Screening for Referral

Purpose

-          ID red flags and determine impact of comorbidities as precautions vs contraindications on patient management

-          On going process

-          Systemic diseases can mimic neuromusculoskeletal dysfunction

PT Implications for GI System

GI System Functions

-          Ingestion, digestion

-          Absorption of nutrients, water, and electrolytes

-          Storage and elimination of waste products of digestion

Digestion

-          Mechanical and chemical breakdown of food; mostly occurs in small intestine

Absorption

-          Most nutrient absorption and 80% of water absorption occurs in small intestine (jejunum)

-          Large intestine absorbs remaining water and electrolytes, little lost in feces

Psychoneuroimmunology

-          Associations between enteric system, immune system, and CNS

-          Adverse life events and psychological distress can be risk factors for disease and contribute to symptoms severity

Liver

-          Synthetic for proteins

-          Excretory- produces bile and cholesterol

-          Metabolism

o   Synthesis of fats, primary source of blood glucose, stores glycogen

-          Detoxification- drugs and toxins

Pancreas

-          Exocrine and endocrine functions

o   Exocrine- secretion of digestive enzymes into duodenum and small intestine

PT Considerations

-          GI pain descriptors- deep, ache, burning, grinding pain

-          Conditions associated with GI disorders: SCI, Parkinson’s, MS, myasthenia gravis, lupus, scleroderma, obesity, aging

-          Major signs and symptoms: nausea, vomiting, diarrhea

-          No technical contraindications for PT in patients with GI disorders

STUDY TBL CHART FOR GI DISORDERS

Abdominal Exam

Percussion

-          Utilized to assess size and density of the organs; can detect air vs. fluid

Surgical and trauma considerations

-          Early mobility can help to decrease post-op complications like pulmonary infection, wound infection, and bed rest deconditioning

-          Early mobility can stimulate return of bowel function

-          Minimize lifting initially

Endocrine System

Functions

-          Plays role in CNS and reproductive development

-          Stimulates growth and development, coordination of reproductive systems, maintenance of homeostasis, adaptive responses when demands occur (stress)

Nervous System vs. Endocrine System

-          Nervous system is quick and immediate

-          Endocrine system is slower, works through the bloodstream

o   Can act nearby and on tissues far away from the source

o   Used for more long-term effects

Hormones

-          3 general classes

o   Protein and polypeptide (most common)

o   Steroid (derived from cholesterol)

o   Derivatives of tyrosine (Epinephrine, NE)

Patterns of Hormone Release

-          Hormonal stimulation- hormones influence secretion of other hormones

-          Humoral stimulation- changing levels of ions and nutrients in blood and other body fluids stimulate hormone release

-          Neural stimulation- neural activity affects hormone release

Feedback

-          Many endocrine glands are controlled by negative feedback loops

Hypothalamus

-          Major target: pituitary gland

-          Functions

o   Integrate communication between endocrine and NS

o   Influence fluid and electrolyte balance and cell metabolism

o   Produce ADH and oxytocin to store in posterior pituitary

-          Secretes the “releasing” hormones

Pituitary Gland

-          Secretion regulated by hypothalamus; controls function of most other glands

-          Controls metabolism, growth, and fluid balance

-          Located just posterior to optic chiasm, can cause visual disturbances with tumor

Anterior Pituitary

-          Linked to hypothalamus and influenced through releasing and inhibiting factors

-          Secretes PRL, TSH, LH, FSH, ACTH, GH

Posterior Pituitary

-          Extension of hypothalamus, contains many nerve fibers

-          Stores oxytocin and ADH, does not produce its own hormones

Adrenal Gland

-          Secretes:

o   Glucocorticoids – regulate glucose metabolism (cortisol)

o   Mineralcorticoids – regulate fluid and mineral balance (aldosterone)

o   Sex hormones

o   Inner medulla secretes epinephrine and NE

Thyroid Gland

-          Produces thyroxine (T4), triiodothyronine (T3) and calcitonin

-          Functions to regulate metabolic rate, stimulate growth, development

Parathyroid Glands

-          Secrete parathyroid hormone to increase blood calcium

-          Not regulated by pituitary or hypothalamus

Pancreas

-          Endocrine and exocrine gland

-          Endocrine function involves secretion of glucagon and insulin to regulate blood glucose

