Susan O sullivan Raymond Siegelman National Phy

202 TABLE 5-7 - CHARACTERISTICS OF DRESSING CATEGORY AND DEFINITION INDICATIONS ADVANTAGES Transparent Films • Stage I and II pressure ulcers • Visual evaluation of wound without removal Clear, adhesive, semipermeable membrane • Secondary dressing in certain situations • Impermeable to external fluids and bacteria dressings. Permeable to atmospheric oxygen • For autolytic debridement • Transparent and comfortable and moisture vapor yet impermeable to water, • Skin donor sites • Promote autolytic debridement bacteria, and environmental contaminants. • Cover for hydrophilic powder and • Minimize friction paste preparations and hydrogels Hydrocolloids • Protection of partial-thickness • Maintain a moist wound environment Adhesive wafers containing hydroactive/absorptive wounds • Nonadhesive to healing tissue particles that interact with wound fluid to form • Conformable a gelatinous mass over the wound bed. May • Autolytic debridement of necrosis • Impermeable to extemal bacteria and contaminants be either occlusive or semi-occlusive. Available or slough • Support autolytic debridement in paste form that can be used as a filler for • Minimal to moderate absorption shallow cavity wounds. • Wounds with mild exudate • Waterproof • Reduce pain Hydrogels • Easy to apply Water or glycerine-based gels. Insoluble in • nme-saving water. Available in solid sheets, amorphous • Thin forms diminish friction gels, or impregnated gauze. Absorptive capacity varies. • Partial- and full-thickness wounds • Soothing and cooling • Wounds with necrosis and slough • Fill dead space Foams • Burns and tissue damaged by • Rehydrate dry wound beds Semipermeable membranes that are either • Promote autolytic debridement hydrophilic or hydrophobic. Vary in thickness, radiation • Provide minimal to moderate absorption absorptive capacity, and adhesive properties • Conform to wound bed • Transparent to translucent Alginates • Many are nonadherent Soft, absorbant, nonwoven dressings derived • Amorphous form can be used when infection from seaweed that have a fluffy cottonlike appearance. React with wound exudate to form is present a viscous hydrophilic gel mass over the wound area. Available in ropes and pads. • Partial- and full-thickness wounds • Insulate wounds with minimal to moderate exudate • Provide some padding Gauze Dressings • Most are nonadherent Made of cotton or synthetic fabric that is absorptive • Secondary dressing for wounds • Conformable and permeable to water and oxygen. May be with packing to provide additional • Manage light or moderate exudate used wet, moist, dry, or impregnated with absorbtion • Easy to use petrolatum, antiseptics, or other agents. Come in • Some newer products are designed for deep cavities varying weaves and with different size interstices. • Provide protection • Wounds with moderate to large • Absorb up to 20 times their weight in drainage amounts of exudate • Fill dead space • Supports debridement in presence of exudate • Wounds with combination exudate • Easy to apply and necrosis • Wounds that require packing and absorbtion • Infected and noninfected exuding wounds • Exudative wounds • Readily available • Wounds with dead space, tunneling, • Can be used with appropriate solutions such as or sinus tracts gels, normal saline, or topical antimicrobials to • Wounds with combination exudate keep wounds moist • Can be used on infected wounds or necrotic tissue • Good mechanical debridement if properly used WET TO DRY • Cost-effective filler for large wounds • Mechanical debridement of necrotic • Effective delivery of topicals if kept moist tissue and slough CONTINUOUS DRY • Heavily exudating wounds CONTINUOUS MOIST • Protection of clean wounds • Autolytic debridement of slough or eschar • Delivery of topical needs

Integumentary Physical Therapy 203 SOME MAJOR DRESSING CATEGORIES CONSIDERATIONS DISADVANTAGES • Allow 1-2 inch wound margin around bed • Shave surrounding hair • Nonabsorptive • Secondary dressing not required • Application can be difficult • Dressing change varies with wound condition and location • Channeling or wrinkling occurs • Avoid in wounds with infection, copious drainage, or tracts • Not to be used on wounds with fragile surrounding skin or infected wounds • Nontransparent • Characteristic odor with yellow exudate that looks similar to pus. Is normal when • May soften and change shape with heat or friction dressing is removed • Odor and yellow drainage on removal (melted dressing • Allow 1 to 1:1.! inch margin of healthy tissue around wound edges material) • Taping edges will help prevent curling • Not recommended for wounds with heavy exudate, sinus • Frequency of changes depends on amount of exudate • Change every 3 to 7 days and as needed with leakage tracts, or infections; wounds that expose bone or tendon; • Avoid in wounds with infection or tracts or wounds with fragile surrounding skin • Dressing edges may curl • Most require a secondary dressing • Sheet form works well on partial-thickness ulcers • Not used for heavily exudating wounds • Do not use sheet form on infected ulcers • May dry out and then adhere to wound bed • Sheet form can promote growth of pseudomonas and yeast • May macerate surrounding skin • Dressing changes every 8-48 hours • Use skin barrier wipe on surrounding intact skin to decrease risk of maceration. • Nontransparent • Change schedule varies from 1 to 5 days or as needed for leakage • Nonadherent foams require secondary dressing, tape, or • Protect intact surrounding skin with skin sealant to prevent maceration net to hold in place • Some newer foams have tape on edges • Poor conformability to deep wounds • Not for use with dry eschar or wounds with no exudate • Require secondary dressing • May use dry gauze pad or transparent film as secondary dressing • Not recommended for dry or lightly exudating wounds • Change schedule varies (with type of product used and amount of exudate) from • Can dry wound bed every 8 hours to every 2 to 3 days • Delayed healing if used improperly • Change schedule varies with amount of exudate • Pain on removal (wet to dry) • Pack loosely into wounds; tight packing compromises blood flow and delays • Labor-intensive • Require secondary dressing wound closure • Use continuous roll of gauze for packing large wounds (ensures complete removal) • If too wet, dressings will macerate surrounding skin • Use wide mesh gauze for debridement and fine mesh gauze for protection • Protect surrounding skin with moisture barrier ointment or skin sealant as needed From Consortium for Spinal Cord Medicine: Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury, Paralyzed Veterans of America, August 2000, with permission.

CHAPTER 6 OTHER SYSTEMS: METABOLIC & ENDOCRINE, GASTROINTESTINAL, GENITOURINARY: PSYCHIATRIC Susan B. O'Sullivan I. The Immune System c. The thymus is the primary central gland of the immune system. It is located behind the ster- A. Overview num above the heart and extends into the neck 1. Anatomy and physiology of the immune system. region to the lower edge of the thyroid gland. a. The immune system consists of immune cells, (I) It is fully developed at birth and reaches max- central immune structures where immune cells imum size at puberty. It then decreases in size are produced (the bone marrow and thymus), and is slowly replaced by adipose tissue. and the peripheral immune structures (lymph (2) It produces mature T lymphocytes. nodes, spleen, and other accessory structures). b. There are several different types of immune d. The lymph system is a vast network of capil- cells. laries, vessels, valves, ducts, nodes, and organs (I) An antigen (immunogen) is a foreign mol- that function to produce, filter, and convey ecule that elicits the immune response. various lymph and blood cells. Antibodies or immunoglobulins are the (I) Lymph nodes are small areas of lymphoid proteins that are engaged to tag antigens. tissue connected by lymphatic vessels (2) Lymphocytes (T and B lymphocytes) are throughout the body. High concentrations the primary cells of the immune system. are found in the axillae, groin, and along (3) Macrophages are the accessory cells that the great vessels of the neck, thorax, and process and present antigens to the lym- abdomen. phocytes. (2) Lymph nodes function to filter the lymph (4) Cytokines are molecules that link immune and trap antigens. Lymphocytes, monocytes, cells with other tissues and organs. and plasma cells are formed in lymph (5) CD molecules (e.g. CD4 helper cells) serve nodes. as master regulators of the immune response by influencing the function of all e. The spleen is a large lymphoid organ located in other immune cells. the upper left abdominal cavity between the (6) Recognition of foreign threat from self stomach and the diaphragm. (autoimmune responses) is mediated by (1) It functions to filter antigens from the blood MHC membrane molecules. and produce leukocytes, monocytes, lym- phocytes, and plasma cells in response to

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 205 infection. b. Can be organ-specific: Hashimoto's thyroiditis. (2) In the embryo the spleen produces red and c. Can be systemic (non-organ-specific): systemic white blood cells; after birth, only lympho- lupus erythematosus (SLE), fibromyalgia. cytes are produced unless severe anemia d. Etiology is unknown; possible factors include exists. 2. The immune response is the coordinated response genetic predisposition, hormonal changes, of the body's cells and molecules that provide pro- environment, viral infection, and stress. tection from infectious disease (bacteria, viruses, B. Acquired Immunodeficiency Syndrome (AIDS) fungi, parasites) and foreign substances (plant pol- 1. Caused by the Human Immunodeficiency Virus lens, poison ivy resin, insect venom, transplanted organs). It also defends against abnormal cells pro- (HIV 1 or HIV2)' duced by the body (cancer cells). 2. Loss of immune system function. a. The innate immune response is the natural resistance to disease and consists of rapidly a. Opportunistic infections: most common is activated phagocytes (macrophages, neu- Pneumocystis carinii pneumonia; al 0 oral and trophils, natural killer cells, dendritic cells). esophageal candidiasis, cytomegalovirus infec- Barriers also provide a natural defense (skin, tion, cryptococcus, atypical mycobacteriosis, mucous membranes) as does inflammation and chronic herpes simplex, toxoplasmosis, fever (antimicrobial molecules). mycobacterium tuberculosis. b. The adaptive immune response includes the slower acting defenses mediated by the lym- b. Malignancies: most common is Kaposi's sarco- phocytes. ma; also non-Hodgkin's lymphoma; primary c. Repeat exposure activates immunologic mem- brain lymphoma. ory producing more rapid and efficient response. c. Neurologic disease: focal encephalitis (CNS d. When the immune response is excessive, the toxoplasmosis); cryptococcal meningitis; AIDS result causes allergies or autoimmune responses. dementia complex; herpes zoster. 3. Immunodeficiency diseases. a. Characterized by depressed or absent immune 3. Pathophysiology. responses. b. Primary immunodeficient disorders result from a. Reduction of CD4 + Helper T cells, resulting in a defect in T cells, B cells, or lymphoid tissues. CD4 + T lymphocytopenia; a major defect in (I) Congenital disorders are a failure of organs to develop and produce mature lympho- the immune system. cytes. b. A retrovirus: replicates in reverse fashion, the (2) Severe combined immunodeficiency disease (SCID). RNA code is transcribed into DNA. c. Secondary immunodeficiency disorders result 4. Transmission is through contact with infected from underlying pathology or treatment that depres e the immune system resulting in fail- body fluids (blood, saliva, semen, cerebrospinal ure of the immune response. fluid, breast milk, vaginal/cervical secretions). (I) Diseases include leukemia, bone marrow a. High risk behaviors for HIV transmission. tumor, chronic diabetes, renal failure, cir- rho is, cancer treatment (chemotherapy, (1) Unprotected sexual contact. radiation therapy). (2) Contaminated needles: sharing, frequent (2) Organ transplant, graft versus host disease. 4. Autoimmune diseases. injection of IV drugs; transfusions (expo- a. Characterized by immune system responses sure to contaminated blood is no longer a directed against the body's normal tissues; self- major risk). destructive processes impair body function. (3) Maternal-fetal transmission in utero or at delivery; contaminated breast milk. b. Low risk behaviors for HIV transmis ion. (I) Occupational transmission: needle sticks. (2) Casual contact: kissing. c. AIDS cannot be contacted through respiratory inhalation, skin contact, or human waste (urine, feces, sweat or vomit). 5. Diagnosis: based on clinical findings and systemic evidence of HIV infection and absence of other known causes of immunodeficiency. a. AIDS-related complex (ARC): presence of acute symptoms secondary to immune system

206 deficiency; early/middle AIDS. (2) Treat opportunistic infections; prophylactic (I) May include: recurrent fever and chills, vaccinations. night sweats, swollen lymph glands, loss of (3) Maintain nutritional status. appetite, weight loss, diarrhea, persistent (4) Provide supportive care for management of fatigue, infections, apathy and depression. (2) May last weeks or months; a precursor to fatigue, e.g., energy conservation full-blown AIDS. techniques, self-care. b. AIDS: exhibits some or all of the symptoms of (5) Respiratory management as needed. ARC, general failure to thrive, and: (6) Provide skin care. (I) Opportunistic infections. (7) Maintain functional mobility and safety; (2) Headaches, blurred vision, dyspnea, dry prevent disability. cough, oral or skin lesions, dysphagia, (8) Provide supportive care, e.g., emotional dementia, seizures, focal neurological signs. support for patients and farnilie . c. Deconditioning, anxiety and depression are 8. Physical therapy goals, outcomes, and intervention . common. a. Observe universal AIDS/illV precautions for d. Laboratory evidence. health care workers (Tables 6-1 and 6-2). (1) HIV-l antibody test (enzyme-linked b. Exercise has a positive effect on the immune immunosorbent assay, or ELISA): 30,000- system; reduces stress level and pain; improves 50,000 copies of HIV per milliliter. cardiovascular endurance and strength (disuse (2) Absolute T4 (CD4) cell counts per deciliter effects common). of blood: normal CD4 counts: 800- c. Exercise recommendations. 1200/ml; symptomatic AIDS CD4 counts: (I) Moderate aerobic exercise training. 200 to 500/ml. (2) Strength training. 6. Clinical cour e. (3) Avoid exhaustive exercise with sympto- a. May exhibit brief early nonspecific viral infec- matic individuals. tion, then remain asymptomatic for many years. (4) During acute stages of opportunistic infec- b. There is no cure. Combination therapies may tions: reduce exercise to mild levels. extend life. Prognosis is poor without treatment, d. Teach activity pacing: balancing rest with or with long-standing disease with secondary activity; scheduling strenuous activities during infections. periods of high energy. 7. Medical interventions. e. Teach energy conservation: analysis and modi- a. Multi-drug (antiviral) therapy, three main fication of daily activities to reduce energy groups of anti-AIDS drugs: expenditure. (I) Nucleoside reverse transcriptase inhibitors f. Teach stress management, relaxation training (NRTIs), e.g., AZT. (e.g., meditation and mindfulness, Tai Chi (2) Protease inhibitors. Chuan, yoga). (3) Non-nucleoside reverse transcriptase g. Neurological rehabilitation for patients with inhibitors (NNRTIs). involvement of the CNS: Refer to Chapter 2. (4) Initiated for symptomatic patients with C. Chronic Fatigue Syndrome (CFS): a complex syn- AIDS, patients with CD4 counts fewer than drome characterized by disabling fatigue accompanied 500; newly infected individuals. by various other complaints. Also called Chronic (5) Red Flags: Common adverse effects of Fatigue and lmmune Dysfunction Syndrome (CFIDS) antiviral therapy include rash, nausea, I. Pathophysiology and clinical characteristics. headaches, dizziness, muscle pain, weakness, a. Etiology: unknown, viral cause suspected; fatigue and difficulty sleeping. With hepato- often preceded by flu-like symptoms. toxicity, signs of carpal tunnel syndrome may b. lmmunologic abnormalities present. be seen. c. Neuroendocrine changes. b. Symptomatic treatment. 2. Diagnosis by exclusion: must have the two major (I) Education to prevent the spread of infection criteria, and either eight symptom criteria or six and disease. symptom criteria with at least 2 physical criteria (CDC case definition).

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 207 a. Major criteria. Objective measure: Modified Fatigue Impact (1) New on et of persistent or relapsing Scale. fatigue; must be present for at least six d. Examine for depression. Determine degree of months; does not resolve with bed rest and emotional support present. reduces daily activity by at least 50%. 5. Physical therapy goals, outcomes and interventions. (2) Exclusion of other chronic conditions. a. Activities are reduced when fatigue is maxi- mal; bedrest contraindicated other than for b. Symptom criteria. sleep. (I) Profound or prolonged fatigue; inability to b. Graded exercise program: short duration, grad- recovery from normal exercise. ually increasing intensity; components include (2) Low-grade fever or chills. stretching, strengthening, aerobic training (e.g., (3) Sore throat: nonexudative pharyngitis. walking). (4) Lymph node pain and tenderness. c. Avoid overexertion. (5) Muscle weakness. d. Teach activity pacing: balancing rest with (6) Muscle discomfort or myalgia. activity; scheduling strenuous activities during (7) Sleep disturbances (insomnia or hypersom- periods of high energy. nia). e. Teach energy conservation: analysis and modi- (8) Headaches. fication of daily activities to reduce energy (9) Migratory arthralgias without joint expenditure. swelling or redness. f. Teach stress management, relaxation training (10) Cognitive impairments: photophobia, in- (e.g., meditation and mindfulness, Tai Chi paired memory, difficulty thinking, inabili- Chuan, yoga). ty to concentrate, irritability, confusion. g. Refer to support group. (II) Main symptom complex develops over a D. Fibromyalgia Syndrome (FMS): a chronic pain syn- few hours or days. drome affecting muscles and soft tissues (nonarticular rheumatism). c. Deconditioning, anxiety and depression are I. Pathophysiology/clinical characteristics. common. a. Etiology unknown; viral cause suspected, mul- tifactoral. d. More common in women than men; younger b. Immunologic and neurohormonal abnormali- ages (20's and 30's). ties are present; genetic factor (autosomal dom- inant). e. Limited recovery: only 5% to 10% recover 2. Characterized by myalgia (muscle pain); general- completely. ized aching; persistent fatigue (mental and physi- cal), sleep disturbances with generalized morning 3. Medical interventions. stiffness; and multiple tender points (trigger a. Antiviral agents in clinical trials. points). b. Supportive and symptomatic treatment; symp- a. Additional signs and symptoms: visual prob- toms may persist for months or years. lems, mental and physical fatigue, spasm, cold (1) Analgesics and anti-inflammatory nons- intolerance, headaches, irritable bladder or teroidal medications for myalgia and bowel, cognitive problems (impaired memory, arthralgia. decreased attention and concentration), restless (2) Nutritional support. legs, atypical patterns of numbness and tin- (3) Psychological support and counseling; gling (sensitivity amplification). antidepres ants. b. Anxiety and depression are common. c. Triggering events: emotional stress/anxiety 4. Physical therapy examination. trauma, hyperthyroidism, infection. a. Examine exercise tolerance levels. Vital signs d. More common in women (75 - 80% of cases) may reveal fluctuations in HR and BP; ortho- than men. static hypotension is common. If decondi- 3. Medical management. tioned, dyspnea with exercise. b. Examine posture. Postural stress syndrome (poor posture) and movement adaptation syn- drome (inefficient movement patterns) may be present and can contribute to chronic pain. c. Examine activity levels and degree of fatigue.

