “heaviness”
I - reversible, pitting, no fibrosis
II - irreversible, less pitting, fibrosis present
III - lymphostatic elephantiasis, excessive fibrosis, sclerosis and skin changes.
10
Q
Describe the manual therapy treatment aimed towards improving lymphodema symptoms.
A
Manual lymphatic drainage massage to re-route damaged lymph pathways. Can teach this to patient themselves.
11
Q
Describe the physical aid treatments that can be used for lymphodema.
A
i) compression garments
ii) k-taping to provide compression
12
Q
What education is necessary to for patients with lymphodema?
A
i) Increased risk of infection due to stasis - important for pt to do skin checks.
ii) signs of infection
iii) role of exercise important to promote flow.
iv) keep cool as heat will exacerbate
v) S/S to watch out for
Note: do not use BP cuffs on affected side
13
Q
What is the lab evidence required for a diagnosis of AIDS?
A
i) HIV-1 virus +ve
ii) CD4 < 200mL
OR
- 14% lymphocytes
OR
-diagnosis of 1 of 26 conditions found in HIV (in lieu of CD4 count, but still HIV+ve).
14
Q
List conditions that HIV+ individuals are more at risk of experiencing.
A
i) pneumonia
ii) TB
iii) cancer
iv) meningitis
v) encephalitis
vi) dementia
vii) herpes
- distal and leuko neuropathies common
15
Q
Explain the pathophysiology of Guillian-Barre syndrome.
A
Autoimmune response, following recent respiratory illness, that demyelinates Shwann cells in the peripheral nervous system causing widespread flaccid paralysis. Onset peaks at 4 weeks.
16
Q
What are the two options for medical treatment of G-B syndrome?
A
i) plasmaphoresis
ii) immunoglobin therapy
17
Q
Describe the pathophysiology of systemic lupus erythematosus.
A
A systemic rheumatoid, inflammatory disease in which the body creates antibodies against its own cells (RBCs, lymphocytes, etc.). Most commonly involved tissues and organs include skin, kidney, CNS, cardiac, pulmonary, and arthritis.
18
Q
Describe common S/S associated with SLE.
A
i) butterfly (malar) rash
ii) mouth and genital ulcers,
iii) photosensitivity
iv) anemia and thrombocytopenia
v) kidney and liver decline
vii) seizures/CNS involvement
vi) +ve or abnormal antinuclear antibodies (ANA) indicative of symmetric arthritis.
- localized edema
- alopecia
Raynaud’s
19
Q
What are the most important considerations in treatment of SLE for PTs.
A
i) education re: skin break down and risk prevention
ii) aerobic exercise
iii) energy conservation training.
20
Q
Describe the pathophys of scleroderma.
A
A connective tissue disease that can cause fibrotic changes to the skin primarily as well as blood vessels and organs. Caused by sclerosis (hardening of the skin secondary to massive fibrotic tissue response). It can be systemic or localized.
21
Q
List some of the associated complications with scleroderma.
A
i) joint contractures
ii) pulmonary fibrosis
iii) HTN
iv) renal
v) GI dysmobility
vi) Raynaud’s
22
Q
Describe the pathophys of polymyositis (muscle only) and dermatomyositis (muscle & skin). List some common signs and symptoms.
A
A chronic inflammatory disease of muscle (+/- skin), particuarly proximal limb girdle muscles, especially of the UEs. Common occurs with photosensitive skin rash, and purple erythematous on the face.
23
Q
Describe the pathophys of haemophilia.
A
A congenital x-linked recessive disorder causing reduced clotting factor of blood or (hemostasis). Hemophiliacs do not bleed FASTER than others, they bleed longer. Comes in Type A and B - just difference deficiency in clotting factor. Treated with Factor Replacement Therapy by infusion ( though some pt develop antibodies to fight this). Or desmopressin if mild.
24
Q
REVIEW AVERAGE LAB VALUES!
A
SERIOUSLY!
25
What are the signs and symptoms of hemophilia?
i) excessive bleeding after post-birth circumcision.
ii) excessive bruising (ex. under arm from lifting)
iii) bleeding in joints and muscles
iv) excessive bleeding after minor trauma (Ex. losing a tooth)
RARE: but be aware of possibility of hemorrhaging into the CNS
26
What is the main concern for hemophiliacs?
```
Joint bleeds (hemoarthosis most common!) and muscle bleeds.
CANNOT TAKE IBUPROFEN OR ASPIRIN AS THEY ARE BLOOD THINNERS.
```
27
Describe the PT management of hemophilia.
i) movement to prevent disuse atrophy, joint contractures and arthritis (all of which contribute to increased bleeding).
ii) Acute joint/muscle bleed management
- factor replacement if indicated (joint)
- RICE
- painfree ROM
iii) Do not overtrain or do max strength testing!
iv) treat complications (ex. peripheral neuropathy 2' hematoma compression).
28
What questions/red flags do you need to ask re: someone with potential rheumatic disease?
