PCE - Multisystems

AIDS results in..

loss of immune system fxn

decreased CD4+ helper T-cells (200-500/ml; norm is 800-1200/ml)

Guillian-Barre Syndrome (GBS) general presentation

Begins in LE and ascends bilaterally:

- weakness

- ataxia

- bilateral paresthesia progress to paralysis

- stocking and glove pattern of loss (aka distal limb affected)

- absent DTR

GBS causes problems with:

respiration

talking

swallowing

bowel and bladder fxn

GBS risk factors

- possibly autoimmune

- association with immunization

- frequently preceded by mild respiratory or intestinal infection

immunoglobins

bind with specific antigens to aid in their destruction

Dx for lupus

+ve serum "antinuclear antibodies (ANA)" symmetric arthritis

lupus S&S

butterfly (malar) rash

localized erythema

localized edema, joint effusion

alopecia

photosensitivity

mucosul ulcers

raynaud's

Haemophilia

body unable to control blood clotting/coagulation

Haemophilia - if mom doesn't have it but father has it what will the son/daughter have?

son - won't have it (dad gives y)

daughter - obligated carrier (dad gives x)

joint bleed symptoms

if not treated leads to?

jt tight + no pain -->

jt tight + pain, no bleed -->

swollen + hot to touch, hard to move -->

*all ROM lost + severe pain -->

bleeding slows in few days (jt full of blood)

leads to arthritis

Normal Sodium Values?

High vs low

135-145 mmol/L

Role: extracellular excitation aka flud shift

Hypoatremia (too much water retention): postural hypotension, syncope, weight loss, loss skin elasticity, confuse, muscle spasm, seizure

Hyperatremia (dehydrated): edema, pulmonary edema, hypertension, effusions rmb salty food --> puffy

Normal potassium levels

High vs low

3.4-5.2 mmol/L

Role: intracellular excitation

Hypokalemia (too little excitation): weak, nausea/vomit, faint, palpitation, hypotonia, arrythmia

Hyperkalemia (too much exciation): cardiac issues

Normal calcium levels

High vs low

2.1-2.6 mmol/L (8.4-10.2 mEqL)

high calcium in blood = decrease muscle contraction

Hypocalcemia: vit D deficient, increased urine excretion (too much calcium peed out), respiratory acidosis, prolonged QT on ECG

Hypercalcemia: stones, groans, bones (muscle weak, bone loss), thrones, psychiatric over tones (decreased cognition), shortened QT

^*they all rhyme! think how high calcium in blood = low in bones = bone loss)

Normal magnesium levels

High vs low

0.7-1.0 mmol/L (1.6-24 mEqL)

Role: relaxes muscles

Hypomagnesemia: muscle cramp, hyperactive reflex, tremor, overall weakness

Hypermagnesemia: nausea/vomit, muscle weakness

Glucose: fasting, impaired glucose tolerance, dx of DM

fasting 3-5.5 mmol/L

5.5-7.8 impaired glucose tolerance

>7.8 diagnostic of diabetes mellitus

international normalized ratio (INR) values

High vs low

0.89-1.3 (2-3 for pt on warfarin)

low = increase risk of thrombosis/clotting

high = excessive bleeding tendencies

RBC levels

High vs low

male: 4.5-6.5

female: 3.5-5.8

low = anemia, leukemia, hemorrhage

high = polycythemia, decreased plasma volume (=increase concentration of RBC)

erythrocyte sedimentation rate (ESR) and implications of fast rate

measures the rate erythrocytes settle to the bottom of a test tube

fast rate = inflammation

normally it settles quite slowly

Main feature of RA

Synovitis (symmetrical pattern)

RA Criteria (8)

- normal stiffness >1 hr (6 wks)

- arthritis of >3 jts (6 wks)

- arthritis of hand jts

- symmetric arthritis (6 wks)

- rheumatoid nodules

- serum rheumatoid factor

- radiographic changes

- abnormal antibody HLA-DR4 (80% of those w/ RA)

think 3-arthritis, 2-rheumatoid, RAS

Questions to ask for rheumatic diseases (4)

1. Red flags: #, septic arthritis, malignancy, central cord, muscle wkness, paresthesia

2. inflammation in jt or around jt

3. focal (<3 jt) or widespread (>3 jt)

4. acute (<6 wks) or chronic (>6 wks)

RA acute phase rx

energy conservation, ice, splints, gentle ROM

NO STRETCHING (may stretch the synovial membrane & cause irreversible damage)

What are the types of surgeries for RA?