208 a. Diagnosis by exclusion. Presence of 11 of 18 b. It is found in about 1% or the population. specified tender points (Copenhagen c. Hospitalized patients with MRSA infections Fibromyalgia Syndrome definition). are isolated and standard mask-gown-gloves b. Anti-inflammatory agents, muscle relaxants, precautions required. pain medications. 7. Vancomycin-resistant Staphylococcus aureus (VRSA) is resistant to vancomycin and can be a c. Nutritional support. life-threatening infection. d. Psychological support and counseling; antide- B. Streptococcal Infections: a common bacterial pathogen. pressants. 1. Types. 4. Physical therapy goals, outcomes, and interventions. a. Group A streptococcus (Streptococcus pyo- genes): pharyngitis, rheumatic fever, scarlet a. See recommendations for chronic fatigue syn- fever, impetigo, necrotizing fasciitis (gangrene), drome. cellulitis, myositis. b. Group B streptococcus (Streptococcus agalacti- b. Patient typically demonstrates exercise intoler- ae): neonatal and adult Streptococcal B infec- ance. Daily exercise is important. Focus is on tions. aerobic training, mild to moderate intensities. c. Group C streptococcus (Streptococcus pneu- moniae): pneumonia, otitis media, meningitis, c. Teach protection strategies to avoid overuse endocarditis. syndromes. 2. Medical interventions. a. Laboratory diagnosis to confirm pathogen. d. Aquatic therapy is ideal to decrease pain and b. Antibiotic therapy; antibiotic resistance com- increase cardiovascular conditioning and mon. strength. c. Skin infections that are untreated can become systemic. e. Teach techniques for taking control: self- C. Hepatitis: inflammation of the liver; may be caused responsibility for own health, education, cop- by viral or bacterial infections; chemical agents (alco- ing strategies, keeping a journal. hol, drugs, toxins). 1. Types. f. Work and work environment adjustments. a. Hepatitis A virus (HAV, acute infectious hepatitis). g. Refer to support group. (1) Transmission is primarily through fecal- II. Infectious Diseases oral route; contracted through contaminat- ed food or water, infected food handlers. A. Staphylococcal Infections: Staphylococcus aureus (2) Prevention: good personal hygiene, hand (SA) is a common bacterial pathogen. washing, sanitation; immunization (vaccine). 1. Typically begins as localized infection; entry is b. Hepatitis B virus (HBV, serum hepatitis). through skin portal, e.g., wounds, ulcers, burns. (1) Transmission from blood, body fluids or 2. Bacterial invasion and spread is through blood- body tissues, through blood transfusion, oral stream or lymphatic system to almost any body or sexual contact, or contaminated needles. location, e.g., heart valves, bones (acute staphylo- (2) Prevention: education, use of disposable coccus osteomyelitis), joints (bacterial arthritis), needles, screening of blood donors; precau- skin (cellulitis, furuncles and carbuncles, ulcers), tions for health care workers; immuniza- respiratory tract (pneumonia), bowel (enterocolitis). tion (vaccine). 3. Infection produces suppuration (pus formation) c. Hepatitis C virus (HCV, non-A, non-B) and abscess. (1) Transmission is same as for HBV (post 4. Medical interventions. transfusion is most common route). a. Laboratory diagnosis to confirm pathogen. 2. Clinical manifestations: may be mild or severe b. Antibiotic therapy; determine antibiotic sensi- (life threatening). tivity. Antibiotic resistance is common. a. Clinical signs and symptoms. c. Drainage of abscesses. d. Skin infections that are untreated can become systemic; sepsis can be lethal. 5. Infection control procedures: Refer to Section III. 6. Methicillin-resistant Staphylococcus aureus (MRSA) is an antibiotic resistant strain. a. MRSA is resistant to all penicillins (especially methicillin) and cephalosporins.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 209 (I) Initial (preicteric phase): low-grade fever, b. Course: variable. anorexia, nausea, vomiting, fatigue, (I) Acute: may last from several weeks to malaise, headache, abdominal tenderness months. and pain. (2) Chronic: HEV and HCV may lead to chronic liver infection, including necrosis, (2) Jaundice (icteric) phase: fever, jaundice, cirrhosis, and liver failure. enlarged liver with tenderness; abatement of earlier symptoms. 3. Medical interventions. (a) No specific treatment for acute viral hepati- (3) Elevated lab values: hepatic transaminases tis; treatment is symptomatic, e.g., IV fluids, and bilirubin. TABLE 6-1 - STANDARD PRECAUTIONS HANDWASHING PATIENT-CARE EQUIPMENT 1. Wash hands after touching blood, body fluids, secretions, excretions, and 1. Handle used patient-care equipment soiled with blood, body fluids, contaminated items, whether or not gloves are worn. secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of 2. Wash hands immediately after removing gloves, between patient con- microorganisms to other patients or environments. tacts, and when otherwise indicated to reduce transmission of microor- ganisms. 2. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. 3. Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. 3. Ensure that single-use items are discarded property. 4. Use plain (nonantimicrobial soap for routine handwashing. ENVIRONMENTAL CONTROL 5. An antimicrobial agent or a waterless antiseptic agent may be used for 1. Follow hospital procedures for the routine care, cleaning, and disinfec- specific circumstances (hyperendemic infections) as defined by Infection tion of environmental surfaces, beds, bedrails, bedside equipment, and Control. other frequently touched surfaces. GLOVES LINEN 1. Wear gloves (clean, unsterile gloves are adequate) when touching blood, 1. Handle, transport, and process used linen soiled with blood, body fluids, body flUids, secretions, excretions, and contaminated items; put on clean secretions, and excretions in a manner that prevents skin and mucous gloves just before touching mucous membranes and nonintact skin. membrane exposures and contamination of clothing, and avoids transfer of microorganisms to other patients or environments. 2. Change gloves between tasks and procedures on the same patient after contact with materials that may contain high concentrations of microor- OCCUPATIONAL HEALTH AND BLOODBORNE PATHOGENS ganisms. 1. Prevent injuries when using needles, scalpels, and other sharp instru- 3. Remove gloves promptly after use, before touching uncontaminated items ments or devices; when handling sharp instruments after procedures; and environmental surfaces, and before going on to another patient; when cleaning used instruments; and when disposing of used needles. wash hands immediately after glove removal to avoid transfer of microorganisms to other patients or environments. 2. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of a MASK AND EYE PROTECTION OR FACE SHIELD needle toward any part of the body; rather, use either a one-handed \"scoop\" technique or a mechanical device designed for holding the nee- 1. Wear a mask and eye protection or a face shield to protect mucous dle sheath. membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of 3. Do not remove used needles from disposable syringes by hand, and do blood, body fluids, secretions, and excretions. not bend, break, or otherwise manipulate used needles by hand. GOWN 4. Place used disposable syringes and needles, scalpel blades, or other sharp items in appropriate puncture-resistant container for transport to 1. Wear a gown (a clean, unsterile gown is adequate) to protect skin and the reprocessing area. prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, 5. Use mouthpieces, resuscitation bags, or other ventilation devices as an secretions, and excretions. alternative to mouth-to-mouth resuscitation. 2. Select a gown that is appropriate for the activity and the amount of fluid PATIENT PLACEMENT likely to be encountered. 1. Use a private room for a patient who contaminates the environment or 3. Remove a soiled gown as soon as possible and wash hands to avoid who does not (or cannot be expected to) assist in maintaining appropri- transfer of microorganisms to other patients or environments. ate hygiene or environmental control. 2. Consult Infection Control if a private room is not available. From Centers for Disease Control. Hospital Infection Control Practices Advisory Committee. Part II Recommendations for Isolation Precautions in Hospitals. February 1997.

210 analgesics. a. Respiratory droplets or sputum: use tissues to (b) Chronic hepatitis: interferon is the main cover nose and mouth when coughing or sneez- ing; disposable containers for sputum, tissues. therapy. D. Thberculosis (TB): an airborne infectious disease b. Soiled dressings. caused by the bacillus Mycobacterium tuberculosis. m. Center for Disease Control (CDC) Guide- 1. Most commonly affects the respiratory system; lines for Isolation Precautions may also affect the gastrointestinal and genitouri- A. Standard Precautions: the primary strategies for nary systems, bones, joints, the nervous system, control of nosocomial (hospital or nursing home and skin. acquired) infection (Table 6-1). Standard Precautions 2. Course: may be acute, generalized or chronic, synthesize major features of: localized. 1. Universal Precautions: blood and body fluid pre- 3. Signs and symptoms. cautions. a. Pulmonary: productive cough, rales, dyspnea, 2. Body Substance Isolation: to reduce the risk of transmission from moist body substances. pleuritic pain, and hemoptysis. 3. Applies to blood, all body fluids, secretions, and b. Systemic: fatigue, low-grade fever, night excretions, except sweat, regardless of whether or not they contain visible blood. sweats, anorexia and weight loss. 4. Medical interventions. B. Transmission·Based Precautions: used for patients with known or suspected infections of higWy trans- a. Chemotherapy: a combination of daily drugs; missible or epidemiologically important pathogens. incidence of drug resistant strains is increasing. Includes Airborne Precautions, Droplet Precautions and Contact Precautions (Table 6-2). b. Isolation and bedrest (limited with advent of chemotherapy). c. Adequate diet. 5. Pulmonary precautions: instruct patient in infec- tion control measures. Transmission is through: TABLE 6·2 • TRANSMISSION·BASED PRECAUTIONS AIRBORNE PRECAUTIONS CONTACT PRECAUTIONS In addition to Standard Precautions, use Airborne Precautions, or the In addition to Standard Precautions, use Contact Precautions, or the equivalent, for patients known or suspected to be infected with serious equivalent, for specified patients known or suspected to be infected or illness transmitted by airborne droplet nuclei (small-particle residue) that colonized with serious illness transmitted by direct patient contact (hand remain suspended in the air and that can be dispersed widely by air cur- or skin-to-skin contact) or contact with items in patient environment. rents within a room or over a long distance (for example, Mycobacterium tuberculosis, measles virus, chickenpox virus). 1. Isolation room. 1. Respiratory isolation room. 2. Wear gloves when entering room; change gloves after having contact with infective material; remove gloves before leaving patient's room; wash 2. Wear respiratory protection (mask) when entering room. hands immediately with an antimicrobial agent or waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not 3. Limit movement and transport of patient to essential purposes only. Mask touch contaminated environmental items. patient when transporting out of area. 3. Wear a gown when entering room if you anticipate your clothing will DROPLET PRECAUTIONS have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, In addition to Standard Precautions, use Droplet Precautions, or the ileostomy, colostomy, or wound drainage not contained by dressing. equivalent, for patients known or suspected to be infected with serious Remove gown before leaving patient's room; after gown removal, ensure illness microorganisms transmitted by large particle droplets that can be that clothing does not contact potentially contaminated environmental generated by the patient during coughing, sneezing, talking, or the perform- surfaces. ance of procedures (for example, mumps, rubella, pertussis, influenza). 4. Single-patient-use equipment. 1. Isolation room. 5. Limit movement and transport of patient to essential purposes only. Use 2. Wear respiratory protection (mask) when entering room. precautions when transporting patient to minimize risk of transmission of microorganisms to other patients and contamination of environmental 3. Limit movement and transport of patient to essential purposes only. surfaces or equipment. Mask patient when transporting out of area. From Centers for Disease Control, Hospital Infection Control Practices Advisory Committee. Part II Recommendations for Isolation Precautions in Hospitals. February 1997.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 211 C. Physical Therapy Related Infection Control b. Quaternary ammonia compounds (0.1 %), e.g., 1. Purpose: to de troy bacteria, infectious organisms. Zephiran. 2. Sterilization: the total destruction of all microor- ganisms by exposure to chemical or physical c. Mercurials (0.1 %). agents; required for all objects introduced into the d. Germicidal soaps: used for bacteriostatic body, e.g., scalpels, catheters, etc. a. Autoclaving: sterilization of instruments by action (e.g., pHisoHex). heat (250-270° F) and water pressure; con- e. Antibacterial additives to whirlpools, tubs, traindicated with heat-sensitive articles. b. Boiling water (212° F): kills non-spore form- tanks, or pools. ing organisms. c. Ionizing radiation: used to sterilize some med- IV. The Hematologic System ications, plastics or sutures. d. Dry heat: prolonged exposure to high heat in A. Overview ovens. 1. Composition of blood e. Gaseous: ethylene oxide, formaldehyde gas. a. Plasma comprises about 55% of total blood 2. Disinfection: the reduction of the number of volume and is the liquid part of blood and microorganisms; typically used on surfaces or lymph; it carries the cellular elements of blood equipment, e.g., respiratory and hydrotherapy through the circulation. equipment. (1) Plasma is composed of about 91 % water, 7% a. Ultraviolet light: used for air and surface disin- proteins, and 2-3% other small molecules. fection; harmful to unprotected skin and eyes. (2) Electrolytes in plasma determine osmotic b. Filtration: used for water or air purification. pressure and pH balance and are important c. Physical cleaning. in the exchange of fluids between capillaries (I) Ultrasonic: disinfects instruments. and tissues. (2) Washing with an antimicrobial product: (3) Carries nutrients and waste products and u ed to disinfect hands and surfaces. hormones. d. Chemicals. (4) Plasma proteins include albumin, globulins, (1) Chlorination: used for water disinfection, and fibrinogen. filtration systems; also used for food sur- (5) Serum is plasma without the clotting factors. face sanitizing. b. Erythocytes or red blood cells (RBC) comprise (2) Iodines: used in hydrotherapy when filter- about 45% of the total blood volume and con- ing system not possible; provides full bac- tain the oxygen-carrying protein hemoglobin tericidal activity when organic matter (skin, responsible for transporting oxygen. feces, urine) is present. (1) RBCs are produced in the marrow of the (3) Phenols: general disinfectants. long bones and controlled by hormones (4) Quaternary ammonia compounds, e.g., (erythropoietin). RBCs are time-limited, Zephiran. surviving for approximately 120 days. (5) Formaldehyde (5%). (2) Normal RBC count is 4.2-5.4 x 106 for e. Hydrotherapy disinfection. men and 3.6-5.0 x 106 for women. RBC (1) Drain and clean tanks after every patient. count varies with age, activity, and environ- (2) Scrub pumps and equipment (e.g. drains, mental conditions. agitator unit) with a germicidal detergent, c. Leukocytes or white blood cells (WBC) com- e.g., sodium hypochlorite (bleach), prise about 1% of the total blood volume and Povidone-iodine, Chlorazene (Chloramine-n. circulate through the lymphoid tissues. (1) Leukocytes function in immune processes (3) Rinse before refilling. as phagocytes of bacteria, fungi, and virus- 3. Anti ep i : procedures that inhibit or destroy es. They also aid in capturing toxic proteins resulting from allergic reactions and cellu- microorganisms on skin or living tissue. lar injury. a. Anti eptic solutions: alcohol, iodines, e.g., (2) Leukocytes are produced in the bone mar- row. Povidone-iodine (Betadine). (3) There are 5 types of leukocytes: lympho- cytes and monocytes (agranulocytes) and

212 c. Vascular disorders as seen in hemorrhagic telangiectasia, vitamin C deficiency, Cushing's neutophils, basophils, and eosinophils disease; senile purpura. (granulocytes). (4) Normal WBC count is 4.4-11.3 x 103. 7. Shock is an abnormal condition of inadequate 2. Hematopoiesis: the normal function and genera- blood flow to the body tissues. It is associated with tion of blood cells in the bone marrow. hypotension, inadequate cardiac output, and a. Production, differentiation and function of changes in peripheral blood flow resistance. blood cells is regulated by cytokines and a. Hypovolemic shock is caused by hemorrhage, growth factors (chemical messengers) acting vomiting, or diarrhea. Loss of body fluids on blood-forming cells (pluripotent stem cells). also occurs with dehydration, Addison's dis- b. Disorders of hematopoiesis include aplastic ease, bums and pancreatitis or peritonitis. anemia and leukemias. b. Orthostatic changes may develop characterized 3. Blood screening tests. by a drop of systolic blood pressure of 10 - 20 a. Complete blood count (CBC) determines the mm Hg or more. Pulse and respirations are number of red blood cells, white blood cells, increased. and platelets per unit of blood. c. Progressive shock is associated with restless- b. White cell differential count determines the rel- ness and anxiety, weakness, lethargy, pallor ative percentages of individual white cell types. with cool, moist skin and fall in body tempera- c. Erythrocyte sedimentation rate (ESR) is the ture. rate of red blood cells that settle out in a tube d. Vital functions must be carefully monitored of unclotted blood, expressed in millimeters and restored as quickly as possible. The patient per hour. should be placed supine or in a modified (1) Elevated ESR indicates the presence of Trendelenburg position to aid venous return. inflammation. (2) Normal values are 1 - 13 mmlhour for men 8. Physical examination of patients with hematologic and 1 - 20 mmlhour for women. disorders reveals typical signs and symptoms. 4. Hemostasis is the termination or arrest of blood a. Easy bruising with spontaneous petechiae and flow by mechanical or chemical processes. purpura of the skin. Mechanisms include vasospasm, platelet aggrega- b. External hematomas may also be present (e.g. tion, and thrombin and fibrin synthesis. thrombocytopenia). a. Blood clotting requires platelets produced in bone marrow, von Willebrand factor produced by 9. Long-term use of certain drugs (steroids, NSAIDs) the endothelium of blood vessels, and clotting can lead to bleeding and anemia. factors produced by the liver using vitamin K. b. Fibrinolysis is clot dissolution that prevents 10. Red Flags: Physical therapy interventions excess clot formation. a. Use extreme caution with manual therapy and 5. Hypercoaguability disorders are caused by: use of some modalities (e.g., mechanical com- a. Increased platelet function as seen in athero- pression). sclerosis, diabetes mellitus, elevated blood b. Strenuous exercise is contraindicated due to the lipids and cholesterol) . risk of increased hemorrhage. b. Accelerated activity of the clotting system as seen in congestive heart failure, malignant dis- B. Anemia eases, pregnancy and use of oral contracep- 1. Decrease in hemoglobin levels in the blood: normal tives, immobility. range is 12-16 gldl for woman and 13.5-18 gldl for 6. Hypocoagulopathy (bleeding) disorders are men. caused by: 2. Causes. a. Platelet defects as seen in bone marrow dys- a. Decrease in RBC production: nutritional defi- function, thrombocytopenia, thrombocy- ciency (iron, Vitamin B, folic acid); cellular topathia, maturation defects, decreased bone marrow b. Coagulation defects as seen in hemophilia, and stimulation (hypothyroidism), bone marrow Von Willebrand disease. failure (leukemia, aplasia, neoplasm), genetic defect. b. Destruction of RBCs: autoimmune hemolysis, sickle cell disease, enzyme defects, parasites