1. Acute or chronic (>6weeks)
2. Focal or widespread (>3 joints)
3. Inflammation IN or AROUND the joint?
4. Red flgs: #, septic arthritis, malignancy, central cord S/S, focal/diffuse muscle weakness, burning/numbness/parasthesias.
29
Describe the pathophys of rheumatoid arthritis.
Chronic, systemic, autoimmune, inflammatory disease causing persistent synovitis. However, structures around the joint (tendon, bursa etc.) can also be affected. Causes swelling, muscle weakness, limited ROM and major disability over time. May extend to affect multiple organs and systems. 40-50% genetic.
30
Describe how rheumatoid arthritis can affect a joint.
Synovitis cause proliferation and thickening of this membrane. A dense cellular membrane known as a pannus proliferates and invades the joint surface(s). It spreads over articular cartilage and releases enzymes that destroy the cartilage and bone. It may also affect tendons and ligaments the end results being:
i) fibrous scar tissue
ii) adhesions
iii) bony ankylosing (fusion)
iv) joint instability
31
List risk factors for RA.
i) family Hx
ii) smoking
iii) female (esp. post-menopause and post-partum)
iv) poor diet (esp. low vitD & antioxidants, high sodium)
v) obesity
vi) high alcohol intake
vii) statins
32
List the criteria for RA Dx.
```
Note: the first four must have persisted for at least 6 weeks.
PATIENT MUST HAVE AT LEAST 4/7 CRITERIA
1. Morning stiffness (>1hr)
2. Arthritis >/=3 joints
3. Arthritis of hand joints
4. Symmetric Arthritis
5. Rheumatoid nodules
6. Serum rheumatoid factor
7. Radiographic changes
** abnormal antibody HLA-DR4 common (80%) as well, but not specific to RA.
```
33
Describe the S/S of rheumatoid arthritis.
i) joint swelling/stiffness (esp. hands and feet)
ii) fatigue
iii) pain
iv) joint deformity
v) muscle atrophy
vii) MORNING STIFFNESS > 1hr
34
Which joints are most commonly affected by rheumatoid arthritis in early presentation?
i) MTPs
ii) MCPs
iii) radiocarpal/DRUJ (wrist)
iv) proximal IPs
35
Explain the medical management of RA.
i) DMARDs (disease-modifying anti-rheumatic drugs) to slow disease process
ii) statins (to reduce CV risk, although controversial since they also increase auttoimmunity).
iii) radiosynovectomy - inject radioactive particles to treat synovitis.
iv) methotrexate - reduce inflammation but may cause liver damage
v) joint surgeries
36
Explain the PT role in treating RA in the acute phase (flare up).
i) energy conservation
ii) pain relief (ice+ other strategies)
iii) gentle ROM maintenance
iv) joint protection: splints, orthoses, gloves
v) ISOMETRIC exercise only
vi) NO STRETCHING - CAN CAUSE DAMAGE
vii) AVOID STAIRS AND LIFTING IF IN KNEES
37
Explain the PT role in treating RA in the chronic phase.
i) relieve pain (modalities, education etc.)
ii) splints and gentle ROM for joint protection
iii) aerobic exercise (aquatics for this population great!)
iv) compression gloves
v) CONTRACTURES CAN BE HELD FOR 6S AND REPEATED 5-10 TIMES DAILY.
vi) fall prevention
vii) functional activities
38
What are the main types of surgeries performed on RA patients?
Remove (MTP resection)
Re-align (tendon rupture)
Rest (arthrodesis - fusion)
Replace (arthroplasty)
39
What joints are most commonly affected by RA?
i) atlanto-axial (transverse ligament - +ve sharp pursor test, cord signs).
ii) TMJ - fusion
iii) shoulder - HOH superior
iv) AC joint
v) elbow - reduced extension (PRUJ, radial head erosion)
vi) hip - groin P, flexion deformity
vii) knee - baker's cyst, valgus, flexion deformity
40
Explain how to conduct an active joint count.
i) joint effusion
ii) joint tenderness: over collateral ligaments, press hard enough to blanch fingernail
iii) stress pain: PROM w/ OP - Ax for pain.
* *these are assessed sequentially in this order. If one iis +ve then do not need to test the next one. But need to test all of them to rule out an active joint.
41
Explain the difference between a two thumb and finger technique for measuring joint effusion.
i) Two thumb: one directs pressure around the joint the other senses for fluid movement. They must be offset a little to prevent just pushing the joint into the thumb.
ii) Four finger: sensor fingers must be DORSAL to the collateral ligaments and PROXIMAL to the joint line. Other two fingers squeeze AP (sensors feel for fluid movement on the sides of the joint).
- IPs usually!
- bursh-stroke-bulge for knee. Hip cannot Ax effusion.
42
Explain hallux valgus (RA).
Valgus at the 1st MTP 2' ligamentous laxity.
43
Explain MTP subluxation (RA).
synovitis causes displacement of flexors and erosion of plantar ligament. Extensors pull 1st MTP into hyperextension due to unopposed force. Callouses are often a sign. Causes lateral drift of toes.
44
Explain claw toe (RA).
MTP hypextension causing PIP and DIP flexion. Often this occurs in all toes except for the big toe (plantar plate again).