Endocrine System PT Implications

-          Look for systemic effects as a sign of endocrine disorders; they can also mimic musculoskeletal dysfunction

Diagnosis

-          Blood and urine tests to assess hormone levels

-          Stimulation/suppression testing

-          Imaging to look for tumors

-          Difficult to diagnose as hormone levels are constantly fluctuating through a range of norms

Pituitary Tumors

-          Treatment via radiation, medication, or surgical removal

-          Removal of pituitary may necessitate lifetime thyroid, adrenal, and gonadal hormone replacement

-          PT: ambulate early, avoid increasing intracranial pressure (cough, sneeze, etc.), monitor neuro and glucose

Glucocorticoid Treatment

-          Used for anti-inflammatory and immunosuppressive function

o   Can cause weakness, atrophy, OP, mood changes, hyperglycemia, increased BP, and other symptoms if prolonged

PT Implications of Endocrine Dysfunction

-          Often begins with musculoskeletal symptoms that don’t seem to get better with therapy

-          Monitor vitals, blood glucose, and fluids closely

-          Exercise is good for many disorders

STUDY TBL CHART FOR ENDOCRINE DISORDERS

Diabetes Management

Diabetes mellitus

-          Systemic disorder of metabolic system resulting in altered metabolism of carbohydrates, protein, and fats

-          Results from defects in secretion of insulin, action of insulin, or both

-          Type 1- insulin dependent; not producing insulin anymore, autoimmune disease

-          Type 2- insulin sensitivity, still producing it but not responding well to it

-          Gestational

Functions of Insulin

-          Anabolic hormone

-          Affects CHO, fat, and protein metabolism

-          Without insulin, glucose would sit in the bloodstream as it cannot get into cells, eventually travels to pancreas and is excreted

Plasma Glucose Levels

-          Normal fasting plasma glucose is < 100 mg/dl

-          A1C – gives average values of sugar on RBCs over 3 months

-          Sugar binds to HgB -> more sugar -> more sugar on Hgb -> higher A1C

Management of Type 1

-          Insulin therapy (injections or pump)

-          Glucose monitoring

-          Coordinate meal plan to insulin timing and exercise program as insulin dose must match carb intake

o   Prevents long term complications of diabetes

o   Exercise will not cure

Management of Type 2

1.      Diet and exercise

2.      Oral agent

3.      Insulin

-          Basic lifestyle changes are usually good enough

-          Achieve and maintain glucose goals, weight reduction, promote exercise/activity

-          Meal timing is important to distribute carbs

Treatment Goals

-          Maintain near normal blood glucose levels through coordination of food, medication, and physical activity

-          Exercise recommendations are the same as the general population

Oral Medications

-          Increase insulin sensitivity, increase insulin level, decrease CHO absorption

-          Sulfonylureas and Meglitinides carry risk for hypoglycemia

-          Metformin is most common and has minimal to no risk for hypoglycemia

Benefits of Exercise

-          Improves insulin sensitivity and glycemic control

-          Promotes weight loss, fitness

-          Improves muscle strength, bone density, HDL, self-esteem, mental health

-          Lowers blood pressure

-          Decreases long term kidney disease and neuropathy risk

Safety

-          Observe for signs of diabetic ketoacidosis (DKA)- fruity/acetone breath, N/V, dehydration, weak and rapid pulse, Kussmaul’s respirations

-          Avoid exercise with blood glucose above 250-300

-          Exercise participation should be timed so it does not coincide with peak insulin absorption

-          Ensure adequate fluid intake

Hypoglycemia

-          Mild/moderate (15-15 rule)

o   15 grams fast acting sugar, wait 15 min, recheck BG, repeat if still low

-          Severe (glucagon injection

o   Used if unconscious or unable to safely swallow or treat self

o   Medical emergency

Lab Values

Basic Metabolic Panel (BMP)- group of eight specific tests for electrolyte level, acid/base balance, blood sugar, and kidney status

-          Sodium – critical determinant of fluid volume

-          Potassium – important for function of excitable cells (nerves, muscles, and heart)

-          Chloride – levels tend to change along with changes in sodium and water (also affected by hyperventilation/hypoventilation)

-          Calcium – regulates neuromuscular activity, excitation of cardiac cells, bone development