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 213 (malaria), hypersplenism, chronic diseases (2) Painful swelling of soft tissue of the hands (rheumatoid arthritis, tuberculosis, cancer). and feet (hand-foot syndrome). c. Loss of blood (hemorrhage): trauma, wound, bleeding, peptic ulcer, excessive menstruation. (3) Persistent headache. 3. Clinical symptoms. b. Bone and joint crises: migratory, recurrent joint a. Fatigue and weakness with minimal exertion. b. Dyspnea on exertion. pain; extremity and back pain. c. Pallor or yellow skin of the face, hands, nail c. Neurologic manifestations: dizziness, convul- beds and lips. d. Tachycardia. sions, coma, paresthesias, cranial nerve palsies, e. Bleeding of gums, mucous membranes or skin blindness, nystagmus. in the absence of trauma. d. Coughing, dyspnea, tachypnea may occur. f. Severe anemia can produce hypoxic damage to e. Vascular complications: stroke, chronic leg liver and kidney, heart failure. ulcers, bone infarcts, avascular necrosis of 4. Medical intervention. femoral head. a. Variable, depends on causative factors. f. Renal complications: enuresis, nocturia, hema- b. Transfusion. turia, renal failure. c. Nutritional supplements. g. Anemic crisis: characterized by rapid drop in 5. Physical therapy intervention. hemoglobin levels. a. Red Flag: Patients with anemia exhibit h. Aplastic crisis: characterized by severe anemia; decreased exercise tolerance. associated with acute viral, bacterial, or fungal (l) Exercise should be instituted gradually infection. Increased susceptibility to infection. I. Splenic sequestration crisis: liver and spleen with physician approval. enlargement, spleen atrophy. (2) Perceived exertion levels should be used 5. Medical interventions. a. Immediate transfusion of packed red cells in (RPE ratings). acute anemic crisis. C. Sickle Cell Disease b. Analgesics or narcotics as needed for pain. c. Short-term oxygen therapy in severe anoxia. 1. Group of inherited, autosomal recessive disorders; d. Hydration, electrolyte replacement. erythrocytes, specifically hemoglobin S (Hb S) are e. Antibiotics for infection control. abnormal. RBC are crescent or sickle-shaped f. Oral anticoagulants to relieve pain of vaso- instead of biconcave. occlusion; associated with increased risk of bleeding. 2. Sickle cell trait: heterozygous form of sickle cell g. Splenectomy may be considered. anemia characterized by abnormal red blood cells. h. Bone marrow transplant in severe cases. Individual are carriers and do not develop the dis- i. Uremia may require renal transplantation or ease. Counseling is important especially if both hemodialysis. parents have the trait. 6. Physical therapy goals, outcomes, and interven- tions. 3. Characteristics. a. Pain control: application of warmth is soothing a. Chronic hemolytic anemia (sickle cell anemia): (e.g., hydrotherapy). hemoglobin is released into plasma with result- b. Red Flag: Cold is contraindicated as it increas- ant reduced oxygen delivery to tissues; results es vasoconstriction and sickling. from bone marrow aplasia, hemolysis, folate c. Relaxation techniques. deficiency, or splenic involvement. d. Emotional support and counseling of family. b. Vaso-occlusion from misshapen erythocytes: e. Patient and family education: avoidance of results in ischemia, occlusion, and infarction of stressors that can precipitate a crisis. adjacent tissue. D. Hemophilia c. Chronic illness that can be fatal. 1. Pathophysiology: a group of hereditary bleeding disorders. 4. Sickle cell crisis: acute episodic condition occur- a. Inherited as a sex-linked recessive disorder of ring in children with sickle cell anemia. blood coagulation; affects males, females are a. Pain: acute and severe from sickle cell clots formed in any organ, bone or joint. (1) Acute abdominal pain from visceral hypoxia.

214 b. Goniometry. c. Joint deformities, e.g., genu valgum, rearfoot/- carriers. forefoot. b. Clotting factor vm deficiency (Hemophilia A) d. Muscle strength; girth. e. Functional mobility skills, gait. is most cornmon; classic hemophilia. f. Pain. c. Clotting factor IX deficiency (Hemophilia B or g. Activities of daily living. 5. Physical therapy interventions: acute stage. Christmas Disease). a. RICE: rest, ice compression, elevation. d. Level of severity and rate of spontaneous b. Maintain position, prevent deformity. 6. Physical therapy interventions: subacute stage bleeds varies by percentage of clotting factor in after hemostasis. blood: mild, moderate, severe. a. Factor replacement best done just before treat- e. Bleeding is spontaneous or a result of trauma, may result in internal hemorrhage and hema- ment. turia. b. Isometric exercise and aquatic therapy early. f. Hemarthrosis (bleeding into joint spaces) most c. Pain management: TENS, massage, relaxation common in synovial joints: knees, ankles, elbows, hips. techniques, ice, biofeedback. (1) Joint becomes swollen, warm, painful with d. Active assistive exercise progressing to active, decreased ROM. isokinetic and open chain resistive exercises. (2) Long term results can include chronic syn- (1) Passive ROM rarely, if ever, used. (2) Closed chain exercise may put too much ovitis and arthropathy leading to bone and cartilage destruction. compressive force through joint. g. Hemorrhage into muscles often affects forearm (3) Important to strengthen hip, knee, elbow flexors, gastrocnemius/soleus and iliopsoas. (1) Produces pain. extensors and ankle dorsiflexors. (2) Decreases movement. e. Contracture management. 2. Medical interventions. a. Blood infusion, factor replacement therapy. (1) Manual traction, mobilization techniques, b. Use of acetaminophen (Tylenol), not aspirin, serial casting, dynamic splinting during the for pain management. day, resting splints at night. c. Rest, ice, elevation, functional splinting and no weightbearing during an acute bleed. (2) Red Flag: Passive stretching rarely used d. HIV or hepatitis transmission a possible trans- due to risk of myositis ossificans. fusion result (before current purification tech- niques). f. Functional and gait training as needed. 3. Complications. (1) Protective use of helmets or pads for very a. Joint contractures. young boys during ambulation and play. (1) Hip, knee, elbow flexion; ankle plantar (2) Temporary use of ambulatory aids as needed. flexion. (3) Foot orthoses, shoe inserts and adhesive b. Muscle weakness around affected joints. taping for ankle or foot problems. c. Leg-length discrepancies. d. Postural scoliosis. 7. Physical therapy interventions: chronic stage. e. Decreased aerobic fitness. a. Daily home exercise program to maintain or f. Gait deviations. increase joint function, aerobic fitness and (1) Equinus gait. strength. (2) Lack of knee extensor torque. b. Outpatient physical therapy as necessary. g. ADL deficiencies, e.g., elbow contractures c. Appropriate recreational activities or adaptive could affect dressing ability. physical education if at school. 4. Physical therapy examination. a. Clinical signs and symptoms of acute bleeding 8. Emotional support for patients and families. episodes: decreased ROM, stiffening, pain, swelling, tenderness, heat, prickling or tingling V. Cancer sensations. A. Overview: Cancer is a broad group of diseases char- acterized by rapidly proliferating anaplastic cells 1. Characteristics: involves all body organs; invasive. a. Etiology: unknown; multiple factors are

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 215 implicated. and blood-forming organs (bone-marrow). (1) Carcinogens: chemical (e.g. asbestos, smok- d. Metastasis: movement of cancer cells from one ing or oral tobacco), radiation (e.g. x-rays, body part to another; spread is via lymphatic sun exposure), or viral (e.g. herpes simplex; system or bloodstream. AIDS/immune system depression). 3. Staging: describes extent of disease. (2) Genetic factors: hereditary. a. Primary tumor (T). (3) Dietary factors: obesity, high-fat diet, diet b. Regional lymph node involvement (N). low in Vitamins A, C, E. c. Metastasis (M). (4) Psychological factors: chronic stress. d. Numbers used to denote extent of involvement, b. Early warning signs. from 1 to 4 (least involvement to most involve- (1) Unusual bleeding or discharge. ment, e.g., T2, Nl, Ml). (2) A lump or thickening of any area, e.g., 4. Medical interventions: curative vs. palliative breast. (relief of symptoms, e.g., pain); can be used alone (3) A sore that does not heal. or in combination. (4) A change in bladder or bowel habits. a. Surgery. (5) Hoarseness or persistent cough. (1) Can be curative (tumor removal following (6 Indigestion or difficulty swallowing. (7) Change in size or appearance of a wart or biopsy) or palliative (to relieve pain, cor- mole. rect obstruction). (8) Unexplained weight loss. (2) Often used in combination with chemother- c. Classification (staging): delineates extent and apy or radiation therapy. prognosis of disease. (3) Can result in significant functional deficits d. Incidence: second leading cause of death in and weakness; edema. U.S. b. Radiation therapy. e. Progno i : aggressive treatments have resulted (1) Destroys cancer cell, inhibit cell growth in higher cure rates, increased survival times. and division. f. Quality of life (maintaining normal function (2) Can be used preoperatively to shrink and life- tyles) is an important issue. tumors, prevent spread. 2. Terminology/pathologies. (3) Can be used postoperatively to kill/prevent a. Tumor or neoplasm: an abnormal growth of residual cancer cells from metastasizing. new tissue that is non-functional and competes c. Chemotherapy. for vital blood supply and nutrients. (1) Drugs can be given orally, subcutaneously, b. Benign tumor (neoplasm): localized, slow intramuscularly, intravenously, intrathecally growing, usually encapsulated; not invasive. (within the spinal canal). c. Malignant tumors (neoplasms): invasive, rapid (2) Usually intermittent doses to allow for growth giving rise to metastases; can be life bone marrow recovery. threatening. d. Biotherapy (immunotherapy). (1) Carcinoma: a malignant tumor originating (1) Strengthens host's ability to fight cancer in epithelial tissues, e.g., skin, stomach, cells. colon, breast, rectum. Carcinoma in situ is (2) Agents can include interferons, interleukin- a premalignant neoplasm that has not 2, cytokine. invaded the basement membrane. (3) Bone marrow (stem cell) transplant; fol- (2) Sarcoma: a malignant tumor originating in lows high doses of chemotherapy or radia- connective and mesodermal tissues, e.g., tion that destroys both cancer cells and muscle, bone, fat. bone marrow cells. (3) Lymphoma: affecting the lymphatic sys- (4) Monoclonal antibodies. tem, e.g., Hodgkin's disease, lymphatic (5) Hormonal therapy. leukemia. e. Red Flags: Local and systemic effects of can- (4) Leukemia and myelomas: affecting the cer therapy. blood (unrestrained growth of leukocytes) (1) With radiation therapy, can see radiation sickness, immunosuppression, fibrosis,

216 burns, delayed wound healing, edema, hair diarrhea, weight loss, fever, progressive muscle loss, CNS effects. weakness (Type II atrophy), diminished DTRs, (2) With chemotherapy, can see gastrointesti- myositis, joint pain. nal symptoms (anorexia, nausea, vomiting, c. Neurological syndromes can include cerebellar diarrhea, ulcers, hemorrhage), bone mar- degeneration, peripheral neuropathy, myasthe- row suppression, skin rashes, neuropathies, nia gravis, etc. pWebitis, hair loss. 5. Red Flags: Adverse side effects of cancer treat- (3) With biotherapy (immunotherapy), can see ment. fever, chills, nausea, vomiting, anorexia, a. With immunosuppressed patient monitor vital fatigue, fluid retention. signs, physiological responses to exercise care- (4) With hormonal therapy, can see gastroin- fully; may see elevated HR and BP, dyspnea, testinal symptoms, hypertension, steroid- pallor, sweating, fatigue. Patient is easily induced diabetes and myopathy, weight fatigued with minimal exertion. gain, hot flashes and sweating, altered b. Muscle atrophy and weakness: secondary to mental status, impotence. high doses of steroids in many chemotherapy 5. Hospice care: care for the terminally ill patient and protocols; weakness may also result from dis- family. use, or tumor compression/invasion. a. Multidisciplinary focus. c. ROM deficits: particularly with high dose radi- b. Palliative care provided at home or in a hospice ation around joints. center. d. Hematological disruptions. c. Provision of supportive services: emotional, (1) White blood cell suppression (leukopenia); physical, social, spiritual, financial. B. Physical Therapy Examination increased susceptibility to infection. 1. Detailed systems assessment dependent upon can- (2) Platelet suppression (thrombocytopenia): cer history. 2. Pain. increased bleeding. a. Cancer pain syndrome: cancer-related pain is a (3) Red blood cell suppression (anemia): common experience, e.g., nerve or nerve root compression, ischemic response to blockage of diminished aerobic capacity. blood supply, bone pain. Sympathetic signs C. Physical Therapy Goals, Outcomes, and and symptoms may accompany moderate to severe pain, e.g., tachycardia, hypertension, Interventions tachypnea, nausea, vomiting. 1. Educate patient and family about disease process, b. Pain at site distal to initial tumor site may sug- gest metastasis. rehabilitation goals, process, and expected out- c. Iatrogenic pain may result from surgery, radia- comes. tion or chemotherapy. 2. Identify and support patient and family. 3. Lung, breast, prostate, thyroid and lymphatic can- a. Assist in coping mechanisms. cers commonly metastasize to bone. Pathological b. Assist through the grieving process. fractures, pain and muscle spasms may result. 3. Provide for proper positioning to prevent or cor- 4. Red Flags: Paraneoplastic syndrome: signs and rect deformities, maintain skin integrity; provide symptoms are produced at a site distant from the for overall patient comfort. tumor or its metastasized sites, from ectopic hor- 4. Edema control: elevation of extremities, active mone production by tumor cells or metabolic ROM, massage; post-operative compression (elas- abnormalities from secretion of tumor vasoactive tic bandages, pressure garments). products. 5. Pain control. a. Cushing's syndrome can result from small cell a. TENS stimulation: may not control deep can- cancer of the lung. b. Symptoms can result from cancer stimulation cer pain; effective for post-operative pain. of antibody production, e.g., anorexia, malaise, 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 strengthen- ing exercises safe for most patients with cancer.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 217 b. Red Flags: Patients with significant bony Table 3-2. metastases, osteoporosis, or low platelet counts 11. Physical agents. Refer to Chapter 10. «20,000). (1) AROM, ADL exercise only. a. Thermal agents (hot packs, paraffin baths, flu- (2) Weight bearing may be restricted; provide idotherapy, infrared lamps) and deep heating appropriate ambulatory aids, orthoses. agents (ultrasound, diathermy). (3) High risk of vertebral compression and Red Flags: other fractures with metastatic disease. Use (1) Do not use directly over tumor. light exercise only. (2) Do not use over dysvascular tissue: tissue exposed to radiation therapy. 8. Maintain or increase activity tolerance and cardio- (3) Do not use with individuals with decreased va cular endurance, e.g., cycle ergometry, ambula- sensitivity to temperature or pain in affect- tion, energy conservation techniques. ed area. a. Following prolonged bedrest or inactivity: (4) Do not use in areas of increased bleeding or careful examination, gradual exercise and hemorrhage, typically the result of corti- activity progression; submaximal aerobic exer- costeroid therapy. cise is indicated. (5) Do not use with acute injury, inflammation, b. Monitor fatigue levels. Use activity pacing, open wounds. carefully balance activity and rest periods; use short sessions throughout the day. Teach ener- b. Cryotherapy. gy conservation techniques. Red Flags: c. Precaution with patients who are anemic: may (1) Do not use with patients with insensitivity experience decreased aerobic capacity. to cold, or delayed wound healing. d. Precaution with certain types of chemotherapy (2) Do not use over dysvascular tissue: tissue (e.g. Adriamycin): may experience cardiac side exposed to radiation therapy. effects. e. Precaution with severe bony metastases, weak- c. Hydrotherapy with agitation. ness: light aerobic exercise (cycling, swim- Red Flags: ming) may be indicated. (1) Do not use over dysvascular tissue: tissue exposed to radiation therapy. 9. Maintain or increase independence. (2) Do not use with individuals with decreased a. Activities of daily living, e.g., self-care. sensitivity to temperature or pain in affect- b. Functional mobility skills, e.g., bed mobility, ed area. transfer, ambulation. (3) Do not use in areas of increased bleeding or c. Coordination, balance, and safety. hemorrhage or open wounds. (4) Risk of cross infection is high with 10. Specific considerations for exercise programs. immunosuppressed patients. a. Post mastectomy. (1) Focus is on restoration of pain-free full VI. The Gastrointestinal System ROM of the shoulder, prevention/reduction of edema, restoration of function. A. Overview (2) Early post-operative exercise is stressed: 1. The gastrointestinal (GI) tract is a long hollow some protocols as early as day one. tube extending from the mouth to the anus. b. Post-bone marrow transplant. Ingested foods and fluids are broken down into (1) Experience prolonged hospitalization and molecules that are absorbed and used by the body inactivity: average is 30 days; prolonged while waste products are eliminated. chemotherapy and radiotherapy, trict iso- a. The upper GI tract consists of the mouth, lation. esophagus, stomach and functions for inges- (2) Focus is on restoration of function, over- tion, and initial digestion of food. coming the effects of deconditioning. b. The middle GI tract is the small intestine (duo- (3) Red Flag: Exercise is contraindicated in denum, jejunum, and ilium). The major diges- patients with Ifiatelet counts 20,000 or less; tive and absorption processes occur here. use caution with counts 20-50,000. Refer to c. The lower GI tract consists of the large intes- tine (cecum, colon, and rectum) with primary