4 R'S

• remove (MTP resection)

• re-align (tendon rupture)

• rest (arthrodesis)

• replace (arthroplasty)

Steps of joint count ax

1. joint effusion (2/4 finger technique)

2. joint line tenderness

3. stress pain

indicator of RA disease activity of RA --> STOP

MTP subluxation

synovitis, displacement of flexors, unopposed extensors pull proximal phalanx into hyperextn, metatarsal head prolapse and get dislocation and lateral drift of toes

Swan neck deformity

Cause? Test?

hyperextension of PIP joint and flexion of DIP joint

caused by contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons

test --> bunnel litter's

Bunnel-Littler test

PIP flexion ROM increase w/ MCP jt flex = instrinsic muscles restriction

no increase in flex = capsular restriction

Boutonniere deformity

cause?

flexion of PIP joint and hyperextension of DIP joint

caused by rupture of central tendinous slip of extensor hood

Ulnar Drift Deformity

test?

volar subluxation/laxity of MCP in radial collateral ligaments

radial collateral ligament test

radial collateral ligament test

passive flex MCP to 90 degrees, apply ulnar force to feel laxity (+ is >45 degrees deviation)

Most common hand deformity

ulnar drift

duck-bill thumb

test?

rx?

MCP at 0, IP at 90 (90/90 position)

grind and crank test

- grind = axial load + MC rot

- crank = axial load + flex/extn

rx: web space massage/stretch, opposition and abduction exercises

Distal Radial Ulnar Joint (DRUJ) instability

synovitis at joint, stretches ulnar carpal ligaments, ulnar head will sublux dorsally, ECU is displaced and more becomes a flexor tendon

TEST: ballottement test

Ballottement test

aka piano key sign - stabilize distal radius and move distal ulnar up/down

Dupuytren's contracture

Thickening and shrinking of the fascia of the palm with fingers being drawn into a flexed position

MCP's + PIP's of 4th and 5th digit

Ape hand

how is it formed?

Thenar muscle wasting with first digit moving dorsally until in line with second (can't abduct thumb)

Results from median nerve dysfunction

List the RA deformities of the feet

hallux valgus

MTP subluxation

claw toe

hammer toe

mallet toe

List the RA deformities of the hand

swan neck

boutonniere

ulnar drift deformity

BD thumb or swan neck

DRUJ instability

Mallet finger

Rupture or avulsion of extensor tendon at its insertion into distal phalanx (generally with trauma)

Causes flexion of DIP

Gamekeeper's Thumb (Skier's Thumb)

Sprain/rupture of ulnar collateral ligament of MCP of first digit leading to medial instability

Caused by falls (ie. while skiing when pole increases forces on thumb)

Gout

most affected joint

• genetic disorder of purine metabolism

• increased serum uric acid (hyperuricemia)

• Acid ▲ to crystals and deposits into joints

• Most affected JOINTS: KNEE, GREAT TOE

Osteoarthritis

release of enzymes + abnormal biomechanical forces = fibrillation + articular cartilage damage

RA rx:

Meds - DMARDS/biologics, methotrexate, NSAIDS/tylenol/cortiosone

Rehab

Lifestyle modification/self mgmt

Surgery

OA dx

x-ray findings 4 features: *jt space, osteophytes, 2subchondral

1. jt space narrowing

2. osteophytosis

3. subchondral cyst

4. subchondral sclerosis

(Grading: Kellgren - Lawrence System (0-4)

4 QUESTIONS

- Pain most days of the last month?

- Pain over the last year?

- Worse with activity - stairs (doing down worse), overdoing it

- Relieved with rest - may have 'gelling' after inactivity period

OA Rx

Weight loss (1 lb loss = 4 lb decrease knee jt stress)

Exercise: 30 min mod aerobic (10 min bouts), LE resistance

Protective aids

Medications: aceteminophen (non-inflammation)

Electromodalites: TENS

dactylitis

sausage fingers d/t swelling

Enthesitis

Inflammation of tissue at muscle insertion on bone

usually in heels and back

Meds for psoriatic arthritis

acetaminophen, NSAIDs, DMARDs, corticosteroids, biological response modifiers

DMARDS is used for what conditions?

IA/RA, JIA, psoriatic arthritis, lupus (NOT AS)

IA = inflammatory arthritis

JIA = juvenile idiopathic arthritis

Biological response modifiers is used for what conditions?