-          BUN and Creatinine – used to evaluate kidney function

o   Creatinine – waste product from muscle metabolism (increased indicates decreased kidney excretion or muscle injury)

o   BUN – reflects balance of nitrogen added to blood from protein metabolism (increased indicates decreased renal function)

-          Glucose – blood sugar levels (A1C is better indicator of glucose control over time)

-          Bicarbonate or CO2 – bicarbonate acts as buffer to prevent changes in pH

Comprehensive Metabolic Panel (CMP)

-          BMP plus additional tests for liver function

-          Liver panel consists of bilirubin, total protein, albumin, and serum enzymes

-          Bilirubin measures ability of liver to clear a product from the blood

-          Albumin – product of liver and major protein of blood; used to assess nutritional status and wound healing

Complete Blood Count (CBC)

-          RBC rarely used as Hb and Hct are better; used to classify anemia

-          Hemoglobin – measures oxygen-carrying capacity of RBCs

o   If low, heart has to work harder to meet oxygen demands

o   Iron required for synthesis of Hb

-          Hematocrit – percentage of whole blood occupied by RBCs

-          WBCs – increased in infection/inflammation

o   Neutrophils are key in bacterial infections

-          Platelets – initiate the clotting sequence

D-Dimer

-          Normally undetectable

-          Released into the blood when in the presence of clotting or coagulation

BNP

-          Higher values considered positive for CHF; found in ventricles of heart

C-Reactive Protein

-          Indicator of systemic inflammation

-          Responds to inflammation anywhere in the body

Homocysteine

-          Amino acid found in blood produced by breakdown of protein

-          Elevated levels linked to increased risk of CVD, Alzheimer’s, HTN, stroke

ESR

-          Nonspecific test for inflammatory disorders

-          More severe inflammation = faster sedimentation rate and higher ESR

-          Used to monitor course and treatment of disease

Inflammatory Markers

-          Rheumatoid Factor and Antinuclear Antibody Test

Hematologic System

RBC Disorders

-          Anemia – reduction in total number of erythrocytes in blood or in quality/quantity of hemoglobin

Immunology

Immunity

-          Innate immunity = 1^st and 2^nd lines of defense

o   Born with, non-specific, no memory

-          Adaptive immunity = 3^rd line of defense

o   Specific, has memory

First Line of Defense (Innate)

1.      Skin

a.      Keratin, defensins, lactic acid

2.      Mucous membranes

a.      Trap foreign particles while lysozymes kill bacteria

Second Line of Defense

1.      Leukocytes

a.      Monocyte – macrophage

b.      Lymphocyte – adaptive immunity

c.      Basophil – assist other immune cells

d.      Eosinophil – parasites and allergies

e.      Neutrophil – attack bacteria

2.      Interferon – specific for viruses to prevent viral replication

3.      Compliment System – utilized for bacteria

a.      Activates processes to kill bacteria such as inflammation, immune clearance, phagocytosis, and cytolysis

4.      Immune Surveillance- find cells infected with virus or cells that have become cancerous

a.      NK cells release perforins, polymerize hole, release granzymes, apoptosis

5.      Fever – protective measure, raising temperature stunts growth of bacteria/virus

6.      Inflammation

a.      Leads to capillary widening, increased permeability, attraction of leukocytes, and systemic response

b.      C-reactive protein, histamine, and kinins are chemical mediators for inflammation

Adaptive Immunity

-          Cellular immunity – T lymphocytes directly destroy foreign cells or altered self-cells

-          Humoral immunity – antibodies neutralize toxins or tag pathogens for destruction

Cellular (cell-mediated) Immunity

-          Cytotoxic T cells – attack enemy cells using perforins and granzymes

-          Helper T cells – coordinate immune response

-          Memory T cells – create memory for subsequent exposure

T Cell Activation - STUDY

Helper T Cells

-          Nonspecific defense, humoral immunity, cellular immunity

Humoral (Antibody-Mediated) Immunity – STUDY

Antibodies

-          Functions

o   Neutralize toxins and antibodies

o   Activate complement

o   Marks pathogens for clearance

-          IgA – lines body tracts and found in secretions

-          IgD – in plasma membrane of B cells

-          IgE – part of allergic reactions

-          IgG – part of secondary immune system

-          IgM – part of primary immune system

Memory

-          First exposure – slow response (3-6 days)

-          Subsequent exposures – fast response (within hours)

Primary Immunodeficiencies

-          A group of disorders characterized by an impaired ability to produce an immune response