218 difficult elimination. (1) Constipation causes increased bowel pres- functions that include absorption of water and electrolytes, storage and elimination of waste sure and lower abdominal discomfort. products. (2) Many different factors can trigger constipa- d. Accessory organs aid in digestion by producing digestive secretions and include the salivary tion including a diet lacking in bulk and glands, liver, and pancreas. fiber, inadequate consumption of fluids, 2. GI motility propels food and fluids through the GI sedentary lifestyle, increasing age, and system and is provided by rhythmic, intermittent drugs (opiates, antidepressants, calcium contractions (peristaltic movements) of smooth channel blockers, anticholinergics). muscle (except for pharynx and upper 1/3 of the (3) Numerous conditions can cause constipa- esophagus). tion including hypothyroidism, diverticular 3. Neural control is achieved by the autonomic nerv- disease, irritable bowel syndrome, ous system (ANS). Both sympathetic and Parkinson's disease, spinal cord injury, parasymphetic plexuses extend along the length of tumors, bowel obstruction and rectal the GI wall. Vagovagal (mediated by the vagus lesions. nerve) reflexes control the secretions and mobility (4) Obstipation is intractable constipation with of the GI tract. resulting fecal impaction, the retention of 4. Major GI hormones include cholecystokinin, gas- hard, dry stools in the rectum and colon. trin, and secretin. Impaction can cause partial or complete 5. Signs and symptoms common to many types of GI bowel obstruction. The patient may exhibit disorders. a history of watery diarrhea, fecal soiling, a. Nausea and vomiting. Nausea is an unpleasant and fecal incontinence. Removal of the sensation that signals stimulation of medullary fecal mass is indicated. vomiting center and often precedes vomiting. (5) Red Flag: Constipation can cause abdomi- Vomiting is the forceful oral expulsion of nal pain and tenderness in the anterior hip, abdominal contents. groin, or thigh regions. (1) Nausea and vomiting can be triggered by (6) Constipation may develop as a result of muscle guarding and splinting, for example, many different causes including food, the patient with low back pain. drugs, hypoxia, shock, inflammation of d. Anorexia is the loss of appetite with an inabili- abdominal organs, distention, irritation of ty to eat. It is associated with anxiety, fear, and the GI tract, and motion sickness. depression along with a number of different (2) Prolonged vomiting can produce fluid and disease states and drugs. electrolyte imbalance, and can result in pul- (1) Anorexia nervosa is a disorder character- monary aspiration and mucosal or GI dam- ized by prolonged loss of appetite and age. inability to eat. Individuals exhibit emacia- b. Diarrhea is the passage of frequent watery tion, emotional disturbance concerning unformed stools. The amount of fluid loss body image, and fear of gaining weight. It determines the severity of the illness. is common in adolescent girls who may (1) Dehydration, electrolyte imbalance, dizzi- also exhibit amenorrhea. ness, thirst, and weight loss are common e. Dysphagia refers to difficulty in swallowing. complications of prolonged diarrhea. (1) Patients experience choking, coughing, or (2) Numerous conditions can trigger diarrhea abnormal sensations of food sticking in the including infectious organisms (E coli, back of the throat or esophagus. rotavirus, Salmonella), dysentery, diabetic (2) Numerous conditions can cause dysphagia enteropathy, irritable bowel syndrome, including lesions of the CNS (stroke, hyperthyroidism, neoplasm, and divertic- Alzheimer's, Parkinson's disease), stric- ulitis. Diet, medications, and strenuous tures and esophageal scarring, swelling, exercise can also cause diarrhea. cancer, and scleroderma. c. Constipation is a decrease in normal elimi- (3) Achalasia is a condition in which the lower nation with excessively hard, dry stools and

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 219 esophageal sphincter fails to relax and food a. Results from failure of the lower esophageal is trapped in the esophagus. sphincter to regulate flow of food from the f. Heartburn is a painful burning sensation felt in esophagus into the stomach and increased gastric the esophagus in the mid-epigastric area behind pressure. the sternum or in the throat. (1) It is typically caused by reflux of gastric b. The diaphragm that surrounds the esophagus content into the esophagus. and oblique muscles also contribute to antire- (2) Certain foods (fatty foods, citrus foods, flux function. chocolate, peppermint, alcohol, coffee, caf- feine), increased abdominal pressure (food, c. Over time, acidic gastric fluids (pH<4.0) dam- tight clothing, back supports, pregnancy), age the esophagus producing reflux esophagitis. and certain positions/movements (bending over or laying down after a large meal) can d. Heartburn commonly occurs 30-60 minutes aggravate heartburn. after eating and at night when lying down (noc- g. Abdominal pain is common in GI conditions. It turnal reflux). is the result of inflammation, ischemia, and mechanical stretching. Visceral pain can occur c. Red Flags. in the epigastric region (T3-T5 sympathetic (1) Atypical pain may present as head and nerve distribution; the periumbilical region neck pain. (TlO sympathetic nerve distribution); and the (2) Chest pain is sometimes mistaken for heart lower abdominal region (TlO-L2 sympathetic attack; it is unrelated to activity. nerve distribution). (3) Respiratory symptoms can occur including h. Red Flags: Referred GI pain patterns. wheezing and chronic cough due to (1) Visceral pain from the esophagus can refer microaspiration, laryngeal injury, and to the mid-back. vagal-mediated bronchospasm. Hoarseness (2) Mid-thoracic spine pain (nerve-root pain) can also result from chronic inflammation can appear as esophageal pain. of the vocal cords. (3) Visceral pain from the liver, diaphragm, or pericardium can refer to the shoulder. f. Complications include strictures and Barrett's (4) Visceral pain from the gallbladder, stomach, esophagus (a pre-cancerous state). pancreas, or small intestine can refer to the mid-back and scapular regions. g. Physical therapy interventions. (5) Vi ceral pain from the colon, appendix, or (1) Positional changes from full supine to pelvic viscera can refer to the pelvis, low modified, more upright positions is indicat- back, or sacrum. ed. I. GI bleeding is evidenced by blood appearing in (2) Valsalva is contraindicated. vomitus or feces. (1) It can result from erosive gastritis, peptic h. Lifestyle modifications include avoiding large ulcers, prolonged use of nonsteroidal anti- meals and certain foods; sleeping with head inflammatory drugs (NSAIDs) and chronic elevated; medications include acid-suppre sing alcohol use. Proton Pump Inhibitors, PPIs (e.g., Prilosec), (2) Occult or hidden blood can only be H-2 blockers (e.g. Zantac, Tagamet), and revealed by stool testing. antacids (e.g., Turns). In severe cases surgery is J. Abdominal pain is generally aggravated by an option. coughing, sneezing, or straining. B. Esophagus 2. Hiatal hernia is the protrusion of the stomach 1. Gastroesophageal Reflux Disease (GERD) is upward through the diaphragm (rolling hiatal her- caused by reflux or backward movement of gastric nia) or displacement of both the stomach and gas- contents of the stomach into the esophagus, pro- troesophageal junction upward into the thorax ducing heartburn. (sliding hiatal hernia). a. May be congenital or acquired. b. Symptoms include heartburn from GERD. c. Conservative or symptomatic treatment is the same as for GERD. Surgery may be indicated. C. Stomach 1. Gastritis is inflammation of the stomach mucosa. Gastritis can be acute or chronic. a. Acute gastritis is caused by severe burns,

220 aspirin or other NSAIDs, corticosteroids, food D. Intestines allergies, or viral or bacterial infections. I. Malabsorption syndrome i a complex of disorders Hemorrhagic bleeding can occur. characterized by problem in intestinal absorption b. Symptoms include anorexia, nausea, vomiting, of nutrients (fat, carbohydrates, proteins, vitamins, and pain. calcium, iron). c. Chronic gastritis occurs with certain diseases a. Can be caused by gastric or small bowel resec- such as peptic ulcer (Helicobacter pylori bacte- tion (short-gut syndrome) or a number of dif- rial infection or H. pylori), stomach cancer, ferent diseases including cystic fibrosis, celiac pernicious anemia or with autoimmune disor- disease, Crohn's di ea e, chronic pancreatitis, ders (thyroid disease, Addison's disease). and pernicious anemia. Malab orption can also c. Red Flag: Patients taking NSAIDs long term be drug-induced (NSAID gastroenteritis). should be monitored carefully for stomach b. Deficiencies of enzymes (pancreatic lipase) pain, bleeding, nausea or vomiting. and bile salts are contributing factors. d. Management is symptomatic and includes c. Symptoms can include anorexia, weight loss, avoiding irritating substances (caffeine, nico- abdominal bloating, pain and cramps, indiges- tine, alcohol), dietary modification, and med- tion, and steatorrhea (abnormal amounts of fat in ications include acid-suppressing Proton Pump feces). Diarrhea, can be chronic and explosive. Inhibitors, H-2 blockers and antacids. d. Red Flags: 2. Peptic ulcer disease refers to ulcerative lesions that (l) Iron-deficiency anemia. occur in the upper GI tract in areas exposed to (2) Easy bruising and bleeding due to lack of acid-pepsin secretions. It can affect one or all lay- vitamin K. ers of the stomach or duodenum. (3) Muscle weakness and fatigue due to lack of a. Caused by a number of factors including bacte- protein, iron, folic acid, and vitamin B. rial infection (H. pylori), acetylsalicylic acid (4) Bone loss, pain, and predisposition to (aspirin) and NSAIDs, excessive secretion of develop fractures from lack of calcium, gastric acids, stress, and heredity. phosphate, and vitamin D. b. Symptoms include epigastric pain which is (5) Neuropathy including tetany, paresthesias, described as a gnawing, burning, or cramp-like. numbness and tingling from lack of calcium, Pain is aggravated by change in position and vitamins Band 0, magnesium, potassium. absence of food in the stomach and relieved by (6) Muscle spasms from electrolyte imbalance food or antacids. and lack of calcium. c. Complications include hemorrhage. Bleeding (7) Peripheral edema. may be sudden and severe or insidious with 2. Inflammatory Bowel Disease (lED) refers to two blood in vomitus or stools. Symptoms can related chronic inflammatory intestinal disorders, include weakness, dizziness or other signs of Crohn's disease (CD) and ulcerative colitis (UC). circulatory shock. Both diseases result in inflammation of the bowel d. Management includes use of antibiotics for and are characterized by remissions and exacerba- treatment of H. pylori along with acid-SUp- tions. pressing drugs (proton Pump Inhibitors, H-2 a. Symptoms include abdominal pain, frequent blockers and antacids. Dietary modification attacks of diarrhea, fecal urgency, and weight including avoidance of stomach irritants is indi- loss. cated. Surgical intervention is indicated for per- Red Flags: foration and uncontrolled bleeding. (1) Joint pain (reactive arthriti ) and skin rash- e. Red Flags: es can occur. Pain can be referred to the low (I) Pain from peptic ulcers located on the pos- back. (2) Complications can include intestinal terior wall of the stomach can present as obstruction and corticosteroid toxicity (low radiating back pain. Pain can also radiate to bone density, increased fracture risk). the right shoulder. (3) Intestinal absorption i di rupted and nutri- (2) Stress and anxiety can increase gastric tional deficiencies are common. secretions and pain.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 221 (4) Chronic IBD can lead to anxiety and d. Regular exercise is an important component of depre ion. treatment. b. Crohn's disease involves a granulomatous type 5. Appendicitis is an inflammation of the vermiform of inflammation that can occur anywhere in the appendix. As the condition progresses, the appen- GI tract. Areas of adjacent normal tissue called dix becomes swollen, and gangrenous and perfo- skip lesions are present. rates. Perforation can be life threatening and lead to the development of peritonitis. c. Ulcerative colitis involves an ulcerative and a. Pain is abrupt in onset, localized to the epigas- exudative inflammation of the large intestine tric or periumbilical area, and increases in and rectum. It is characterized by varying intensity over time. amount of bloody diarrhea, mucus, and pus. b. Rebound tenderness (Blumberg's sign) is pres- Skip lesion are absent. ent in response to depression of the abdominal wall at a site distant from the painful area. 3. Irritable Bowel Syndrome (IBS) is characterized c. Point tenderness is located at McBurney's by abnormally increased motility of the small and point, the site of the appendix located 11/2 - 2 inches above the anterior superior iliac spine in large intestines. ms is also known as spastic the right lower quadrant. d. Red Flag: colon, nervous or irritable colon. Immediate medical attention is required. e. Elevations in WBC count (>20,OOO/mm3) is a. ms is associated with emotional stress and cer- indicative of perforation. Surgery is indicated. tain foods (high fat content or roughage, lac- 6. Peritonitis is inflammation of the peritoneum, the tose intolerance). No structural or biochemical serous membrane lining the walls of the abdominal abnormalities have been identified. cavity. b. Symptoms include persistent or recurrent a. Peritonitis results from bacterial invasion and abdominal pain that is relieved by defecation. infection of the peritoneum. Common agents Patients may experience constipation or diar- include E. coli, bacteroides, fusobacterium and rhea, bloating, abdominal cramps, flatulence, streptococci. nausea, and anorexia. b. A number of different factors can introduce c. Stress reduction and medications to reduce infecting agents including penetrating wounds, anxiety or depression are an important compo- surgery, perforated peptic ulcer, ruptured nents of treatment. appendix, perforated diverticulum, gangrenous d. Regular physical activity is effective in reduc- bowel, pelvic inflammatory disease, and gan- ing stress and improving bowel function. grenous gall bladder. 4. Diverticular di ease is characterized by a pouch c. Symptoms include abdominal distension, like herniations (diverticula) of the mucosal layer severe abdominal pain, rigidity from reflex of the colon through the muscularis layer guarding, rebound tenderness, decreased or a. Diverticulosis refers to pouchlike herniations absent bowel sounds, nausea and vomiting, and of the colon, especially the sigmoid colon. tachycardia. (1) Symptoms are minimal but can include rec- d. Elevated WBC count, fever, electrolyte imbal- ance, and hypotension are common. tal bleeding. e. Peritonitis can lead to toxemia and shock, cir- (2) Dietary factors (lack of dietary fiber), lack culatory failure, and respiratory distress. f. Treatment is aimed at controlling inflammation of physical activity, and poor bowel habits and infection and restoring fluid and elec- contribute to its development. trolyte imbalances. Surgical intervention may (3) Diverticulosis can lead to diverticulitis. be necessary to remove an inflamed appendix b. Diverticulitis refers to inflammation of one or or close a perforation. more diverticula. Fecal matter penetrates diver- ticula and causes inflammation and abscess. E. Rectum (I) Symptoms include pain and cramping in 1. Rectal fissure is a tear or ulceration of the lining of the lower left quadrant, nausea and vomit- ing, slight fever, and an elevated WBC. (2) Complications include bowel obstruction, perforation with peritonitis, and hemorrhage. c. Red Flag: Patient may complain of back pain.

222 the anal canal. Constipation and large, hard stools Red Flag: Heart disease and stroke risk are factors. increases after menopause. 2. Hemorrhoids (piles) are varicosities in the lower 5. The breasts are mammary tissues located on the rectum or anus caused by congestion of the veins anterior chest wall between the 3rd and 7th ribs. in the hemorrhoidal plexus. a. Breast function is related to production of sex a. Hemorrhoids can be internal or external, (pro- hormones and pregnancy, producing milk for infant nourishment. truding from the anus). B. Pregnancy: Normal b. Symptoms include local irritation, pain, rectal 1. Pregnancy weight gain: average 20-30 lbs. 2. Physical therapist teach childbirth education itching. classes. c. Prolonged bleeding can result in anemia. a. Relaxation training: e.g., Jacobsen's progres- d. Straining with defecation, constipation, and sive relaxation, relaxation response, mental imagery, yoga. prolonged sitting contribute to discomfort. b. Breathing management: slow, deep, diaphrag- e. Pregnancy increases the risk of hemorrhoids. matic breathing; Lamaze techniques; avoid- f. Treatment includes topical medications to ance of Val salva. c. Provide information about pregnancy and shrink the hemorrhoid, dietary changes, sitz childbirth. baths, and local hot or cold compresses, and 3. Common changes with pregnancy and physical ligation or surgical excision. therapy interventions. a. Postural changes: kyphosis with scapular pro- VII. The Genital/Reproductive System traction, cervical lordosis and forward head; lumbar lordosis; postural stress may continue A. Overview: The Female Reproductive System into postpartum phase with lifting and carrying 1. External genitalia, located at the base of the pelvis, the infant. con ist of the mons pubis, labia majora, labia (1) Postural evaluation. minora, clitoris, and perineal body. (2) Teach postural exercise to stretch, 2. The urethra and anus are in close proximity to the strengthen, and train postural muscles. external genital structures and cross-contamina- (3) Teach pelvic stabilization exercises, e.g., tion is possible. posterior pelvic tilt. 3. The internal genitalia consist of the vagina, the (4) Teach correct body mechanic, e.g., sitting, uterus and cervix, the fallopian tubes, and paired standing, lifting, ADLs. ovaries. (5) Limit certain activitie in the third 4. Sexual and reproductive functions. trimester, e.g., supine position to avoid a. The ovaries store female germ cells (ova) and inferior vena cava compression, bridging. produce female sex hormones (the estrogens b. Balance changes: center of gravity shifts for- and progesterone) under control of the hypo- ward and upward as the fetu develops; with thalamus (gonadotropin-releasing hormone) advanced pregnancy, there will be a wider base and the anterior pituitary gland (gonadotropic of support, increased difficulty with walking follicle-stimulating and luteinizing hormones). and stair climbing, rapid challenges to balance. b. Sex hormones influence the development of (1) Teach safety strategies. secondary sex characteristics, regulate the men- c. Ligamentous laxity secondary to hormonal strual cycle (ovulation), maintain pregnancy influences (relaxin). (fertilization and implantation, gestation), and (1) Joint hypermobility (e.g., sacroiliac joint), influence menopause (cessation of the men- pain. strual cycle). (2) Predisposition to injury especially in (1) Estrogens decrease the rate of bone resorp- weight bearing joints of lower extremities tion. and pelvis. Red Flag: Osteoporosis and risk of bone (3) May persist for some time after delivery; fracture increase dramatically after menopause. (2) Estrogens increase production of the thy- roid and increase high-density lipoproteins (a protective effect against heart disease).