45
Explain hammer toe (RA).
Due to MTP and PIP synovitis. Causes flexion of PIP an extension of DIP (similar to boutennieres in hand). usually 2nd toe - may be 3rd or fourth too. Callouses.
46
Explain mallet toe (RA).
flexion of the DIP joint only - usually affects the longest toe.
47
Explain swan neck deformity (RA).
MCP in flexion
PIP in extension
DIP in flexion
Caused by volar plate erosion or tear of flexor tendons to the middle phalanx.
Ax: Bunnel Littler (PIP flexion first w/ MCP extendended, then with MCP flexed. If same - capsular. If more w/ flexed - lumbricals limiting ROM).
48
Explain Boutinniere deformity (RA).
PIP flexion
DIP extension
Caused by rupture of central slip of extensor expansion (often w/ compromised transverse ligaments of extensor expansion).
Ax: central slip tenodesis test (flex PIP 90', ask pt to extend DIP, feel for middle phalanx - +ve if low to no pressure over middle phalanx.)
49
Explain ulnar drift deformity (RA).
MOST COMMON
MCP synovitis causes laxity/rupture of volar plate and radial collateral ligaments. Phalanges oriented towards ulnar side. 1st dorsal interossei compromise (turns into flexor when capsule stretched).
Ax: radial collateral ligament stress test (w/ MCP in 90' flexion), extensor tendon subluxation test.
Rx: radial finger walking, splinting, prevent ulnar forces in daily use (Ex. getting up from chair).
50
Explain DRUJ instability in the context of RA.
ulnar collateral ligament at the wrist becomes lax causing dorsal displacement of ulnar head. ECU will become volarly displaced and act as more of a flexor.
Ax: Balottement test/Piano Key Test
51
Explain Swan neck deformity of the thumb (RA).
CMC flexion
MCP extension
IP flexion
(Swan neck, just starting at MCP)
52
Explain Boutenniere deformity of the thumb.
```
90/90 position
MCP flexed
IP extended
hitchhiker's thumb/z-deformity
Ax: grind & crank test (Thumb CMC grind test)
```
53
Explain Gamekeeper's thumb deformity (RA).
Note: skier's thumb if traumatic.
Rupture of UCL of the 1st MCP causing a radially deviated 1st phalanx.
Stener lesion - if adductor becomes interposed betw/ UCL and supposed attachment on prox phalanx.
54
Explain Ape hand deformity (RA).
Median nerve palsy/dysfunction. Thenar wasting.
55
Explain Dupuytren's contracture (RA).
Contracture of palmar aponeurosis. 4th and 5th digits most affected (MCP and PIP). Involves nodules formation.
56
Explain Mallet finger (RA).
Avulsion or rupture of extensor expansion/lateral bands at distal attachment on distal phalanx. DIP flexion.
57
Explain the pathophysiology of gout and the PT role.
```
A purine (protein) metabolic disorder resulting in crystal-induced arthritis (uric acid crystals). May be inherited (primary), secondary to another pathology or idiopathic. Attacks will reccur and tend to become more severe as they do.
- pseudogout: primarily knee, similar episodic nature but less frequent.
```
58
Explain the medical and PT management of gout.
1.NSAIDS (daily low dose to prevent, analgesia during), COX2 inhibitors
2. uricosuric drugs
3. dietary changes
PT:
- weight loss
- control inflammation
- ROM/spinting as needed
59
List the risk factors for osteoarthritis.
i) age
ii) high BMI
iii) F>M
iv) Sedentary
v) Injury
vi) Joint Stress (occupation)
* Weak quads!
60
List the most commonly affected joints by OA.
i) knee (MOST COMMON!) - varus, flexion contracture
ii) hip - trendelenberg, flexion deformity
iii) Spine - facets (lateral stenosis), spondylosis
iv) 1st MTP - hallux valgus +/- rigidus
v) Hand
- 1st CMC
- Bouchard node (PIP)
- Hebernen's node (DIP)
Less common sites:
- shoulder/elbow/wrist (post-traumatic scaphoid #)
61
List the most commonly affected joints by OA.
i) knee (MOST COMMON!) - varus, flexion contracture
ii) hip - trendelenberg, flexion deformity
iii) Spine - facets (lateral stenosis), spondylosis
iv) 1st MTP - hallux valgus +/- rigidus
v) Hand
- 1st CMC
- Bouchard node (PIP)
- Hebernen's node (DIP)
Less common sites:
- shoulder/elbow/wrist (post-traumatic scaphoid #)
62
What specific questions should be asked in the case of suspected osteoarthritis?
i) pain most days of the month?
ii) pain over the last year?
iii) Worse w/ activity
63
Describe the Rx for OA for PT.
i) weight loss
ii) exercise (aerobic and light resistance)
iii) protective and gait aids
iv) non-inflammatory meds
64
Describe the S/S of OA.
i) moring pain < 30min
ii) capsular pattern of restriction
iii) worse w/ activity and WBing
iv) Consider persons age and occupation
v) mostly diffuse global pain, insidious onset
vi) often paired w/ crepitus
* ** +ve patellar tap test for swelling.