RA, axial spondylitis, psoriatic arthritis

Grading: Kellgren - Lawrence System (0-4) for OA

Gr 0 - no features

Gr 1 - minute osteophyte

Gr 2 (minimal; OA Dx) - definite osteophyte; unimpaired jt. space;

Gr 3 (moderate) - moderate diminution of jt space; Gr 4 (severe) - jt space greatly impaired, sclerosis of subchondral bone

ulcerative colitis

same as crohn's but no skipped lesions, only affects colon, significant bleeding/anemia

Crohn's disease - s/s, rx

affects entire GI tract from mouth-anus, small and large intestines

can have skipped lesions

ulcers, fissure (narrow tear from spincter to canal), fistulas (tract from anal canal --> hole in skin near anus), alterations in digestion and absorption --> malnutrition

rx: antinflammatory drug for bowel, prednisone (immunosupressant), antibiotics, biologic therapy

Reactive arthritis

triggered by infection (possibly STI) in bowel/GI tract

dx for ankylosing spondylitis

HLA-B27

ankylosing spondylitis

a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae

stiffness/fusing of spine d/t inflammation

ankylosing spondylitis onset?

before 40 disease of young adults

M>F

ankylosing spondylitis features

Sacroilitis HALLMARK SIGN

Enthesitis - common sites: spine, hip, peripheral regions

Synovitis - peripheral jts usually (shoulder, hip, knee, ankles)

lungs - apical fibrosis, restrictive lung disease, avoid smoking

heart (inflammation), eyes, bowels

AS Diagnostic Criteria (3)

A diagnosis is made if radiologic criterion of sacroiliitis grade 2 bilaterally or grade 3-4 unilaterally is present with at least one clinical criterion:

- Low back pain and stiffness for >3months that improves with exercise, but is not relieved with rest

- Limitation of motion of L-spine in both sagittal and frontal planes

- Limitation of chest expansion relative to normal values correlated for age and sex

Typical AS posture

HFP, thoracic kyphosis, flattening of anterior chest wall, protrusion of abdomen, flattening

of lumbar lordosis, slight hip flex

Criteria for Inflammatory Back Pain (IBP)

If back pain > 3 months, and 4/5 of below:

- Improvement with exercise

- No improvement with rest

- Insidious onset, age <40 years at onset

- Pain at night

AS breathing mechanics

decreased chest expansion

diaphragmatic breathing pattern

decreased vital capacity

AS physical assessment

posture (tragus to wall), lateral trunk flexion, trunk flexion (modified Schober's), trunk extension

(Smythe test), trunk rotation, chest expansion, cervical mobility, muscle length and strength, enthesitis sites, peripheral joint scan

smythe test

mark X at PSIS w/ pt bent forward

make 3 consecutive 10cm marks above

measure difference when pt in prone/extn

Modified Shober Test

mark X at PSIS, 5cm below, 10 cm above

measure change from 15cm during flexion

Outcome measures for AS

Bath ankylosing spondylitis functional index (BASFI) - impact on disease on fxn in last week

Bath ankylosing spondylitis disease activity index (BASDAI) - how disease is managed

inflammatory vs mechanical back pain

- duration

- age of onset

- max P/stiffness

- type of condition

- x-ray

RA primarily affects

primarily affects MCP + PIP, rheumatoid cachexia (breakdown of muscle fibers), fatigue!!!

OA primarily affects

affects weight bearing joints - hip, spine, DIP, PIP, first CMC, first MTP

Exercise in OA and RA

aerobic, resistance, and stretching/ROM --> pool is great for both

follow ACSM general but based on individual pattern presentation

CI/red flags for exercise in RA/OA

- Increase pain, fatigue or AM stiffness

- sudden pain at joint or joint deformity

- joint becomes red, swollen and hot after doing exercise (within 24 hrs)

- decrease muscle strength and function (local myositis)

- neurological SSx (CV involvement)

- SOB on mild exertion

What are the 3 domains of the ICF?

aka International Classification of Functioning, Disability and Health (ICF)

- body function & structure (impairment)

- activity (limitation)

- participation (restrictions)

type 1 vs type 2 diabetes

Type 1 (insulin deficiency): juvenile onset, require insulin, decrease circulating insulin

- weight loss, increase urination, dehydration

Type 2 (insulin resistance): adult onset, don't need insulin b/c DOESN'T RESPOND TO IT --> cause insulin resistance in peripheral tissues

- obese, acanthosis nigricans (hyperpigmented skin in axilla, groin, back of neck), HTN

hypoglyecemia

dizzy, nausea, weak, sweating profusely (rules out orthostatic hypotension), fatigue, irritability, confusion, fainting

hyperglycemia

blurred vision, fatigue, thirst, frequent urination, weakness, abnormal breathing, acetone breath

*think of too much sugar making you thirsty, pee alot, blurry vision, etc

long term effects of hyperglycemia

Damage to:

- small blood vessels (retinopathy, diabetic nephropathy)

- large blood vessels: increased cholesterol levels --> vessel wall damage --> atherosclerosis, MI, stroke

- peripheral nerves (diabetic neuropathy)

Normal glucose levels for fasting - normal vs DM

normal: 5.6 mmol/L

diabetes: >7 mmol/L

impaired = <5.6, >7

DM Rx

- regular ex

- talk to MD about insulin levels for ex

- snack before ex

- monitor blood sugar levels pre, during, and post ex

- avoid ex at night --> may sleep and slip in hypoglycemic coma and die!!!!