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 223 teach joint protection strategies. sit-ups or bilateral straight leg raising. d. Muscle weakness: abdominal muscles are (2) Resume abdominal exercises when separa- stretched and weakened as pregnancy devel- tion is less than 2 cm: teach safe abdominal ops; pelvic floor weakness with advanced preg- strengthening exercises, e.g., partial sit-ups nancy and childbirth. Stress incontinence sec- (knees bent), pelvic tilts; utilize hands to ondary to pelvic floor dysfunction (experi- support abdominal wall. enced by 80% of women). 2. Pelvic floor disorders: the result of weakening of (1) Teach exercises to improve control of pelvic floor muscles (pubococcygeal muscles, PC). pelvic floor, maintain abdominal function. a. PC muscles normally function to support the (2) Stretching exercises to reduce muscle vagina, urinary bladder, and rectum and help maintain continence of the urethra and rectum. cramping. b. Weakness or laxity of PC muscles typically (3) Avoid Valsalva maneuver: may exacerbate results from overstretching during pregnancy and childbirth. Further loss of elasticity and condition. muscle tone during later life can result in par- e. Urinary changes: pressure on bladder causes tial or total organ prolapse. Examples include. (1) Cystocele: the herniation of the bladder frequent urination; increased incidence of into the vagina. reflux, urinary tract infections. (2) Rectocele: the herniation of the rectum into f. Respiratory changes: elevation of the the vagina. diaphragm with widening of thoracic cage; (3) Uterine prolapse: the bulging of the uterus hyperventilation, dyspnea may be experienced into the vagina. with mild exercise during late pregnancy. c. PC muscles can also go into spasm. g. Cardiova cular changes: increased blood vol- d. Symptoms include pelvic pain (perivaginal, ume; increased venous pressure in the lower perirectal, lower abdominal quadrant), urinary extremities; increased heart rate and cardiac incontinence, and pain with sexual intercourse. output, decreased blood pressure due to venous Red Flag: Pain can radiate down the posterior distensibility. thigh. (1) Teach afe progression of aerobic exercises. e. Surgical correction is often required, depend- ing on degree of prolapse. (a) Exercise in moderation, with frequent f. Physical therapy intervention (pelvic floor rests. rehabilitation). (1) Observe for: urinary frequency and urgency, (b) Stress use of familiar activities; avoid- painful urination, painful defecation; low ance of unfamiliar. back and perineal pain with prolapse. (2) Teach pelvic floor exercises (Kegel exercis- (c) Postpartum: emphasize gradual return es) to strengthen the PC muscles is indicated. to previous level of activity. (3) Postural education and muscle reeducation, pelvic mobilization, and stretching of tight (2) Stress gentle stretching, adequate warm-ups LE muscles are also important components. and cool-downs. 3. Low back and pelvic pain. a. Physical therapy interventions (3) Teach ankle pumps for lower extremity (1) Teach proper body mechanics. edema (late stage pregnancy); elevate legs (2) Balance rest with activity. to assist in venous return. (3) Emphasize use of a fIfm mattress. (4) Massage, modalities for pain (no deep (4) Wear loose, comfortable clothing. heat). h. Altered thermoregulation: increased basal 4. Sacroiliac dysfunction secondary to postural changes, ligamentous laxity. metabolic rate; increased heat production. C. Pregnancy-related Pathologies 1. Diastasis recti abdominis. a. Lateral separation or split of the rectus abdo- minis; separation from mid-line (linea alba) greater than 2 cm is significant; associated with loss of abdominal wall support, increased back pain. b. Physical therapy interventions. (1) Teach protection of abdominal muscula- ture: avoid abdominal exercises, e.g., full

224 a. Symptoms include posterior pelvic pain; pain a. The ectopic tissue responds to hormonal influ- in buttocks, may radiate into posterior thigh or ences but is not able to be hed as uterine tissue knee. is during menstruation. b. Associated with prolonged sitting, standing, or b. Endometrial tissue can lead to cysts and rup- walking. ture producing peritonitis and adhesions as well as adhesions and obstruction. c. Physical therapy interventions. (1) External stabilization, e.g., sacroiliac sup- c. Symptoms include pain, dysmenorrheal, dys- port belt, may help reduce pain. pareunia (abnormal pain during sexual inter- (2) Avoid single limb weight-bearing: may course), and infertility. aggravate sacroiliac dysfunction. Red Flag: Patients may complain of back pain. Endometrial implants on muscle (e.g. psoas 5. Varicose veins: may produce discomfort or pain. major. pelvic floor muscles) may produce pain a. Physical therapy interventions. with palpation or contraction. (1) Elevate extremities; avoid crossing legs which may press on veins. d. Treatment involves pain management, endome- (2) Use of elastic support stockings may help. trial suppression, and surgery. 6. Preeclampsia: pregnancy induced, acute hyperten- 2. Pelvic inflammatory disease (PID) is an inflam- sion after the 24th week of gestation. mation of the upper reproductive tract involving a. May be mild or severe. the uterus (endometritis), fallopian tubes (salpingi- b. Evaluate for symptoms of hypertension, tis), or ovaries (oophoritis). edema, sudden excessive weight gain, head- a. PID is caused by a polymicrobial agent that ache, visual disturbances, or hyperreflexia. ascends through the endocervical canal. c. Initiate prompt physician referral. b. Symptoms include lower abdominal pain that typically starts after a menstrual cycle, purulent 7. Cesarean childbirth. cervical discharge, and painful cervix. Fever, a. Surgical delivery of the fetus by an incIsIOn elevated WBC count and increa ed ESR (ery- through the abdominal and uterine wall; indi- throcyte sedimentation rate) are present. cated in pelvic disproportion, failure of the c. Complications can include pelvic adhesions, birth process to progress, fetal or mother dis- infertility, ectopic pregnancy, chronic pain, and tress, or other complications. abscesses. b. Physical therapy interventions. d. Treatment involves antibiotic therapy to treat (1) Postoperative TENS can be used for inci- the infection and prevent complications. sional pain; electrodes are placed parallel to the incision. 3. Pelvic floor disorders (previously discussed). (2) Prevent post-surgical pulmonary complica- E. Overview: The Male Reproductive System tions: assist patient in breathing, coughing. (3) Post-cesarean exercises. 1. The male reproductive system is composed of (a) Gentle abdominal exercises; provide paired testes, genital ducts, accessory glands, and incisional support with pillow. penis. (b) Pelvic floor exercises: labor and push- ing is typically present before surgery. 2. The testes or male gonads are located in the scro- (c) Postural exercises; precautions about tum, paired egg-shaped acs located outside the heavy lifting for 4-6 weeks. abdominal cavity. They function in the production (4) Ambulation. of male sex hormones (testosterone) and sperma- (5) Prevent incisional adhesions: friction mas- toazoa (male germ cells). sage. 3. The accessory glands (seminal vesicles, prostate D. Disorders of the Female Reproductive System gland, and bulbourethral glands) prepare sperm for 1. Endometriosis is characterized by ectopic growth ejaculation. and function of endometrial tissue outside of the uterus. Common sites include ovaries, fallopian 4. The ductal system (epididymides, vas deferens, tubes, broad ligaments, uterosacral ligaments, and ejaculatory duct) tore and transports sperm. pelvis, vagina, or intestines. 5. The urethra, enclosed in the penis, function for elimination of urine and semen. 6. Sperm production requires an environment that is 2_3°C lower than body temperature.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 225 7. Te tosterone and other male sex hormones (andro- a. Types include acute bacterial, chronic prostatitis, gens). and nonbacterial. a. During development, induce differentiation of (1) Acute bacterial prostatitis involves bacteri- the male genital tract. al urinary tract infection (UTI) infection b. Stimulate development of primary and second- and is associated with catheterization and ary sex characteristics during puberty and multiple sex partners. Symptoms include maintains them during life. urinary frequency, urgency, nocturia, c. Promote protein metabolism, musculoskeletal dysuria, urethral discharge, fever and growth, and subcutaneous fat distribution (ana- chills, malaise, myalgia and arthralgia, and bolic effects). pain. Red Flags: Dull aching pain may be found 8. The hypothalamus and anterior pituitary gland in lower abdominal, rectal, lower back, maintain endocrine via gonadotropic hormones sacral, or groin regions. (follicle stimulating hormone, FSH, and luteiniz- (2) Chronic prostatitis can also be bacterial in ing hormone, LH). origin and is associated with recurrent UTI. a. FSH initates initiates spermatogenesis. Symptoms include urinary frequency, and b. LH regulates testosterone production. urgency, myalgia and arthralgia, and pain in the low back or perineal region. F. Disorders of the Male Reproductive System (3) Nonbacterial inflammatory prostatitis pro- 1. Erectile dysfunction (ED) or impotence is the duces pain in the penis, testicles and scro- inability to achieve and maintain erection for sex- tum, painful ejaculation, low back pain or ual intercourse. pain in the inner thighs, urinary symptoms, a. Organic cau es. decreased libido and impotence. (1) Neurogenic causes: stroke, cerebral trauma, spinal cord injury, multiple sclerosis, b. Because the prostate encircles the urethra, Parkinson's disease. obstruction of urinary flow can result. (2) Hormonal causes: decreased androgen lev- els with hypogonadism, hypothyroidism, VIII. The Renal and Urologic Systems hypopituitarism. (3) Vascular causes: hypertension, coronary heart A. Overview disease, hyperlipidemia, cigarette smoking, 1. Anatomy. diabetes mellitus, pelvic irradiation. a. Kidneys are paired, bean-shaped organs locat- (4) Drug-induced: antidepressants, antipsy- ed outside of the peritoneal cavity (retroperi- chotics, anti androgens, antihypertensives; toneal) in the posterior upper abdomen on each amphetamines, alcohol. side of the vertebral column at the level of T12 (5) Aging increases risk of ED. to L2. b. Psychogenic causes. b. Each kidney is multilobular; each lobule is (l) Performance anxiety composed of more than a million nephrons (the (2) Depression and psychiatric disorders functional units of the kidney). (schizophrenia). c. Each nephron consists of a glomerulus that fil- c. Surgical causes. ters the blood and nephron tubules. Water, elec- (1) Transurethral procedures. trolytes, and other substances vital for function (2) Radical prostatectomy. are reabsorbed into the bloodstream while (3) Proctocolectomy. other waste products are secreted into the (4) Abdominoperineal resection. tubules for elimination. d. Advancing age d. The renal pelvis is a wide, funnel-shaped struc- e. Treatment requires accurate identification and ture at the upper end of the urethra that drains remediation of specific causes of ED. the kidney into the lower urinary tract (bladder f. Medication are available to improve function and urethra). (e.g., Viagra). e. The bladder is a membranous sac that collects 2. Prostatiti involves infection and inflammation of urine and is located behind the symphysis the pro tate gland. pubis.

226 f. The ureter extends from the renal pelvis to the B. Urinary Regulation of Fluids and Electrolytes: bladder and moves urine via peristaltic action. homeostasis regulated through thirst mechanisms and renal function via circulating antidiuretic hormone g. The urethra extends from the bladder to an (ADH) external orifice for elimination of urine from 1. Fluid imbalances: daily fluid requirements vary the body. based on presence or absence of sweating, air tem- perature, fever, etc. h. In females, proximity of the urethra to vaginal a. Dehydration: excessive loss of body fluids; and rectal openings increases the likelihood of fluid output exceeds fluid intake. urinary tract infection (UTI). (1) Causes: poor intake; excess output: profuse sweating, vomiting and diarrhea, diuretics; 2. Functions of the kidney closely linked to sodium deficiency. a. Regulates the composition and pH of body fluids (2) Observe for: poor skin turgor, dry mucous through reabsorption and elimination; controls membranes, headache, irritability, postural mineral (sodium, potassium, hydrogen, chloride, hypotension, incoordination, lethargy, dis- and bicarbonate ions) and water balance. orientation. b. Eliminates metabolic wastes (urea, uric acid, (3) May lead to uremia and hypovolemic shock creatinine) and drugs/drug metabolites. (stupor and coma). c. Assists in blood pressure regulation through (4) Decreased exercise capacity, especially in rennin-angiotensin-aldosterone mechanisms hot environments. and salt and water elimination. b. Edema: an excess of body fluids with expan- d. Contributes to bone metabolic function by acti- sion of interstitial fluid volume. vating vitamin D and regulating calcium and (1) Causes. phosphate conservation and elimination. (a) Increased capillary pressure: heart fail- e. Controls the production of red blood cells in ure, kidney disease, premenstrual the bone marrow through the production of retention, pregnancy, environmental erythropoietin. heat stress; venous obstruction (liver f. The glomerular filtration rate (GFR) is the disease, acute pulmonary edema, amount of filtrate that is formed each minute as venous thrombosis). blood moves through the glomeruli and serves (b) Decreased colloidal osmotic pressure: as an important gauge of renal function. decreased production or loss of plasma (I) Regulated by arterial blood pressure and proteins (protein-losing kidney disease, renal blood flow. liver disease, starvation, malnutrition). (2) Measured clinically by obtaining creatinine (c) Increased capillary permeability: levels in blood and urine samples. inflammation, allergic reaction, (3) Normal creatinine clearance is 115 to 125 malignancy, tissue injury, burns. mL/min. (d) Obstruction of lymphatic flow. g. Blood urea nitrogen (BUN) is urea produced in (2) Observe for swelling of the ankles and feet, the liver as a by product of protein metabolism weight gain; headache, blurred vision; that is eliminated by the kidneys. muscle cramps and twitches. (I) BUN levels are elevated with increased (a) Edema can be restrictive, producing a protein intake, gastrointestinal bleeding, tourniquet effect. and dehydration. (b) Tissues are susceptible to injury and (2) BUN-creatinine ratio is abnormal in liver delayed healing. disease. (c) Pitting edema occur when the amount of inter titial fluid exceeds the absorp- 3. Normal values of urine (urinalysis findings). tive capacity of tissues. a. Color: yellow-amber. 2. Potassium imbalance: normal serum level is 3.5 to b. Clarity: clear. 5.5 mEqlL. c. Specific gravity: 1.010-1.025 with normal fluid a. Hypokalemia: decreased pota ium in the intake. d. pH: 4.6-8.0; average is 6 (acid). e. Protein: 0-8 mg/dl. f. Sugar: O.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 227 blood. (4) Anorexia, nausea, weight loss, lethargy. (1) Muscle weakness and fatigue, leg cramps; 5. Magnesium imbalance. hyporeflexia. a. Hypomagnesemia: decreased magnesium. (2) Postural hypotension, dizziness, arrhyth- (I) Hyperirritability, confusion, delusions, hal- lucinations, convulsions. mias, ECG abnormalities: flat T wave, pro- (2) Tetany, leg and foot cramps. longed Q-T interval; depressed S-T segment, (3) Arrhythmias, vasomotor changes (vasodi- U wave appears; arrhythmias. lation and hypotension), occasionally (3) Respiratory distress. hypertension. (4) Irritability, confusion, depression. (5) Gastrointe tinal: nausea and vomiting, b. Hypermagnesemia: increased magnesium. anorexia, diarrhea. (I) Hyporeflexia, muscle weakness, flaccid b. Hyperkalemia: excess of potassium in the paralysis. blood; common in acute renal failure. (2) Respiratory muscle paralysis. (I) Muscle weakness, flaccid paralysis. (3) Drowsiness, flushing, lethargy, confusion, (2) Tachycardia and later bradycardia; arrhyth- diminished sensorium. mias; ECG changes: tall, peaked T wave, (4) Bradycardia, weak pulse, hypotension, prolonged P-R interval and QRS duration. heart block and cardiac arrest. (3) Gastrointestinal: nausea, diarrhea, abdomi- nal cramps. 6. Acid-Base balance: balance of acids and bases in 3. Sodium imbalance: normal serum level is 134-145 the body (normally a ratio of 20 base to 1 acid; mEqlL. normal serum pH is 7.35 to 7.45 [slightly alka- a. Hyponatremia: decreased sodium in the blood. line]); regulated by blood buffer systems (the (1) Muscle weakness and twitching. lungs and the kidneys). (2) Hypotension, tachycardia; progressive cir- a. Metabolic acidosis: a depletion of bases or an culatory collapse and shock. accumulation of acids; blood pH falls below (3) Anxiety, headaches, restlessness, convul- 7.35. sions. (1) Causes: diabetes, renal insufficiency or (4) Respiratory: cyanosis with severe sodium failure, diarrhea. deficiency. (2) Observe for: hyperventilation (compensa- (5) Skin: cold, clammy, decreased turgor. tory), deep respirations; weakness, muscu- b. Hypematremia: excess of sodium in the blood. lar twitching; malaise, nausea, vomiting (1) Circulatory congestion: pitting edema, and diarrhea; headache; dry skin and excessive weight gain, ultimately pul- mucous membranes, poor kin turgor. monary edema with dyspnea, respiratory (3) May lead to stupor, and coma (death). arrest. b. Metabolic alkalosis: an increase in bases or a (2) Hypertension, tachycardia. reduction of acids; blood pH rises above 7.45. (3) Agitation, restlessness, convulsions. (1) Causes: excess vomiting, excess diuretics, (4) Flushed kin, sticky mucous membranes. hypokalemia; peptic ulcer and excessive 4. Calcium imbalance. intake of antacids. a. Hypocalcemia: decreased calcium in the blood. (2) Observe for: hypoventilation (compensa- (1) Muscle cramps, tetany, spasms. tory), depressed respirations; dysrhyth- (2) Paresthesias (tingling and numbness). mias; prolonged vomiting, diarrhea; weak- (3) Anxiety, irritability, twitching, convulsions. ness, muscle twitching; irritability, agita- (4) Arrhythmias, hypotension. tion, convulsions and coma (death). b. Hypercalcemia: excess of calcium in the blood. c. Respiratory acidosis: CO2 retention, impaired (1) Decreased muscle tone, weakness, bone alveolar ventilation. pain, pathologic fractures. (1) Causes: hypoventilation, drugs/over-seda- (2) Drowsiness, lethargy, headaches, irritabili- tion, chronic pulmonary disease (e.g. ty, confusion. emphysema, asthma, bronchitis, pneumo- (3) Heart block, cardiac arrest, hypertension. nia) or hypermetabolism (sepsis, bums). (2) Observe for: dyspnea, hyperventilation

228 cavities that form along the nephron and can lead to renal degeneration or obstruction. cyanosis; restlessness, headache. a. Types include polycystic, medullary sponge, (3) May lead to disorientation, stupor and acquired, and simple renal cysts. coma, death. b. Symptoms can include; pain, hematuria, and d. Respiratory alkalosis: diminished CO2, alveo- hypertension. Fever can occur with associated lar hyperventilation. infection, Cysts can rupture producing hema- (1) Causes: anxiety attack with hyperventila- turia. Simple cysts are generally asymptomatic. 3. Obstructive disorders: developmental defects, tion, hypoxia (emphysema, pneumonia), renal calculi, prostatic hyperplasia or cancer, scar impaired lung expansion; CHF, pulmonary tissue from inflammation, tumors and infection, embolism; diffuse liver or CNS disease; tumors. salicylate poisoning; extreme stress (stimu- a. Pressure build-up backwards from site of lation of respiratory center). obstruction; can result in kidney damage. (2) Observe for: tachypnea, dizziness, anxiety, Dilation of ureters and renal pelves may be difficulty concentrating, numbness and tin- used to reduce obstruction. Observe for pain, gling; blurred vision; diaphoresis; muscle signs and symptoms of UTI, and hypertension. cramps, twitching or tetany, weakness; b. Renal calculi (kidney stones): crystalline struc- arrhythmias, convulsions. tures formed from normal components of urine C. Renal and Urologic Disorders (calcium, magnesium ammonium phosphate, 1. Urinary Tract Infections (UTIs): infection of the uric acid, cystine). urinary tract with microorganisms. (1) Etiological influences include concentra- a. Lower UTI: cystitis (inflammation and infec- tion of the bladder) or urethritis (inflammation tion of stone components in urine and a uri- and infection of the urethra). nary environment conducive to stone for- (1) Usually secondary to ascending urinary mation. tract infections; may also involve kidneys (2) Symptoms include renal colic pain (pain and ureters. from a stone lodged in the ureter made (2) Associated with symptoms of urinary fre- worse by stretching the collecting system). quency, urgency, burning sensation during Pain may radiate to the lower abdominal urination. Urine may be cloudy and foul- quadrant, bladder, area, and perineal areas smelling. Pain is noted in suprapubic, lower (scrotum in the male and labia in the abdominal or groin areas, depending on site female). Nausea and vomiting are common of infection and the skin may be cool and clammy. b. Upper UTI: pyelonephritis (inflammation and (3) Extracorporeal shock wave lithotripsy infection of one or both kidneys). (ESWL) is used to break up stones into (I) Associated with symptoms of systemic fragments to allow for easy pa sage. involvement: fever, chills, malaise, (4) Treatment/prevention can also include: headache; tenderness and pain over kidneys increased fluid intake, thiazide diuretics, (back pain); tenderness over the costoverte- dietary restriction of foods high in oxalate, bal angle (Murphy's sign). Symptoms also acidification or alkalinization of urine include frequent and burning urination; depending on type of stone. nausea and vomiting may occur. 4. Renal failure. (2) Palpitation or percussion over the kidney a. Acute renal failure: sudden loss of kidney func- typically causes pain. tion with resulting elevation in serum urea and (3) Can be acute or chronic; generally more creatinine. serious than lower UTI. (1) Etiology: may be due to circulatory disrup- d. Increased risk of UTI in persons with autoim- tion to kidneys, toxic substances, bacterial munity, urinary obstruction and reflux, neuro- toxins, acute obstruction, or trauma. genic bladder and catheterization, diabetes, and b. Chronic renal failure: progressive loss of kid- kidney transplantation. Older adults and ney function leading to end-stage failure. women are also at increased risk for UTI. 2. Renal cystic disease: renal cysts are fluid filled