65
Describe the pathophys of spondyloarthritis.
Non-rheumatoid (seronegative for RF), inflammatory arthritis. Often affects the spine, SI and peripheral joints unilaterally. May be hereditary - often paired w/ ocular disease.
66
Describe the pathophys of psoriatic arthritis.
Chronic, progressive, inflammatory joint disease that is associated with psoriasis. Can affect both peripheral and axial joints. Tends to be milder being more of a nuisance that actually disabling. Typically involves eventual joint destruction.
67
Describe the five clinical presentations of psoriatic arthritis.
i) DIP dominance: only fingers and toes invovled
ii) Symmetrical: 30% 5 or more joints symmetrically
iii) Asymmetrical: 70% 4 or less asymmetrically
iv) spondylitis (inflammation of the spine)
v) arthritis mutlians: most debilitating also rarest (1%), mutilation of fingers and toes appearing like sausage fingers (called dactylitis).
NOTE: enthesitis is inflammation where ligament or tendon meets bone (often in heels and back).
68
List the S/S of psoriatic arthritis.
i) psoriasis: skin inflammation, red papules
ii) nail lesions
iii) joint inflammation
iv) soft tissue involvement (ligaments and tendons)
v) extra-articular features: iritis, urethritis, etc.
69
Describe the pathophys of enteropathic spondylitis.
Spondylitis associated with inflammatory disease of the bowel. Namely, i) Crohn's: affects whole digestive system and ii) Ulcerative colitis: affects lower digestive system. The severity of IBD and arthritis symptoms are correlated. Often involves arthritis is one limb (usually leg), may involve spine (usually SI dominant).
70
Describe the pathophys associated with reactive arthritis.
Triggered by infection in one part of the body (often genitourinary, often STI) which results in arthritis in joints as well as manifestations in other symptoms (ex. derma, GI etc.). Often affects ASYMMETRICAL LOWER EXTREMITY. May go away and return. Pts sometimes develop ankylosing spondylitis afterward.
71
Describe the pathophys of Reiter's syndrome.
A form of reactive arthritis (a form of spondyloarthritis) which is characterized by three criteria:
i) conjunctivitis
ii) urethritis
iii) arthritis
* Often associated with HIV+
72
Describe the pathophys of ankylosing spondylitis.
A form of spondyloarthritis that primarily affects men before the age of 40. It is primarily characterized by low back pain and sacroiliitis. Begins with insidious onset inflammatory low back pain. Pt develop kyphotic deformity in whole spine. May involve peripheral joints as well. Tx w/ DMARDs similar to RA.
73
Describe the S/S of ankylosing spondylitis.
i) Sacroiliitis - HALLMARK SIGN
ii) Enthesitis - effects rip cage, chest expansion, eventually causes osteopenia.
iii) synovitis
ivI Inflammation, scarring and fibrosis of the:
-heart
-lungs
-eyes
-bowels
v) syndesmophytes: osteophytes on opposite sides of the bone that begin to fuse together.
74
List the clinical criteria for ankylosing spondylitis.
* *****i) LBP & stiffness for >3months.
ii) Morning stiffness >30min
iii) Altered posture/muscle imbalances (kyphosis)
iv) Decreased strength
* ****v) Reduced L/S ROM in frontal and sagittal plane
vi) Fatigue
* ****vii) Altered breathing: reduced CP, diaphragmatic breathers.
75
What would be assessed for a pt w/ ankylosing spondylitis?
i) L/S ROM: SF (lat SF test)and flex (modified schober's) esp., rot'n as well., extension (smythe test)
ii) C/T/S mobility
iii) CHEST EXPANSION
iv) Peripheral joint scan ** enthesitis sites!
v) Posture: occiput to wall (measure distance from tragus).
76
Explain the PT role in Rx ankylosing spondylitis.
i) control inflammation
ii) postural correction
iii) pain management
iv) muscle strength/endurance/cardio
v) Reduce stiffness, increase ROM (pool therapy!)
77
Describe the pathophys of juvenile onset idiopathic arthritis (formerly juvenile rheumatoid arthritis).
Idiopathic arthritis occuring before the age of 16 ( usually betw/ 1-3 onset), twice as many females as males. Several categories similar to adult (ex. oligoarthritis, symmetrical, psoriatic etc.). Commonly in, but not limited to, hands and feet. Some pts go into complete remission on adulthood.
78
Describe the S/S of Juvenile Idiopathic Arthritis.
i) joitn deformity
ii) antalgic gait
iii) myalgia
iv) recurrent fever/skin rash
v) growth problems
vi) ocular problems
79
List some common outcome measures in rheumatology.
i) Health Assessment Questionnaire: questionnaire most difficult ADLs in PAST WEEK, most widely used, 5 dimensions (lower score better). usually RA.
ii) MACTAR: 5 activities and questionnaire, short term, RA specific, McMaster Toronto Arthritis Patient Preference Questionnaire
iii) Time Chair Stand Test: functional status/falls, time for 1-5or10 reps. OR reps in 30s period.