PT always monitor pt for S&S of hyper/hypoglycemia

A delta fibers vs C fibers

A delta fibers are large and myelinated, these respond to sharp pain., localized, fasting adapting - meds work well

C fibers are small and unmyelinated, these respond to dull pain, diffuse, slow adapting and persistent. - meds don't work

*think D for deanne - super sharp/fast

*think C for calvin - dull and slow

explain conduction of pain

- at spinal cord --> go up lateral spinothalamic tract (pain/temp) --> thalamus --> cortex

-periaqueductal grey (primary control center for descending pain modulation) releases endorphins --> inhibits subs P and glutamate release --> no pain

Explain chronic pain and it's rx

chemical change in brain --> receptors hypersensitive --> allodynia + hyperalgesia --> increase activity in pain pathways

Rx: desensitive area, education, restore normal fxn (meds but not our scope, electrotherapy, cryotherapy, thermotherapy, ex/stretch (reduce pain caused by muscle spasm)

Allodynia

Pain due to a stimulus that does not normally provoke pain

Hyperalgesia

excessive sensitivity to painful stimuli

Fibromyalgia

chronic condition with widespread aching and pain in the muscles and fibrous soft tissue

etiology unknown (F>M) *rmb pt from community placement

Dx of fibromyalgia

11/18 of the points are tender

Rx for fibromyalgia

anti-inflammatories, mm relaxants, pain meds, psychological support, nutrition, like heat and not ice

PT rx: energy conservation, aquatic therapy

sepsis

presence of whole body inflammatory state (SIRS) + presence of known or unknown infection

septic shock

severe sepsis but hypoperfusion abnormalities in spite of adequate fluid resuscitation

normal response to infection is local, but then causes widespread vasodilation and vascular permeability

shock

types of shock (4)

- poor distribution of blood at microcirculation level

- decrease tissue perfusion --> cell death

Types:

- hypovolemic aka blood loss

- cardiogenic aka heart damage

- distributive - hypotension and general tissue hypoxia

- obstructive (great vessel of heart)

Systemic Inflammatory Response Syndrome (SIRS)

whole body inflammatory state

How to dx SIRS (4)

With: body temp, HR, RR, WBC

Need to have 2+ signs:

- body temp: >38, <36

- HR >90bpm

- RR >20 or PaCO2 <32 (35-45 normal)

- WB count >12000 or <4000

What to be mindful for exercise in obese pt?

mindful of response to heat (used therapeutically) or in response to exercise - excess fat leads to heat insulation --> overheating

postural changes in pregnancy

- increased thoracic kyphosis, lumbar lordosis

- HFP

- increase breast size

- shoulder protraction

- decreased form/force closure - pelvic floor on stretch, lig laxity (hypermobile SI jt)

PT antepartum (before birth) concerns

antepartum bleed, preterm labour (mini contractions), ruptured membrane (slow trick of fluid), incompetent cervix/changes

varicose veins

abnormally swollen, twisted veins with defective valves; most often seen in the legs

heaviness, dull pain/ache in legs with standing/walking

Rx for varicose veins

- posture, positioning elevation, limit cross leg time

- pressure grades stockings/tights/underwear, circulatory ex

Stress vs urge incontinence

Stress - leakage of urine when coughing, sneezing, laughing, lifting, jogging, or doing anything that causes the abdominal pressure transmitted to the bladder pressure to be stronger than the bladder's closure mechanism

Urge - sudden involuntary contraction of the bladder muscle and is associated with a strong desire to urinate and the inability to delay voiding long enough to get to a toilet.

Gestational DM

Rx - what to avoid

Do: 20 min walk post meal

Avoid:

- valsalva (stress PF/ab)

- rapid uncontrolled movements

- positions of inversion (aka downward dog)

- manual therapy (take care with end feels)

- positioning - supine okay for short period of time, prone not well tolerated

- glute strategy for rolling and STS

cystocele

protrusion of the bladder

rectocele

protrusion of the rectum