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 229 (1) Etiology: may result from prolonged acute (5) Examine for multisystem dysfunction: vital urinary tract obstruction and infection, dia- signs, strength, sensation, ROM, function bete, ystemic lupus erythematosus, and endurance. uncontrolled hypertension. d. Transplantation is a major treatment choice (2) Uremia: an end-stage toxic condition (renal allograft). resulting from renal insufficiency and retention of nitrogenous wastes in blood; 5. Urinary incontinence: inability to retain urine; the symptoms can include anorexia, nausea, result of loss of sphincter control; may be acute mental confusion. (due to transient causes, e.g., cystitis) or persistent (e.g., stroke, dementia). (3) Red Flags: May lead to multisystem a. Types. abnormalities and failure. (1) Stress incontinence: sudden release of (a) Dizziness, headaches, anxiety, memo- urine due to: ry loss, inability to concentrate, con- (a) Increases in intra-abdominal pressure, vulsions and coma. e.g., cough, laugh, exercise, straining, (b) Hypertension, dyspnea on exertion, obesity. heart failure. (b) Weakness and laxity of pelvic floor (c) Chronic pain: ischemic leg pain, musculature, sphincter weakness, e.g., painful cramps. postpartum incontinence, menopause, (d) Edema: peripheral edema, pulmonary damage to pudendal nerve. edema. (2) Urge incontinence: bladder begins con- (e) Muscle weakness: peripheral neuropa- tracting and urine is leaked after sensation thy, cramping, restless legs. of bladder fullness is perceived; an inabili- (f) Skeletal: osteomalacia, osteoporosis, ty to delay voiding to reach toilet due to: bone pain, fracture. (a) Detrusor muscle instability or hyper- (g) Skin: pallor, ecchymosis, pruritus, dry reflexia, e.g., stroke. skin. (b) Sensory instability: hyper ensitive (h) Anemia, tendency to bleed easily. bladder. (i) Decreased endurance; functional losses. (3) Overflow incontinence: bladder continu- U) Autonomic nervous system dysfunc- ously leaks secondary to urinary retention tion: decreased heart rate, blood pres- (an overdistended bladder or incomplete sure; orthostatic hypotension. emptying of bladder), due to: (a) Anatomic obstruction, e.g., prostate c. Dialysis: process of diffusing blood across a enlargement. emipermeable membrane for the purposes of (b) Acontractile bladder, e.g., spinal cord removal of toxic substances; maintains fluid, injury, diabetes. electrolyte, and acid-base balance in presence (c) Neurogenic bladder, e.g., multiple of renal failure; peritoneal, or renal (hemodial- sclerosis, suprasacral spinal lesions. ysis). (4) Functional incontinence: leakage associat- ed with inability or unwillingness to toilet; (1) Dialysis disequilibrium: symptoms of nau- due to: sea, vomiting, drowsiness, headache and (a) Impaired cognition (dementia); depres- seizures; the result of rapid changes after sion, e.g., Alzheimer's disease. beginning dialysis. (b) Impaired physical functioning, e.g., stroke. (2) Dialysis dementia: signs of cerebral dys- (c) Environmental barriers. function (e.g., speech difficulties, mental b. Management. confusion, myoclonus, seizures, eventually (1) Dietary management: control of food and death); the result of longstanding, years of beverages that aggravate the bladder or dialy is treatment. incontinence, e.g., limit citrus fruit or juices, caffeine, chocolate, etc.; control (3) Locate dialysis shunts: taking BP at the shunt ite is contraindicated. (4) Locate peritoneal catheters (if used): avoid trauma to area.

230 fluid intake. (c) Biofeedback: uses pressure recordings (2) Medical management. to reinforce active contractions, relax bladder. (a) Identify and treat acute, reversible problems, e.g., cystometry. (d) Progressive strengthening: use of weighted vaginal cones for home exer- (b) Drug therapy for urge, stress, and over- cises or pelvic floor exerciser. flow incontinence, e.g., estrogen with phenylpropanolamine. (e) Incorporating Kegel exercise into everyday life: with lifting, coughing, (c) Control of medications that may aggra- changing positions, etc. vate incontinence, e.g., diuretics for CHF, anticholinergic or psychotropic (2) Provide behavioral training. drugs. (a) Record keeping: patients are asked to keep a history of their voiding (voiding (d) Catheterization: used for overflow diary). incontinence and other types if unre- (b) Education: regarding anatomy, physi- sponsive to other treatments and skin ology, reasons for muscle weakness, integrity is threatened; associated with incontinence; avoidance of Valsalva, high rates of urinary tract infection. heavy resistance exercises. (e) Surgery: bladder neck suspension, (3) Functional mobility training as needed. removal of prostate obstructions; Ensure independence in sit-to-stand transi- suprapubic cystostomy. tions, ambulation, safe toilet transfers. (3) Bladder training: prompted voiding to (4) Environmental modifications as needed: toi- restore a pattern of voiding. let rails, raised toilet seat, or commode, etc. (a) Involves toileting schedule: taking patient to bathroom at regular intervals. (5) Maintain adequate skin condition. (b) May also include intermittent catheteri- (a) Teach appropriate skin care, maintain zation, e.g., for patients with overdisten- toileting schedule. tion, persistent retention, e.g., multiple (b) Adequate protection: adult diapers, sclerosis. underpads. c. Examination. (6) Provide psychological support: emotional (l) Symptoms of incontinence: onset and dura- and social consequences of incontinence tion, urgency, frequency, timing of are significant. episodes/causative factors. (2) Strength of pelvic floor muscles using a IX. The Endocrine and Metabolic Systems perineometer. (3) Functional mobility, environmental factors. A. Overview of the Endocrine System 1. The endocrine system uses hormones (chemical d. Physical therapy goals, outcomes, and inter- messengers) to relay information to cells and ventions for stress and urge incontinence. organs and regulate many of the body functions (1) Teach pelvic floor muscle exercises (pubo- (digestion, use of nutrients, growth and develop- coccygeus muscle): used to treat stress ment, electrolyte and water balance, and reproduc- incontinence. tive functions). The hypothalamus and pituitary (a) Kegel exercises: active, strengthening gland along with the nervous system comprise the exercises; Type 1 works on holding con- central network that exerts control over many tractions, progressing to 10 second holds, other glands in the body with wide ranging func- rest 10 seconds between contractions; tions. Endocrine functions are also closely linked Type 2 works on quick contractions to with the immune system. shut off flow of urine, 10-80 repetitions a a. Hormones bind to specific receptor sites which day. Avoid squeezing buttocks, or con- are linked to specific systems and functions. tracting abdominals (bearing down). b. The hypothalamus controls release of pituitary (b) Functional electrical stimulation: for hormones (corticotropin-releasing hormone muscle re-education if patient is unable (CRH); thyrotropin-releasing hormone (TRH); to initiate active contractions. growth hormone-releasing hormone (GHRH);

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 231 and somatostatin. b. May be acquired, familial, idiopathic, neuro- c. The anterior pituitary gland controls the release genic, or nephrogenic. Possible virall autoim- mune and genetic etiology. of growth hormone (GH), adrenocorticotropic hormone (ACTH); follicle-stimulating hor- c. Type I, Insulin-dependent diabetes mellitus mone (FSH); luteinizing hormone (LH); and (IDDM). Also known as juvenile-onset dia- prolactin. betes, ketosis-prone diabetes, or brittle dia- d. The posterior pituitary gland controls the betes. Characteristics include: release of antidiuretic hormone (ADH) and (1) Decrease in size and number of islet cells oxytocin. resulting inadequate production of insulin. e. The adrenal cortex controls the release of miner- (2) Long preclinical period, often with abrupt al corticosteroids (aldosterone); glucocorticoids onset of symptoms around the age of (cortisol), adrenal androgens (dehydroepiandros- puberty. terone (DHEA) and androstenedione. (3) Insulin dependent. f. The adrenal medulla controls the release of epi- (4) Prone to ketoacidosis. nephrine and norepinephrine. g. The thyroid control the release of triiodothy- d. Type II, Noninsulin-dependent diabetes melli- ronine and thyroxine. Thyroid C cells control tus (NIDDM) results from inadequate utiliza- the release of calcitonin. tion of insulin. Also known as adult-onset or h. The parathyroid glands control the release of maturity-onset diabetes, ketosis-resistant dia- parathyroid hormone (PTH). betes, or stable diabetes. Characteristics i. The pancreatic islet cells control the release of include: insulin, glucagons, and somatostatin. (1) Gradual onset; may have familial pattern. j. The kidney controls the release of 1, 25-dihy- (2) Usually not insulin dependent. droxyvitarnin D. (3) Individual is not prone to ketoacidosis k. The ovaries control the release of estrogen and (may form ketones with stress). progesterone. (4) Linked to obesity, (can occur in nonobese), 1. The testes control the release of androgens and older adults (typically over the age of (testosterone). 40). B. Diabetes mellitus (DM) 1. Definitions: a complex disorder of carbohydrate, e. Metabolic syndrome (insulin resistance syn- fat, and protein metabolism caused by deficiency drome, syndrome X). or absence of insulin secretion by the beta cells of (1) Leads to type 2 diabetes. the pancreas or by defects of the insulin receptors. (2) Characterized by 3 or more of the follow- a. Signs and symptoms of uncontrolled DM. ing: obesity, high triglycerides (equal to or (1) Elevated blood sugar (hyperglycemia). greater than 150 mg/dL); low high density (2) Elevated sugar in urine (glycosuria). (3) Presence of ketone bodies in the urine, the lipoproteins « 50 mg/dL in women and byproducts of fat metabolism < 40 mg/dL in men), elevated blood pres- (ketonuria). sure (> 130/85 mm Hg) and fasting plasma (4) Exces ive excretion of urine (polyuria). glucose (> llOmg/dL). (5) Exce ive thirst (polydipsia). f. Secondary diabetes: associated with other con- (6) Excessive hunger (polyphagia) and weight ditions (pancreatic disease, hormonal disease, loss (usually Type 1). drugs, chemical agents). (7) Fatigue and weakness. g. Impaired glucose tolerance (lGT): asympto- (8) Blurred vision. matic or borderline diabetes with abnormal (9) Irritability. response to oral glucose test. Ten to fifteen per- (IO)Numbness and tingling in the hands and cent of individuals will convert to Type II dia- feet. betes within 10 years. (11)Prolonged healing times (cuts, bruises, h. Gestational diabetes mellitu (GDM): glucose infections). intolerance associated with pregnancy; most likely in third trimester. 2. Red Flags: Signs and symptoms of hypoglycemia (low blood sugar).

232 6. Medical goals and interventions. a. Maintain insulin glucose homeostasis. a. Rapid onset (minutes). (1) Frequent monitoring of blood glucose level! b. Glucose is low: <60 mg/dL. Results from fail- (2) Dietary control: weight reduction, contrc of carbohydrate, protein, fat, and calori ure to eat after taking insulin, excessive insulin; intake. can be precipitated by exercise. (3) Oral hypoglycemic agents to lower bloo c. CNS changes: labile, irritable, headache, glucose; indicated for Type II diabetes. blurred vision, slurred speech, difficulty con- (4) Insulin to lower blood glucose via injec centrating, confusion, incoordination. tions, infusion pump, or intraperitone~ d. Sympathetic changes: diaphoresis, pallor, pilo- dialysis for patients with renal failun erection, tachycardia, heart palpitations, nerv- Indicated for Type I diabetes or for mor ousness and irritability, weakness, shakiness/ severe Type II diabetes. trembling, hunger. b. Health promotion. e. Hypoglycemic coma: a loss of consciousness that results from an abnormally low blood 7. Physical therapy goals, outcomes, and interven sugar levels. tions. f. First aid: If patient is awake, give sugar Guice, a. Exercise: delays disease onset; improves blool candy bar). If unresponsive, call for help; intra- glucose control and circulation, reduces cardia venous glucose is required. vascular risk (Type II diabetes). Exercise alSI 3. Red Flags: Signs and symptoms of hyperglycemia assists in weight control, improves strength (abnormally high blood sugar). and reduces stress (Type I and II diabetes). a. Gradual onset (days). (1) Exercise testing is recommended prior tl b. Glucose is high: >250 mg/dL. Results from exercise due to increased cardiovascula untreated diabetes. risk. c. CNS changes: dulled senses, confused, dimin- (2) Exercise pre cription: daily aerobic exercis, ished reflexes, paresthesias. is recommended; duration and intensit: d. Thirst. may be decreased (moderate or lower en, e. Flushed, signs of dehydration. of functional capacity). f. Nausea/vomiting, abdominal pain. (3) Response to exercise is dependent UpOI g. Deep, rapid respirations. adequacy of disease control. h. Pulse: rapid, weak. (4) Exercise-induced hypoglycemia rna: I. Fruity odor to the breath. occur. J. Weakness. b. Red Flags: Exercise precautions. k. Hyperglycemic coma: a diabetic coma caused (1) Monitor glucose level prior to and followinl by hyperosmolarity of extracellular fluid and exercise. Have carbohydrate snack readil~ dehydration; can lead to death. available during exercise. 4. Complications associated with long-term diabetes (2) Do not exercise when blood glucose level and poor glucose control. are high (at or near 250 mg/dL) or poorl~ a. Neuropathy: sensory, motor, autonomic neu- controlled. ropathy. (3) Do not exercise without eating at least : b. Retinopathy: retinal disease. hours before exercise. c. Dyslipidemia accelerated atherosclerosis, (4) Do not exercise without adequate hydra increased risk of cardiovascular disease, stroke tion. Maintain hydration during exercise and renal artery stenosis. session. d. Peripheral vascular disease and ulcerations. (5) Do not exercise alone. Some patients ma~ e. Osteoporosis. require close upervi ion. f. Nephropathy: renal disease. (6) Do not exercise if urine test is positive fo g. Erectile dysfunction. ketones. 5. Diagnosis. (7) Do not inject short-acting insulin in exercis a. Fasting plasma glucose test, urine analysis. ing muscles or sites close to exercising mus b. Symptoms: frequent urination and increased thirst are hallmark early signs.

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 233 cles as insulin is ab orbed more quickly. fatigue is associated with hypermetabolic state. (8) Do not exercise patients with poorly con- D. Adrenal Disorders trolled complications, e.g., cardiovascular 1. Primary adrenal insufficiency (Addison's disease). disease, hypertension, retinopathy, neu- a. Partial or complete failure of adrenocortical ropathy, nephropathy. function; results in decreased production of (9) Do not exercise in extreme environmental cortisol and aldosterone. temperatures (very hot or cold). b. Etiology: autoimmune processes, infection, c. Emphasize proper diabetic foot care: good neoplasm or hemorrhage. footwear, hygiene. c. Signs and symptoms. d. Patient and family education. (1) Increased bronze pigmentation of skin (I) Control of risk factors (obesity, physical (2) Weakness, decreased endurance inactivity, prolonged stress, smoking). (3) Anorexia, dehydration, weight loss, gas- (2) Injury prevention strategies. trointestinal elisturbances. (3) Self-management strategies. (4) Anxiety, depression. C. Thyroid Disorders (5) Decreased tolerance to cold. I. Hypothyroielism: decreased activity of the thyroid (6) Intolerance to stress. gland with deficient thyroid secretion. d. Medical interventions. a. Metabolic processes are slowed. (1) Replacement therapy: glucocorticoid, adre- b. Etiology: decreased thyroid releasing hormone nal corticoids. ecreted by the hypothalamus or by the pitu- (2) Adequate fluid intake, control of sodium itary gland; atrophy of the thyroid gland; and potassium. chronic autoimmune thyroiditis (Hashimoto's (3) Diet high in complex carbohydrates and disease); overdosage with antithyroid medica- protein. tion. c. Symptoms include weight gain, mental and 2. Secondary adrenal insufficiency: can result from physical lethargy, dry skin and hair, low blood prolonged steroid therapy (ACTH) rapid with- pres ure, constipation, intolerance to cold, and drawal of drugs; hypothalamic or pituitary tumors. goiter. d. If untreated, leads to myxedema (severe 3. Cushing's syndrome: metabolic eli order resulting hypothyroidism) with symptoms of swelling of from chronic and excessive production of cortisol hands, feet, face. Can lead to coma and death. by the adrenal cortex or from drug toxicity (over e. Treatment: life-long thyroid replacement therapy. administration of glucocorticoids). f. Red Flags: Can result in exercise intolerance, a. Etiology: most common cause is a pituitary weakness, apathy; exercise-induced myalgia; tumor with increased secretion of ACTH. reduced cardiac output. b. Signs and symptoms. 2. Hyperthyroidism: hyperactivity of the thyroid (I) Decreased glucose tolerance. gland. (2) Round \"moon\" face. a. Etiology unknown. (3) Obesity: rapidly developing fat pads on b. Thyroid gland is typically enlarged and chest and abdomen; buffalo hump. secretes greater than normal amounts of thy- (4) Decreased testosterone levels or decreased roid hormone (thyroxine), e.g., Graves' disease, menstrual periods. thyroid storm, thyrotoxicosis. (5) Muscular atrophy. c. Metabolic processes are accelerated. (6) Edema. d. Symptoms include nervousness, hyperreflexia, (7) Hypokalemia. tremor, hunger, weight loss, fatigue, heat intol- (8) Emotional changes. erance, palpitations, tachycarelia, and diarrhea. c. Medical interventions. e. Treatment: antithyroid drugs. (1) Goal is to decrease excess ACTH: irradia- f. Raelioactive iodine may also be prescribed or tion or surgical excision of pituitary tumor surgical ablation may be necessary. or control medication levels. g. Red Flags: Can result in exercise intolerance; (2) Monitor weight, electrolyte, and fluid bal- ance.