80
Describe the pathophy of diabetes mellitus. Differentiate Type I and Type II.
Metabolic disorder in which the body is unable to regulate blood glucose due to dysfunction in insulin production or sensitivity. Insulin causes tissues to take up glucose to lower blood sugar, without it, hyperglycemia can occur.
Type I: juvenile onset, the islet cells in the pancreas (beta) do not produce insulin.
Type II: adult-onset, prolonged high blood sugars decrease sensitivity resulting in an eventual resistance to insulin (no longer responds).
81
Describe the presentation of Type I and Type II DM.
```
BOTH:
i) increased urination and dehydration
ii) fatigue
iii) increased thirst
Type I:
- weight loss
Type
- obesity
- HTN
- acanthosis nigrans (hyperpigmented axilla, groin, back of neck)
```
82
Describe the medical management of DM.
I: intra-muscular insulin injections
II: hypoglycemic oral pharma (metformin) or insulin sensitizing drugs.
- Diet and exercise education and programming
- Weight loss
83
List the S/S of hypoglycemia.
i) dizziness and confusion
ii) weak
iii) sweating profusely
iv) fatigue and irritability
v) fainting
vi) nausea
vii) headache
NOTE: can occur hours after exercise
84
List the S/S of hyperglycemia.
i) fatigue
ii) weakness
iii) thirst/frequent urination
iv) blurred vision
v) weakness
vi) trouble concentrating
vii) abnormal breathing pattern
ACETONE BREATH (smells sweet)
Concern: diabetic coma if prolonged - can be fatal.
85
List the potential complications of long term hyperglycemia.
i) diabetic retinopathy
ii) diabetic neuropathy
iii) peripheral vascular disease (amputation)
iv) increased cholesterol (atheroscleroma, MI)
v) diabetic nephropathy
86
How can you mitigate the risk of hypoglycemia w/ exercise in DM pts?
i) bring glucose tablets
ii) take BS at baseline and 2 hrs after exercise
iii) exercise at a consistent time each day (timed w/ insulin injection)
iv) insulin injection >1hr prior
87
How is DM diagnosed? What is normal fasting plasma glucose?
Normal: 5.6 mmol/L
Impaired is >5.6mmol/L and diabetes is >7mmol/L
Pt fasts for 8 hours then glucose tablet given. BS measured before and two hours after glucose administration.
88
Describe the criteria for chronic pain.
Pain that persists past the normal healing time (3 months or 6 months).
NOTE: very common post-SCI!
89
Explain the neuroscience of the two main pain conducting nerve types.
A-delta: sharp pain, fast acting (myelinated), fast adapting, responds well to medication.
C-fibres: low threshold, dull, aching, diffuse, unmmyelinated (slow), do not respond well to medication.
90
Describe the PT management of chronic pain.
i) Pain neuroscience education
ii) desensitization
iii) graded exposure to exercise (use TIME, not pain as indicator for progress)
iv) restore function
v) goal setting
vii) flare up management lists.
91
Describe the pathophys of chronic fatigue syndrome as well as the S/S.
Idiopathic cause for overwhelming tiredness for at least 6 months regardless of sleep or caffeine. Redces daily activity by at least 50%. Diagnosis of exclusion. PT to Rx pain management and increase activity tolerance as able.
i) myalgia
ii) hypotension (neurally induced ' fatigue)
iii) weakness
iv) impaired cognition and memory
92
Describe the pathophysiology of fibromyalgia.
Persistent, widespread chronic pain with no known tissue mechanism.
S/S:
i) sleep problems
ii) headaches
iii) stiffness in muscles and connective tissue.
iv) environmental sensitivity.
Tx like other chronic pain.
93
List the criteria for a fibromyalgia Dx.
1. Pain at least 4/5 regions (limbs and torso)
2. Symptoms for at least 3 months
3. Widespread pain index >7 and Symptom Severity Score >5.
Old criteria: At least 11 of 18 points.
94
Explain the pathophys of sepsis and septic shock. How is it diagnosed?
Presence of whole body inflammatory state (SIRS) + presence of infection. 2 or more of the following for Dx:
i) HR >90
ii) RR >20 or PaCO2 <32
iii) Temp >38, <36
iv) WBC: >12000 or <4000
95
List the S/S of septic shock.
i) widespread vasoD causing very low BP
| ii) reduced perfusion causes cell death and multi-system organ failure.
96
Describe the relevant changes to a woman's body during pregnancy.
i) 20-30lbs weight gain
ii) ligamentous laxity (esp. SI)
iii) increased lordosis and kyphosis
iv) breast enlargement
v) protracted shoulders
vi) balance changes
viii) incontinence
97
Describe the pathophysiology of diastasis recti and Rx.
Lateral separation/split of the rectus abdominus (stretching or rupture of the linea alba). Usually >2cm considered +ve. Tenting often observed on sit to lie. Usually resolves in 2-6 months. Tx w:
i) abdominal binders
ii) deep breathing to retrain the diaphragm
iii) pelvic floor exercise.
iv) postural and biomechanic training
v) surgery in severe cases.
NO SIT UPS OR CRUNCHES.