-          Cause: mutations in genes involved in the development and/or function of immune organs, cells, and chemical messengers

Secondary Immunodeficiencies

-          Immune system is weakened by an external factor like infections, medications, or other conditions

Autoimmune Diseases

-          Immune system attacks and destroys healthy body tissues by mistake

-          Systemic autoimmune diseases

o   Auto-antigen present all over body

-          Organ-specific autoimmune diseases

o   Auto-antigens are organ, tissue/cell specific

-          More common in females

Prevention of Graft Rejection

-          ABO match, MHC alleles closely match

-          Immunosuppressive agents for life

o   Corticosteroids (prednisolone)

o   Synthetic cytotoxic agents (azathioprine)

o   Cyclosporin A

Cancer immunology

-          Oncogenes – mutations in the gate keeping proteins that allows for uncontrolled replication

-          Tumor cells display some type of flag that allows it to potentially be cleared from the system

Cancer Treatment

-          Cellular therapy – transfer of human cells to replaced bad ones

-          Immunomodulators – medications to boost parts of immune system

-          Oncolytic virus therapy – lab modified virus that infects and kills cancer cells without harming normal cells

-          Monoclonal antibodies – man made proteins that attack specific part of cancer cell

-          Cancer treatment vaccines – medicines that train immune system to recognize and destroy cancer cells

Organ Transplant

Organ Donation

-          Cadaveric Donors

o   Severe neurologic trauma

o   Cardiopulmonary support to preserve viability of organ

o   No evidence of malignancy, sepsis, or communicable disease

-          Living Donors

o   Always used for BMT

o   Frequently kidneys

o   Occasionally lung, liver, intestines

o   Potential need for genetic match

Criteria for Transplant

-          Patient with end stage organ damage

-          Failure of conventional medicine

-          Life expectancy < 1-3 years

-          Absence of untreatable malignancy or irreversible infection

-          Absence of systemic diseases

Pre-Transplant Activity

-          Promote functional mobility and strengthen proximal muscle groups

-          Education on expectation and potential complications

Post-Op Care

-          Infection and rejection are leading causes of morbidity and mortality in first year post-transplant

Rejection

-          Graft rejection is normal immune response

o   Try to minimize with immunosuppressive drugs

-          Hyper-acute - ischemia and necrosis within 48 hours

-          Acute - 4-10 days to within 1 year, typically treatable

o   Sudden weight gain, edema, fever, chills, malaise, dyspnea, increased BP

-          Chronic – typically after months or years

o   Gradual and progressive deterioration of the graft, failure of organ may take years; meds do not stop these rejections but may slow

Infection

-          Highest risk in first 3 months, can cause graft failure if untreated

Renal Transplant

-          Most common

-          Normally on dialysis pre-treatment, used for ESRD and others

-          Living donor transplants have better survival rate

-          Original kidney left in place

Pancreas Transplant

-          Candidates typically have insulin dependent type 1 diabetes

-          Not a life saving procedure and not done very often

-          Often performed along with kidney transplant; native organ left there

Liver Transplant

-          Usually take out old liver

-          Indications: hepatic disease, cirrhosis, hepatitis

-          Multiple types of transplants – cadaver, living adult, split liver

-          Long wait list times, significant deconditioning, and low functional level

-          Large incision limits deep breathing and coughing

General Activity and Exericse Guidelines

-          Aerobic 5 days/week, moderate intensity

-          Strength training 2-3 days/week

-          ROM

-          Balance, coordination, functional training

-          Deep breathing and coughing

-          Regular exercise limits secondary effects of immunosuppression and lower risk of CVD and diabetes

-          Avoid heavy lifting, sports, and swimming for 3-6 months

Autoimmune Disorders

Hypersensitivity Disorders

-          Exaggerated immune response in presence of antigen

-          Grouped by mechanism and by source of antigen

Autoimmune Disorders

-          Immune reaction against self-antigens, failure to recognize self, breakdown of self-tolerance

-          Thought to be multifactorial acquired disease

o   Heredity, gender, environmental factors, infectious agent

Diagnosis

-          Combo of history, exam, imaging, and lab tests

-          Can be difficult to diagnose due to vague and similar symptoms

Treatment

-          Requires balance of autoimmune suppression and maintenance of immune functioning

-          Early intervention vital for optimal outcomes