234 unconscious behaviors by which the individual resolves or conceals conflicts or anxieties. x. Psychiatric Conditions a. Compensation: covering up a weaknes by A. States stressing a desirable or strong trait, e.g., a 1. Anxiety: feelings of apprehension, worry, uneasi- learning disabled child becomes an outstanding ness; a normal reaction to tensions, conflicts, or athlete. stress. b. Denial: a refusal to recognize reality, e.g., a. Degree of anxiety is related to degree of per- refusal to acknowledge a fatal di ease. ceived threat and capacity to engage behaviors c. Repression: refusal or inability to recall unde- that can reduce anxiety. sirable past thoughts or events. b. Anxiety can be constructive, stimulate an indi- d. Displacement: the transferring of an emotion to vidual toward purposeful activity or neurotic a less dangerous substitute, e.g., yelling at your (pathologic). child instead of your bo s. c. Sympathetic responses (fight or flight) general- e. Reaction formation: a defensive reaction in ly accompany anxiety, e.g., increased heart which behavior is exactly opposite what is rate, dyspnea, hyperventilation, dry mouth, GI expected, e.g., a messy individual becomes neat. symptoms (nausea, vomiting, diarrhea); palpi- f. Projection: the attributing of your own undesir- tations. able behavior to another, e.g., \"he made me do 2. Depression: altered mood characterized by morbid it\" . sadness, dejection, sense of melancholy. Can be a g. Rationalization: the justification of behaviors chronic, relapsing disorder. using reasons other than the real reason, e.g., a. Red Flags: Clinical manifestations. presenting an attitude of not caring. (1) Loss of interest in all usually pleasurable h. Regression: resorting to an earlier, more imma- outlets, e.g., work, family. ture pattern of functioning, e.g., in traumatic (2) Poor appetite, weight loss; or weight gain. brain injury; common under high tress itua- (3) Insomnia or hypersomnia; decreased ener- tions. gy. 4. General adaptation syndrome (GAS): total body (4) Psychomotor imbalance: agitation or coping/adaptation to a catastrophic event (illness, excessive fatigue; irritability. trauma). (5) Feelings of worthlessness, self-reproach, a. Alarm stage, or \"fight-or-flight\" response: acti- guilt, hopelessness. vation of the sympathetic system. (6) Impaired concentration, ability to think. b. Sustained resistance. (7) Recurrent thoughts of suicide or death. c. Chronic resistance, exhaustion leading to b. Management. stress-related illnesses. (I) Treatment is pharmacologic, tricyclic anti- B. Pathologies depressant drugs. 1. Anxiety disorders (anxiety neurosis): excessive Red Flags: Patients on these medications anxiety not associated with realistically threaten- may exhibit disturbed balance, postural ing specific situations, e.g., generalized anxiety. hypotension, falls and fractures, increased a. Panic attacks: acute, intense anxiety or terror; HR, dysrhythrnias, ataxia, seizures. may be uncontrollable, accompanied by sym- (2) Cognitive-therapy may help. pathetic signs, loss of mental control, sense of c. Physical therapy interventions. impending death. (1) Maintain a positive attitude, consistently b. Phobias: excessive and unreasonable fear leads demonstrate warmth and interest. to avoidance behaviors, e.g., agoraphobia (fear (2) Acknowledge depression, provide hope. of being alone or in public places). (3) Use positive reinforcement, build in suc- c. Obsessive-compulsive behavior: persistent anx- cessful treatment experiences. iety is manifested by repetitive, tereotypic acts; (4) Involve the patient in the treatment deci- behaviors interfere with social functioning, e.g., sions. hand-washing, counting, and touching. (5) Avoid excessive cheerfulness. 2. Posttraumatic stress disorder (PTSD): exposure to (6) Take all suicide thoughts and acts seriously. 3. Coping and adapting mechanisms: typically

Other Systems: Metabolic & Endocrine, Gastrointestinal, Genitourinary, Psychiatric 235 a traumatic event produces a variety of stress-relat- by disruptions in thought patterns; of unknown eti- ed symptoms. ology; a biochemical imbalance in the brain. a. PTSD symptoms. a. Symptoms. (1) Re-experiencing the traumatic event. (1) Disordered thinking: fragmented thoughts, (2) Psychic numbing with reduced responsive- errors of logic, delusions, poor judgment, memory. ness. (3) Detachment from the external world, and (2) Disordered speech: may be coherent but unintelligible, or incoherent, mute. survival guilt. (4) Exaggerated autonomic arousal, hyper- (3) Disordered perception: hallucinations and delusions. alertness. (5) Disturbed sleeping. (4) Inappropriateness of affect: withdrawal of (6) Ongoing irritability. interest from other people and from the out- (7) Impaired memory and concentration. side world; loss of self-identity, self-direc- b. PTSD can be acute (symptoms last less than 3 tion; disordered interpersonal relations. months) or chronic (3 months or longer); onset can also be delayed. (5) Functional disturbances: inability to func- c. Symptoms should not be ignored. A mental tion in daily life, work. health consultation is indicated. 3. Psychosomatic disorders (somatoform disorders): (6) Little insight in problems and behavior. physical signs or diseases that are related to emo- b. Paranoia: a type of schizophrenic disorder tional causes, e.g., psychosocial stress. a. Characteristics. characterized by feelings of extreme suspi- (1) Cannot be explained by identifiable disease ciousness, persecution, grandiosity (feelings of power or great wealth), or jealousy; withdraw- process or underlying pathology. al of all emotional contact with others. (2) Not under voluntary control; provides a c. Catatonia: a type of schizophrenic disorder characterized by mutism or stupor; unrespon- means of coping with anxiety and stress. siveness; catatonic posturing (remains fixed, (3) Patient is frequently indifferent to symptoms. unable to move or talk for extended periods). b. Types. 5. Bipolar disorder (manic-depressive illness): a dis- (1) Conversion disorder (hysterical paralysis): order characterized by mood swings from depres- sion to mania; a biochemical dysfunction. loss or altered physical functioning repre- a. Often intense outbursts, high energy and activ- senting psychosocial conflict or need, e.g., ity, excessive euphoria, decreased need for can result in paralysis, hemiplegia, etc. sleep, unrealistic beliefs, distractibility, poor (2) Hypochondria: abnormal or heightened judgment, denial. concerns about health or body functions; b. Followed by extreme depression (see depres- false beliefs about suffering from some dis- sion symptoms). ease or condition. c. Treatment is pharmacologic, e.g., lithium car- c. Management. bonate. (1) Physical symptoms are real: treat the 6. Perseveration: the continued repetition of a move- patient as you would any other patient with ment, word, or expression, e.g., patient gets stuck similar symptoms. and repeats the same activity over and over again; (2) Provide a supportive environment. often accompanies traumatic brain injury or (3) Identify primary gain (internal conflicts); stroke. assist patient in learning new, alternate C. Grief Process: the emotional process by which an methods of stress management. individual deals with loss, e.g., of a significant loved (4) Identify secondary gains (additional advan- one, body part, or function, etc. tages,. e.g., attention, sympathy); do not 1. Characteristics. reinforce. a. Somatic symptoms: fatigue, sighing, hyperven- (5) Provide encouragement and support for the tilation, anorexia, insomnia, etc. total person. b. Psychological symptoms: sorrow, discomfort, 4. Schizophrenia: a group of disorders characterized regret, guilt, anger, irritability, depression, etc.

236 c. Resolution may take months or years. b. Maintain hope without supporting unrealistic 2. Stages. expectations. a. Shock and disbelief, inability to comprehend E. Physical Therapy Goals, Outcomes, and loss. Interventions: Motivating patient, managing the human side of rehabilitation b. Increased awareness and anguish; crying, or 1. Establish boundaries of the professional relation- anger are common. ship: identify problems, expectations, purpose, roles and responsibilities. c. Mourning. 2. Provide empathic understanding: the capacity to d. Resolution of loss. understand what your patient is experiencing from e. Idealization of lost person or function. that patient's perspective. 3. Management. a. Recognize losses, allow opportunity to mourn a. Provide support and understanding of the grief \"old self'. b. Ask open-ended questions that reflect what the process. patient is feeling. b. Encourage expression of feelings, memories. (1) Empathetic response: \"it sounds like you c. Respect privacy, cultural or religious customs. are worried and anxious about your pain D. Death and Dying and are trying your best\". 1. Physical symptoms: decreasing physical and men- (2) Non-empathetic response: ... \"don't worry tal functioning, gradual loss of consciousness. about your pain\", ...\"you're over-reacting\". 2. Stage (Kubler-Ross). c. Sympathy is not helpful or therapeutic; care- a. Denial: patients insist they are fine, joke about giver is closely affected by the patient's behav- iors, e.g., therapi t cries when the patient crie . themselves, are not motivated to participate in 3. Set realistic, meaningful goals; involve the patient treatment. and family in the goal setting process, self-deter- (1) Allow denial: denial is a protective com- mination is important. 4. Set realistic time frames for the rehabilitation pro- pensatory mechanism necessary until such gram; recognize symptom, stages of the grief time as the patient is ready to face his/her process or death and dying and adjust accordingly. illness. 5. Recognize and reinforce healthy, positive, socially (2) Provide opportunities for patient to ques- appropriate behaviors; allow the patient to experi- tion, confront illness and impending death. ence uccess. b. Anger, resentment: patients may become dis- 6. Recognize secondary gains, unacceptable behav- ruptive, blame others. iors; do not reinforce, e.g., malingering behaviors (1) Be supportive: allow patient to express such as avoidance of work. anger, frustration, resentment. 7. Provide an environment conducive to the patient's (2) Encourage focus on coping strategies. emotional state, learning and optimal function. c. Bargaining: patients bargain for time to com- a. Provide a message of hope tempered with real- plete life tasks; turn to religion or other indi- ism. viduals, make promises in return for function. b. Keep patients informed. (1) Provide accurate information, honest, c. Lay adequate groundwork or preparation for truthful answers. expected changes or discharge. d. Depression: patients acknowledge impending d. Help to re-establish personal dignity and self- death, withdraw from life; demonstrate an worth; acknowledge whole person. overwhelming sense of loss, low motivation. 8. Help patients identify feelings, successful coping (1) Observe closely for suicide ideation. strategies, recognize successful conflict resolution, (2) Allay fears and anxieties, especially loneli- and rehabilitation gains. ness and isolation. a. Stress ability to overcome major obstacles. (3) Assist in providing for comfort of the b. Stress that recovery is unique and illgWy indi- patient. vidual. e. Acceptance and preparation for death: accept- ance of their condition; relate more to their family, make plans for the future. 3. Management. a. Support patient and family during each stage.

CHAPTER 7 PEDIATRIC PHYSICAL THERAPY Linda Kahn-D'Angelo I. Theories of Development, Motor Control, B. Motor Control 1. The study of postures and movements and parts of and Motor Learning mind and body which control posture and movement. 2. Theories of motor control. A. Development a. Neuromaturationist theory. I. The sequence of events through which the individual (1) Cortex is command center with descending grows, changes, evolves and matures. control and inhibition of lower centers by 2. Theories of development. higher one in CNS. a. Maturationist theories. b. Systems theory. (1) Individual genetically and biologically (1) Command center changes from cortex to determined. other levels depending on task. (2) There are preformed innate aspects of (2) Stresses interaction between brain, body human behavior. and environment including biomechanics b. Empiricist theories. and body geometry. (1) Source of human behavior is the environment. (3) Sensory systems mature, become integrated c. Behavioral theory. and connected to muscle coordination patterns (1) Environmental reinforcement is the motivator starting with visual system. and shaper of cognitive and motor behavior. (4) Immature postures involve cocontraction of (2) Used in behavior modification treatment agonists and antagonists, cocontraction where desired behaviors are positively rein- decreases with maturation. forced, and unwanted behaviors are c. Neuronal group selection theory. ignored. (1) Genetic code of species outlines limits of d. Interactionist theory. neural network formation. (1) Child is an active social being who con- (2) Actual network formation results from tribute to hi development. individual experience. e. Piagetian theory. (3) Cell death of unexercised ynaptic and ( I ) Interaction of environment and neural matura- strengthening of synaptic connections tion results in piraling of development with selectively activated. equilibrium and disequilibrium resulting.

238 II. Fetal Sensorimotor Development C. Early Motor Learning A. Gestational Age: age of fetus or newborn, in weeks, 1. Motor skill is any motor activity which becomes from first day of mother's last normal menstrual period better organized, more effective and efficient as a 1. Normal gestational period 38-42 weeks. result of practice. 2. Gestational period divided into 3 equal trimesters. 2. Enhancement of early motor skills development. a. Use of goal oriented tasks. B. Conceptional Age: age of a fetus or newborn in b. Internal feedback via corollary discharge and weeks since conception effector organ feedback (i.e., visual, somatosen- sory vestibular feedback). C. Sensory-Motor Development (Table 7-1) c. External feedback through knowledge of results and knowledge of performance feed- III. Developmental Sequence Summary back from instructor, i.e., every other time and after a delay. A. 1 Month d. Practice of high intensity and duration as tolerated. 1. Decreased flexion. 2. Momentary head elevation with minimal forearm D. Principles of Motor Development support. 1. Occurs in cephalocaudal direction. 3. Tracks a moving object. 2. Unrefined to refined movement. 4. Head usually to side. 3. Stability to controlled mobility. 5. Reciprocal and symmetrical kicking. 4. Occurs in spiraling manner, with periods of equi- 6. Positive support and primary walking reflexes in librium and disequilibrium. supported standing. 5. Sensitive periods occur when infant/child is espe- 7. Hands fisted with indwelling thumb most of the cially affected by environmental input. time. 8. Neonatal reaching. 9. Alert, brightening expression. TABLE 7-1 - FETAL SENSORy..MOTOR DEVELOPMENT FIRST TRIMESTER SECOND TRIMESTER THIRD TRIMESTER Muscle Spindle 0 muscle starts to differentiate o motor end plate forms o some muscles are mature and Touch and Tactile System o tissue becomes specialized o clonus response to stretch functional, others still maturing o touch functional 0 first sensory system to develop o receptors differentiate o actual temperature discrimination o response to tactile stimulus at the end of the third trimester o most mature sensory system at birth Vestibular System o functioning at the end of the o startle to light first trimester (not completely o visual processing occurs o fixation occurs Vision developed) o able to focus (fixed focal length) Auditory o will turn to auditory sounds o debris in middle ear, loss of hearing Olfactory o eyelids fused o nasal plugs disappear, some Taste o optic nerve and cup being formed olfactory perception Movement o can\" respond to different tastes o taste buds develop (sweet, sour, bitter, salt) o 28 weeks primitive motor reflexes o sucking, hiccuping o quickening o rooting, suck, swallow o fetal breathing o sleep states o palmar grasp o quick generalized limb movement o grasp reflex, o plantar grasp o positional changes o reciprocal and symmetrical o MORO o 7~ weeks: bend neck and trunk limb movements o crossed extension away from perioral stroke

B. 2 Months Pediatric Physical Therapy 239 1. Head elevation to 45 degrees in prone, prone on elbows with elbows behind shoulders. 5. Pulls-to-stand through kneeling. 2. Head bobs in supported sitting. 6. Cruises sideways, can stand alone. 3. Does not accept weight on lower extremities (astasia- 7. Reaches with closest arm, radial digital grasp, abasia). 4. Responds to friendly handling. radial palmar, 3 jaw chuck grasp, and inferior pincer grasp with thumb and forefinger. C. 3 Months 8. Can transfer objects from one hand to the other. 1. Prone on elbows, weight bearing on forearms. I. 10-15 Months 2. Elbows in line with shoulders, head elevated to 90 1. Begins to walk unassisted. degrees. 2. Begins self feeding. 3. Head in midline in supine, hands on chest. 3. Reaches with supination, neat pincer grasp, can 4. Increased back extension with scapular adduction release, build a tower of 2 cubes. in supported sitting. 4. Searches for hidden toys. 5. Takes some weight with toes curled in supported 5. Suspicious of strangers. standing. 6. Plays patty-cake and peek-a-boo. 6. Coos, chuckles. 7. Imitates. D. 4 Months J. 20 Months 1. Rolls prone to side, supine to side. 2. Sits with support. 1. Ascends stairs step-to pattern (two feet on each step). 3. No head lag in pull-to-sit. 2. Running more coordinated. 4. Optical and labyrinthine head righting present. 3. Jumps off of bottom step. 5. Bilateral reaching with forearm pronated when 4. Plays make believe. trunk supported. K. 2 Years 6. Ulnar palmar grasp. 1. Runs well. 7. Laughs out loud. 2. Can go up stairs foot over foot (reciprocal stair E. 5 Months climbing). 1. Rolls from prone to supine. 3. Active, restless, tantrums. 2. Weight shifting from one forearm to the other in L. 3 Years prone. 1. Rides tricycle. 3. Head control in supported sitting. 2. Stands on one foot briefly. 3. Jumps with two feet. F.6Months 4. Understands sharing. 1. Prone on hands with elbows extended, weight M. 31/2 Years shifting from hand to hand. 1. Hops on one foot. 2. Rolls supine to prone. 2. Kicks ball. 3. Independent sitting. N. 4 Years 4. Pulls-to-stand, bounces. 1. Hops on one foot several times. 2. Stands on tiptoes. G. 7 Months 3. Throws ball overhand. 1. Can maintain quadruped. 4. Relates to friends. 2. Pivots on belly. Infant in prone moves body in a O.5Years circle. 1. Skips. 3. Pivot prone (prone extension) position. 2. Kicks ball well. 4. Assumes sitting from quadruped. 3. Dresses self. 5. Trunk rotation in sitting. 6. Recognizes tone of voice. IV. Pediatric Examination 7. May show fear of strangers. A. Patient Interview H. 8-9 Months 1. Mother's pregnancy and birth history: prematurity, 1. Belly crawls. fetal distress, difficult labor, umbilical cord around 2. Quadruped creeping. neck. 3. Moves quadruped to sitting. 2. Medical history: special care unit admission, 4. Side-sitting. diagnoses, intubated and on ventilator, surgeries, medications.