98
List common conditions that women are more prone to during pregnancy.
i) carpal tunnel
ii) de quervain's
iii) varicose veins
iii) SI hypermobility
iv) HTN
v) glucose intolerance
99
Describe urinary incontinence and the types.
Often, post partum women experience urinary incontinence - especially after vaginal delivery. Stress incontinence is when it occurs on physical exertion (ex. coughing, sneezing) whereas urge incontinence is when it happens with associated urgency to use the bathroom but an inability to retain it. There is also mixed incontinence which is a combination of the two.
100
Describe the Rx for urinary incontinence.
i) pelvic floor exercise (kegel's, co-contract PF and TA)
ii) bladder training: fluid intake changes, peeing on a schedule vs urgency to retrain, use of diary.
iii) postural and biomechanic training: lift technique, retention techniques.
101
Describe the pathophys of gestational diabetes. How does this affect Rx?
```
Diabetes occurring transiently during pregnancy.
i) Pt should walk 20min post every meal
ii) dietary change
iii) insulin, if needed
iv) safe exercise program
AVOID
i) valsalva
ii) positions of inversion?
```
102
Describe the pathophys of pre-eclampsia.
Acute HTN in a pregnant woman after 20 months of gestation. S/S
- edema
- headache
- bruise easily
- urinate infrequently
- visual disturbance
- hyperreflexia
103
Describe the PT Rx post c-section.
i) scar mobes/management
ii) pelvic and postural retraining
iii) breathing exercise
iv) pain control.
104
Describe the three degrees of burns.
I - superficial, erythema (e. sun burn)
II - partial thickness, blistering appearance
III - full thickness , necrosis - SCARRING
105
Describe the rule of 9's with regard to burns.
Allows you to quickly estimate the percentage of body surface are burned by assigning a % that is a multiple of 9% to each part of the body. Summed together, they provide the value.
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head = 9% (4.5% each for front and back)
torso = 36% (9% each for each quadrant of upper/lower and front/back)
arm = 9% (4.5% each for front and back)
leg = 18% (9% each for front and back)
pubic area = 1%
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In paeds - same torso and arms but head = 18% and legs = 14%
106
Describe the stages of healing as it relates to burns.
I - inflammatory (up to 2 days): eliminate necrotic tissue and deliver materials for healing
II - proliferative (days to months): rebuild dermis and epidermis fibroplasias/neovaascularization to produce granulation tissue
III - remodelling (months): wound contracts and increases strength, scar.
107
List the ways that a burn can be classified, apart from degree.
acute vs chronic
partial vs full thickness
primary (closed by surgery) or secondary (left to heal) intention
108
Explain the zones of wounds/burn healing.
i) Zone of coagulation: part of maximum damage, irreversible tissue loss
ii) zone of stasis: reduces tissue perfusion, potentially salvageable - area of FOCUS for Rx!
iii) zone of hyperemia: increased perfusion, will recover (unless sepsis occurs), erythema
109
Describe the effects of burns on the bodily systems.
i) CV: increased capillary permeability, interstitial edema, peripheral vasoconstriction, hypovolemia, reduced CO (hypotension) causing reduced organ perfusion.
ii) Resp: bronchoconstriction, ARDS, CO poisoning
iii) Metabolism X3
iv) Immune system: compromised
v) Renal: vasoconstriction due to loss of fluids, reduced GFR, more myoglobin is made and can block tubules
110
What are the signs of inhalation injury? What is the injury process timeline?
i) singed eyebrows, nose hairs, burnt fce
ii) Hx of being in an enclosed room
iii) black oral/nasal discharge
iv) swollen lips and hoarse voice
v) abnormal oxygenation
W/in 24 hours, pulmonary edema arises as well as upper airway obstruction. After 48 hours bronchiolitis, alveolitis, pneumonia and ARDS can arise.
111
What is the PT Rx for inhalation injury (burns)?
i) early mobilization
ii) breathing
iii) postural drainage
112
What is the PT Rx for burn management?
i) AROM/PROM within the FIRST 24 hours! Integral!
ii) Splinting and position to keep wound on stretch and prevent contractures
iii) keep wound moist (paraffin wax during Rx)
iv) electrotherapy (HVPC) and ultrasound
v) edema management (compression garment if indicated)
vi) scar management (massage/mobilization etc.)
vii) passive stretching in subacute
113
List the post-burn contraindications to exercise
i) exposed joint
ii) fresh skin graft
iii) DVT
iv) compartment sydrome
114
Describe the different kinds of skin grafts and their special considerations.
i) Split thickness graft: involves the epidermis (some dermis) only. More fragile - immobilized for 5 days!
ii) full thickness graft: all of skin, including the hypodermis. Cosmetic outcomes better. Can only be plced in highly vascular areas.
- ROM, protect from sun, pressure garments, scar massage.
115
List risk factors for wound development.
i) obestiy
ii) sensory loss
iii) malnutrition
iv) smoking
v) incontinence
vi) depression
vii) age
viii) spasticity
ix) increase tissue temp and moisture
116
List the areas at risk for wounds in lying and sitting.
i) sitting: ITs, coccyx, posterior knee, foot, shoulder blade
ii) lying: heel, malleoli, coccyx, greater trochanter, occiput, elbows
* ** MANY OF THESE MEASURED BY THE BRADEN SCALE. 23 pts, under 16 is risk.
117
Explain the pathophys of arterial and venous ulcers.
i) venous: due to venous congestion (impaired valvular function, DVT etc.) medial calf common
ii) arterial: reduced perfusion often due to PVD, atheroscleroma etc. dorsum of foot or lateral calf common
118
List and describe the causes of pressure ulcers.
i) pressure - prolonged and unrelieved (reduce blood flow to the area causing skin breakdown and ulcer formation.
ii) shear: of tissues/layers during transfers
iii) friction forces (abrasions - blisters - common w/ spasticity)
iv) deep tissue injury (Ex. bruising).
119
Describe the stages of pressure ulcers.
I - non-blanchable erythema
II - partial thickness loss, skin broke, small crater
III - full thickness tissue loss, may have necrotic tissue
IV - muscle/bone/joint exposed
X - Unstageable until eschar removed
120
List the potential complications of surgical wounds.
i) infection
| ii) dehiscence (edges come apart).
121
What are the causes of diabetic foot ulcers?
i) PVD
ii) peripheral neuropathy ( sensory loss)
iii) Charcot arthropathy deformities causing areas of high pressure
iv) autonomic neuropathy (dry, fissured skin)
122
List the stages of wound healing.
i) hemostasis - platelets, clotting
ii) inflammatory 0 - 4 days: phagosytosis
iii) proliferative: 4-21 days, closure, re-establish skin
iv) remodelling: 21 days - 2 years, develop tensile strength.
123
Differentiate healing from primary or secondary intention.
i) primary: edges apposed, no granulation tissue, epidermis grows overtop, no infection, minimal fobrous scar
ii) secondary:
124
List the factors to assess and report in wound assessments.
Measure size (length, depth, width, volume etc.)
Exudate (quality and quantity)
Appearance of wound bed (red, pale, necrotic etc.)
Suffering (pain level)
Undermining (presence/absence)
Re-evaluate all parameters every week.d
Edge (undermining, tunneling, width etc.)
125
Describe measures that can be taken to protect skin from wound development.
i) frequent position changes (2 hours)
ii) cushioning, boots and gel pads
iii) shear/friction HOB <30'
iv) nutrition (+ fluid intake, less protein)
v) hygiene re: moisture and incontinence
vi) zinc paste to prevent moisture
vii) regular skin checks (daily)
viii) proper foot wear, wheelchair seating etc.
ix) foot care: nails, callouses etc.
126
Describe the pathophys of psoriasis. What are the five cardinal signs?
Chronic autoimmune disease causing abnormal and excessive epidermal proliferation and profound inflammation. The end result is red, itchy , scaly, skin patches.
i) placque (raised lesion)
ii) well circumscribed margins
iii) bright salmon red colour
iv) silvery micaceous scale
v) symmetrical distribution
127
List the common sites for psoriatic placques.
Extensor surfaces over bony prominences (elbow, knees), scalp, retroauricular, ears, palms and soles, genitals, shins, lumbar. ** In contrast to eczema, ti is more likely to be found on the outer surface of joints.
128
Describe some of the complications associated with psoriasis.
i) physical (pruitis, bleeding and lesions)
ii) INCREASED RISK OF CARDIOVASCULAR DISEASE
iii) increased risk of Crohn's, ulcerative colitis, and celiac disease
129
How is psoriasis managed?
i) topical creams
ii) UV therapy
iii) immunosuppressive drugs
iv) vitD or A
v) tar
130
Describe the pathophys of eczema.
A form of dermatitis resulting in itchy, red, swollen, cracked skin Characterized by itching, lichenification (thickening of skin lines), and exorciations (scratching or picking at skin). There are two types:
1. Atopic (endogenous) dermatitis:
In adults, hands and feet are most commonly affected. In children the backs of knees and front of elbow are more affected (flexor areas). Whole body in infants. Allergic type reaction.
Rx: moisturizer, glucocorticoid, UV therapy, antihistamines
2. Contact dermatitis
i) allergic: immune hypersensitivity to allergen in contact w/ skin (ex. posion ivy, nickel etc.)
ii) irritant: contact w/ irrirtants ex. harsh detergents and chemicals
Rx: topical steroids, gone in 7-10 days
131
Explain the pathophys of suborrheic dermatitis.
Dermatitis occurring in areas of high sebaceous gland activity (oily areas - ex. scalp, face, central chest and back). Probably due to excessive immune response from yeast. Erythema with scale. Frequently seen in NEUROLOGIC population (SCI, stroke, TBI, PD) and HIV patients.
Rx: anti-fungals.
132
Describe the pathophys of hepatitis. What are some of the S/S?
Inflammation of the liver. Impaired normal function of the liver (albumin formation, clotting factors, ammonia metabolism to urea and kidney). S/S: yellow skin, ascites, itching, bleeding, esophygeal varices.
All hep: dark urine, ascites, abdominal pain, fatigue, lethargy, muscle and joint pain, dark or white stool, nausea and vomiting, appetite loss.
133
Differentiate between hepatitis A, B, and C.
Hep A:
- transission by fecal or oral route
- vaccine preventable.
-RF: travel
NOTE: children are usually asymptomatic
Hep B:
- transmission mother to child or through sexual or needles
- usually acute lasting weeks to months but CAN BE CHRONIC resulting in cirrhosis or hepatic carcinoma.
- vaccine preventable
Hep C:
- 80% asymptomatic, more likely to become chronic and result in the same complications
- transmission through needle stick or sex
134
Explain the pathophys of Grave's disease.
Autoimmune disease causing hyperthyroidism. It increase thyroid stimulating hormone causing increased circulating thyroxine (T4) and occasionally T3. Affects women more than men.
135
Explain the S/S of Grave's disease.
i) GOITERS
ii) thin hair
iii) tremors
iv) dermopathy
v) tremors
vi) TACHYCARDIA
vii) light sensitivity
viii) dysphasia
ix) diahrrea
x) amenhorrea
xi) BULGING EYES (exophthalmos)
PT RELATED:
i) MYOPATHY AND PROXIMAL MUSCLE WEAKNESS (esp. pelvis and thigh)
ii) REDUCED CR FUNCTION = REDUCED EXERCISE TOLERANCE
iii) HEAT INTOLERANCE
136
What is the Rx for Grave's disease?
i) beta blockers for heart
ii) surgery to remove thyroid
iii) radioactive iodine
137
Describe the pathophys of hashimoto thyroiditis.
Autoimmune destruction of the thyroid gland causing hypothyroidism. Reduced levels of T3 and T4 cause and increase in TSH produced by the pituitary gland causing hyperfunction of the thyroid. Prolonged hyperfunction causes the autoimmune attack to destroy the thyroid.
138
Describe the S/S and Rx for Hashimoto disease.
i)painless thyroid enlargement
ii) cold intolerance
iii) pale, dry skin
iv) bradycardia
v) fatigue and lethargy
vi) weight gain
vii) myalgia and stiffness
viii) depression
ix) constipation
x) bradycardia
xi) puffy face
xii) proximal muscle weakness
Rx: thyroid hormone replacement
139
Describe the pathophys for Addison's disease.
Autoimmune disease against the adrenal cortex. This causes a reduction in cortisol and aldosterone which eventually causes major fluid and metabolic imbalances in the body. Most commonly occurs in middle-aged white females. Often not diagnosed until 90% of the adrenal gland is destroyed.
140
List the S/S of Addison's disease.
i) hyperpigmentation
ii) gradual muscle weakness and fatigue\
iii) hypotension secondary to hyponatremia (due to reduced aldosterone)
iv) severe abdominal, low back, or leg pain.
v) GI disturbance (nausea vomiting)
vi) hypoglycemia
vii) salt cravings
NOTE: osteoperosis often results due to long term use of steroids for medical management.
141
What are some things to consider in patients with Addison's disease for PT Rx.
i) avoid aquatics - this places too much stress on the system to create cortisol and raise BP.
ii) GRADUAL progression and low intensity due to decreased physical stress tolerance.
iii) Monitor signs of addisonian crisis "profuse sweating, , dizziness, nausea, shaking, tachycardia"
142
Describe the pathophys of Cushing's disease.
Due to chronic glucocorticoid excess, often medications (iatrogenic form). Also caused by excess cortisol secretion from the adrenal gland (often due to tumour on the gland).
143
List some of the S/S of Cushings disease.
i) moon face
ii) abdominal obesity
iii) "buffalo hump" dorsal supraclavicular and cervical fat pad excess
iv) acne
v) thin skin causing poor wound healing and ulcers
vi) abdominal striations (stretch marks)
vii) KYPHOSIS
viii) OSTEOPENIA/PEROSIS
ix) MUSCLE WEAKNESS
x) CARDIAC HYPERTROPHY/HTN
- masculinization in women.
144
Describe the Rx for Cushing's syndrome.
Radiation, drug or surgery for tumour ablation. high protein diet for muscle wasting.
145
Differentiate between Crohn's and ulcerative colitis forms of IBS.
1. crohns affects entire GI from mouth to rectum, small and large intestine. can have skipped lesions (meaning normal segments)
2. Ulcerative colitis affects the colon only and does not have skipped lesions.
Both involve ulcers, fistulas, fissures and malnutrition due to impaired absorption.
146
Describe the staging fo the Wagner scale. What does it measure?
I - Superficial ulcer of skin or subcutaneous tissue
II - Through bone, tendon, capsule
III - As above w/ osteomyelitis or abcess
IV - Partial foot gangrene
V - Whole foot gangrene
147
Describe the differing characteristics of arterial and venous ulcers.
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Venous:
i) irregular shape
ii) superficial
iii) contact dermatitis develops
iv) often medial
Arterial:
i) often lateral foot
ii) full thickness
iii) punched out appearance
iv) nocturnal pain relieved with placing the limb below the heart.
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