240 5. Range of motion. a. Newborn has decreased range of motion into 3. Family history: caretakers, current home situation, extension due to physiological flexion, but support to family, socioeconomic status. increased dorsiflexion of ankles. B. Preterm Infant Examination 6. Posture. 1. Neurological assessment of preterm and full-term a. Physiological flexion of all four limbs due to newborn infant. position in utero. a. Neurologic items include newborn reflexes, b. Head to one side. infant states of alertness. b. Neurobehavioral items from Neonatal 7. Movements. Behavioral Assessment Scale (NBAS). a. Spontaneous and reflexive. c. Assessment of gestational age by evaluation of b. Occasional tremulousness normal. muscle tone, physical characteristics. 2. Assessment of Premature Infant Behavior (APIB). 8. Neonatal reflexes or primary motor patterns, and a. Refinement and extension of the NBAS. infant reflexes and reactions. b. Assesses the organization and balance of a. Present at birth and become \"integrated\" or infant's physiological, motor, and behavioral inhibited, or not evident later in development. states. b. In CNS lesions they may persist and interfere c. Test is lengthy, used mainly for research. with motor milestone attainment, or cause 3. Newborn Individualized Developmental Care and deformities. Assessment of Progress (NlDCAP). c. Babinski reflex - stroke lateral aspect of the a. Systematic behavioral observation of preterm plantar surface of foot, get extension and fan- or full-term infant in nursery or home during ning of toes (0-12 months). environmental input, caretaking, and treatments. d. Flexor withdrawal - sharp, quick pressure b. Note what stresses, consoles infant. stimulus to the sole of the foot or palm of hand, 4. Test of Infant Motor Performance (TIMP). get withdrawal of stimulated extremity (0-2 a. Developed for infants 32 weeks postconceptual months, although some sources say present age to 3.5 months post term. throughout life). b. Evaluates spontaneous and elicited movements e. Crossed extension - sharp, quick pressure to evaluate postural alignment and selective stimulus to sole of foot results in withdrawal of control for functional movements. stimulated lower extremity and extension of opposite leg (0-2 months). C. FuU-Term Newborn, Infant, and Child Examination f. Galant or trunk incurvation reaction - sharp 1. APGAR-screening test administered to newborn at stoke along paravertebral line from scapula to 1,5, 10 minutes after birth. top of iliac crest results in lateral trunk flexion a. Five items: heart rate, respiration, reflex irritabil- towards stimulated side (0-2 months). ity, muscle tone, color each scored 0, I, or 2. g. Moro reflex - sudden extension of neck b. Score of 7 and above considered good. results in flexion, abduction of shoulders, 2. Neurological examination of the newborn. extension of elbows, and then extension, a. Assigns states of consciousness. abduction of shoulders, flexion of elbows. b. Tests newborn reflexes. Usually also results in crying. Test last! (0-4 3. Neonatal Behavioral Assessment Scale. months). a. Tests interactive, self organizational abilities, h. Primary standing reaction - hold infant in and newborn reflexes and muscle tone. supported standing and infant supports some 4. Skeletal system examination. weight and extends lower extremities. If this a. Fractured clavicle. reflex persists, will interfere with walking by b. Dislocated hip: asymmetric gluteal folds, hip causing extension of all joints of the lower click. extremity and not allowing disassociation of c. Spine: curved, inflexible, kyphosis, scoliosis; flexion and extension. spinal bifida occulta: dimple, patch of hair, i. Primary walking - hold infant in supported pigmentation visible, xray-verify. standing, tilt trunk forward slightly, reciprocal d. Talipes equinovarus (clubfoot): ankle in plantar stepping motions in lower extremities. (0-2 flexion, forefoot adduction. months unless practiced).

J. Neonatal neck righting (neck righting on body, Pediatric Physical Therapy 241 NOB) - turn head when infant is in supine, body logrolls toward same side (0-6 months). months, sideward sitting 6 months, forward sit- ting 7 months, backward sitting 9 months; k. Rooting - stroking of perioral region results these reactions persist through life. in head turning to that side with mouth opening v. Body righting reaction acting on the head (0-3 months). Important feeding reflex. (BOH) - contact of the body with a solid surface results in head righting with respect to gravity, I. Sucking - touch to lips, tongue, palate results interacts with labyrinthine righting reaction on in automatic sucking (0-6 months). Important head to maintain orientation of head in pace. feeding reflex. Begins at 4-6 months and persists through life. w. Body righting reaction acting on the body m. Startle - loud noise, sudden light or cold stim- (BOB) - rotation of head or thorax results in ulus causes a sudden jerking of whole body or rolling over with rotation between trunk and extension and abduction of upper extremities pelvis. Begins at 6-8 months and persists. followed by adduction of shoulders (0-6 x. Symmetric tonic neck reflex - extension of months). cervical joints produces extension of upper extremities and flexion of lower extremities; n. Tonic labyrinthine reflex (classic) - prone flexion of cervical joints products flexion of position results in maximal flexor tone and upper extremities and extension of lower supine position results in maximal extensor extremities (6-8 months). If reflex persists it tone. If reflex persists and is strong, may block may interfere with development of stable rolling from supine due to increased extensor quadruped position and creeping. tone (0-6 months). y. Landau reaction - if infant is held in ventral suspension there will be extension of neck, o. Asymmetric tonic neck reflex - rotation of trunk and hips (4-18 months). head results in extension of face side extremities z. Tilting reactions - slow shifting of base of and flexion of skull side extremities. Stronger support or slow displacement of body in space in lower extremities of neonates. (0-5 months) will result in lateral flexion of spine toward ele- If reflex persists may result in scoliosis, or hip vated side of support, abduction of extremities dislocation, and may interfere with grasping on elevated side, and sometimes trunk rotation and hand to mouth activities. toward elevated side. Prone begins at 5 months; supine begins at 7 months; sitting at 8 months; p. Palmar gra p - pressure stimulus against palm quadruped at 12 months. These reactions persist re ult in grasping of object with slow release. throughout life. (0-4 months). 9. Screening tests. a. Denver Developmental Screening Test II. q. Plantar grasp - pressure stimulus to sole, or (1) To screen for developmental delay. lowering of feet to floor results in curling of (2) Tests social, fine, gross motor, and language toes. Must be integrated before walking occurs (0-9 months). skills from birth to 6 years of age. b. Alberta Infant Motor Scale (AIMS): observation- r. Placing reactions - drag dorsum of foot or back of hand against edge of table, get placing al scale for assessing gross motor milestones in of foot or hand onto table top (0-6 months). infants from birth through independent walking. 10. Standardized motor tests. s. Traction or pull-to-sit (pull infant to sit from a. Movement Assessment of Infants. supine): upper extremities will flex and there (1) To identify motor dysfunction and changes will be head lag until about 4-5 months. in the status of motor dysfunction and t. Optical and labyrinthine righting - the head establishing an intervention program for orients to a vertical position when the body is infant from birth to 1 year. tilted. Labyrinthine righting is tested with the (2) Criterion reference exam of muscle tone, eyes blindfolded; (1 month - throughout life). reflexes, automatic reactions, and volitional movements. u. Protective extension - quick displacement of trunk in a downward direction, while held, or while sitting in a forward, sideward, or back- ward direction will result in extension of legs in downward, and extension of arms in the sitting position to catch weight. Downward begins at 4

242 b. Pediatric PT may work with physical therapist assistant in delivery of care in many settings. b. Peabody Developmental Motor Scales. (1) Assesses gross and fine motor development 3. Parent education: Pediatric PT is always involved from birth to 42 months. in parent/family or caretaker education. (2) Includes spontaneous, elicited, reflexes, and automatic reactions. B. Goals, Outcomes, and Intervention 1. Primary prevention of disability through education c. Gross motor function test. and treatment. (1) Developed to measure change in gross 2. Prevention and/or improvement of secondary dis- motor function over time in children with abilities such as contractures/deformities. cerebral palsy. 3. Attainment of maximal functional goals of child (2) All items on the test could be accomplished by and family. a 5 year-old with typical motor development. (3) Focuses on voluntary movement in 5 devel- C. Pediatric Therapies opmental dimensions: prone and supine, 1. Developmental activities to facilitate development sitting, crawling and kneeling, standing, of functional motor skills. These activities use pos- walking and jumping. tures and movements from the developmental sequence to increase strength, range of motion, 11. Sensory Integration and Praxis Test. coordination. Remember, play is the work of the a. Sensorimotor assessment for children between child, make activities fun. ages of 4 and 9 years having mild to moderate 2. Neurodevelopmental Treatment (NDT). learning impairment. a. Utilizes reflex inhibiting patterns (RIPS) which b. Includes tests of balance, proprioceptive and tac- are active/passive movements or postures oppo- tile sensation, and control of specific movements. site to the spastic flexion or exten ion synergies. b. Encourages active, functional movements 12. Comprehensive developmental assessments. appropriate for the developmental level and a. Bayley Scales of Infant Development revision: individual needs of the child and goals of the Norm-referenced motor and mental scales for child and family. children from birth to 42 months of age. 3. Motor control/motor learning approaches utilize principles of motor control and early motor learning 13. Pediatric functional assessments. appropriate for individual child (refer to previous a. Pediatric Evaluation of Disability Inventory sections). (PEDI): interview or questionnaire scale of 4. Sensory integration. ADL with or without modification completed a. Goal is to facilitate child's organization and by caregiver. processing of proprioceptive, tactile and b. Functional Independence Measure for children vestibular input. (WeeFIM): assesses function in self-care, b. Facilitation will influence postural responses, mobility, locomotion, and communication and environmental awareness, and motor planning. ocial cognition. VI. Pediatric Nervous System Conditions V. Overview of Pediatric Physical Therapy Intervention A. Prematurity Physical therapy practice in the Special Care Nursery and Neonatal Intensive Care Unit is a A. Roles of the Pediatric Physical Therapist subspecialty of pediatrics and requires advanced 1. Direct care provider: didactic and supervi ed practical experience. This is a a. In children's hospital settings. brief introduction. b. In Special Care Nurseries, Neonatal Intensive 1. Definition and categories. Care Units. a. Birth of infant before 37 weeks gestation. c. Pediatric Rehabilitation settings. b. Categorized by birthweight. d. In Early Intervention Programs (EIPs) (0-3 2. Preterm Postural and Movement Profile. years of age) (refer to EI section). a. Preterm infant does not develop the physiolog- e. In educational settings (refer to school section). ical flexion of full-term newborn. 2. ConsultantlIndirect Care Provider. b. May exhibit hyperextended neck and trunk a. Pediatric PT may be consultant in educational set- tings, instructing teachers and teacher's assistant in facilitating attainment of educational goals.

(may be partially a result of supine and intuba- Pediatric Physical Therapy 243 tion po ition ). c. Shoulders may be elevated, abducted, extended (1) Ischemia results in inflammatory, infected with scapular retraction. bowel. d. Hips abducted and extended. e. Pelvis tipped anteriorly (increased lumbar lor- h. Increased fragility of skin. dosis). I. Thermoregulation problems. f. Decreased midline arm movement. J. Feeding problems. g. May weightbear on toes when in supported k. Interaction/attachment problems with care- standing. 3. Medical complications and medical surgical treat- givers. ment in prematurity. 4. Phy ical therapy examination in prematurity. a. Complications depend on severity of prematurity and birthweight. a. Medical history review. b. Respiratory Distress Syndrome (RDS) or hya- b. Autonomic functions. line membrane disease. c. Neurobehavioral organization(interactive items (1) Respiratory distress due to atelectasis after infant is 32 weeks conceptional age). caused by insufficient surfactant in prema- d. Muscle tone. ture lungs. e. Postural control. (2) May lead to acute respiratory failure and f. Spontaneous movements. death. g. Reflexes including feeding. (3) Treatment includes oxygen supplementation, h. Musculoskeletal evaluation. assisted ventilation, and surfactant admin- I. Family needs. istration. j. Test of Infant Motor Performance (TIMP), (4) Chronic RDS may lead to bronchopul- monary dysplasia. Newborn Individualized Developmental Care c. Bronchopulmonary dysplasia. Plan (NIDCAP), Assessment of Premature (1) Chronic lung disease as a result of damage Infant Behavior (APIB). Refer to Preterm to lungs from mechanical ventilation, oxygen infant examination section. administration, and chronic RDS. 4. Intervention/activities to teach parents. (2) Predisposes child to frequent respiratory a. Play activities and positioning to facilitate infections and developmental disability. shoulder protraction and adduction such as (3) Treatment includes respiratory support, supported sidelying while doing visual (use infection control, and bronchodilator black, white and red objects 9 inches away) and administration. auditory tracking, and reaching. d. Periventricular leukomalacia (PVL). b. Midline positioning of head. (1) Necrosis of white matter adjacent to ventricles c. Encourage reaching for toys, parent's face if of the brain due to systemic hypotension or infant is over 32 weeks conceptional age. i chemia. d. Supervised sidelying and prone positioning (2) May result in cerebral palsy. (tummy time) for periods during the day. e. Periventricular-intraventricular hemorrhage. Academy of Pediatrics recommends sleeping (1) Bleeding into immature vascular matrix. in the supine position to decrease possibility of (2) Bleeds graded I-IV, grades II-IV may result Sudden Infant Death Syndrome (SillS). in cerebral palsy. e. Avoid activities which may increase extensor f. Retinopathy of Prematurity (ROP). tone such as use of infant jumpers and walkers. (1) Due to combination of low birth weight and B. Cerebral Palsy (CP) high oxygen levels. 1. Pathology. (2) Sequelae may range from non-significant a. Group of disorders which are prenatal, perinatal, to detachment of retinas and blindness. or postnatal in origin. g. Necrotizing enterocolitis. b. Major causes include hemorrhage below lining of ventricles, hypoxic encephalopathy, malfor- mations and trauma of CNS. c. Preterm birth associated with CPO 2. Classifications of CPO a. By area of body showing impairment. (1) One limb - monoplegia.

244 (4) Visual, auditory, cognitive and oral motor deficits may be associated with spastic CPo (2) Two lower limbs - diplegia. (3) Upper and lower limbs of one side of the b. Athetoid cerebral palsy. (1) Generalized decreased muscle tone, floppy body - hemiplegia. baby syndrome. (4) All four limbs - quadriplegia. (2) Poor functional stability especially in prox- b. Type of most obvious impairment. imal joints. (I) Spastic - increased tone, lesion of motor (3) Ataxia and incoordination when child assumes upright positions with decreased cortex or projections from motor cortex. base of support and muscle tOne fluctuations. (2) Athetosis - fluctuating muscle tone, (4) Poor visual tracking, speech delay, and oral motor problems. lesion of basal ganglia. (5) Tonic reflexes uch as ATNR, STNR, TLR (3) Ataxia - instability of movement, lesion may be persistent, blocking functional pos- tures and movement. of the cerebellum. c. Gross Motor Function Classification System C. Ataxia cerebral palsy. (1) Low postural tone with poor balance. for CPo (2) Stance and gait are wide-based. (I) Level I - walks without restrictions, limi- (3) Intention tremor of hands. (4) Uncoordinated movement. tations in more advanced gross motor skills. (5) Ataxia follow initial hypotonia. (2) Level II - walks without assistive devices; (6) Poor visual tracking, nystagmus. (7) Speech articulation problems. limitations walking outdoors and in the (8) May occur with spastic or athetoid CPo community. (3) Level ill - walks with assistive mobility 5. Functional limitations. devices; limitations walking outdoors and a. Dependent on classification of CPo in the community. b. Spasticity may lead to decrea ed range of (4) Level IV - self-mobility with limitations; motion which may limit mobility. children are transported or use power C. Ambulation. mobility outdoors and in the community. (1) Ambulation without use of aSSlstlve (5) Level V - self-mobility is severely limited devices may be attained by children with even with the use of assistive technology. hemiplegia, and some with diplegia and 3. Impairments for all classifications of CPO ataxia. a. Insufficient force generation. (2) With use of rollator walkers, crutches by b. Tone abnormality. some children with diplegia, athetosis, and C. Poor selective control of muscle activity. a few with mild quadriplegia, ambulation d. Poor regulation of muscle activity in anticipation may be attainable. of postural changes. e. Decreased ability to learn unique movements. 6. Interventions and goals in CPo f. Abnormal patterns of movement in total flexion a. Very individualized, depending on abilities, and extension. age, type of CPo Incorporate child and family in g. Persistence of primitive reflexes. intervention planning, implementation and (1) Interfere with normal posture and movement. goal etting. (2) May cause contractures and deformities. b. Focus on prevention of di ability by minimiz- 4. Impairments by classification of CPo ing effects of impairment, preventing or limit- a. Spastic cerebral palsy. ing secondary impairment such as contractures, (1) Increased muscle tone in antigravity muscles. scoliosis. (2) Abnormal postures and movements with (I) Utilize tatic (positioning) and dynamic mass patterns of flexion/extension. patterns of movement opposite to habitual (3) Imbalance of tone across joints may cause abnormal spastic patterns. contractures and deformities especially of (2) Facilitate symmetry in postures. hip flexors, adductors, internal rotators, and knee flexors, ankle plantarflexors in lower extremities; scapular retractors, gleno- humeral extensors, and adductors, elbow flexors, forearm pronators.

Pediatric Physical Therapy 245 (3) Elongate spastic hamstrings and heelcords. (4) Utilize adaptive equipment as necessary. (4) Serial casting may be used to increase (a) Seating should maintain head in neutral position, trunk upright, hips, knees, length of muscle and decrease tone. and ankles at 90 degrees flexion (hips c. Emphasize maximizing gross motor functional in abduction if spastic adductors). Wheelchair or seat may be tilted poste- level. riorly to decrease extensor tone and (1) Use principles of motor learning, and motor maintain hip flexion. (b) Prone or supine standers, and para- control, facilitate the attainment of functional podium will promote weight bearing motor skills including voluntary movement, through lower extremities and encourage anticipatory and reactive postural adjustments. bone mineralization, GI function, tone, Use toys, fun activities, balls and bolsters to strengthening of lower extremity mus- facilitate postural control and developmental cles, and social interaction. Tonic activities. labyrinthine reflex (TLR) will elicit (2) Use weightbearing and postural challenge more extensor tone in supine, more to increase muscle tone and strength. flexor tone in prone. (3) Incorporate orthoses as necessary. (c) Sidelying will help decrease effect of (a) AFO most commonly used, may be TLR. (d) Rollator walkers often used. Posterior rigid or with articulated ankle. (b) Submalleolar orthosis for forefoot and rnidfoot malalignment e.g., pronated foot. TABLE 7-2 - IMPAIRMENT AND FUNCTION IN MYELODYSPLASIA NEUROSEGMENTAL MUSCLES PREAMBULATION AMBULATION ASSISTIVE FUNCTIONAL MUSCULOSKELETAL DEVICES PROGNOSIS PROBLEMS LEVEL INNERVATED ORTHOSES ORTHOSES Thoracic Abdominal Standing frame Reciprocating Parallel bars Wheelchair Spinal deformity Upper lumbar gait orthosis Decubiti Mid-lumbar Walker Low-lumbar Above & hip Standing frame Reciprocating Forearm crutches Wheelchair Hip flexion flexors gait orthosis Parallel bars contractu res Lumbosacral Possible household Walker or therapeutic ambulation Forearm crutches Standing transfers Parallel bars Above & knee None HKAFO Wheelchair for Hip dislocation, extensors, hip adductors community, subluxation Orthoses for house- hold ambulation Above & hip None KAFO Walker Household or Foot deformities abductors, knee AFO (depending Forearm crutches community flexors, ankle & on quad strength) ambulators foot dorsiflexors, Parallel bars evertors, invert- KAFO ors, toe flexors AFO Walker Forearm crutches None Above & ankle None AFO or none Walker Community Foot pressure plantar flexors, ambulators sores foot intrinsic AFO recommended muscles to maintain gait quality & decrease compensatory None overactivity of muscles Goal Attainment and Habilitation of Infants and Children with Spinal Bifida. Ryan.K. Eman.J, Ploski. C.APTA National Conference. 1991.

246 (2) Most often done with hip adductors trans- ferred to hip abductor. rollator walker helps child maintain upright position and arm position helps c. Osteotomies. to decrease extensor tone. (1) Cutting, removing, or repositioning bone to 7. Prognosis in cerebral palsy. facilitate normal alignment, prevent ub- a. Prognosis depends on severity of brain lesion. luxation/dislocation. b. Most children with spastic hemiplegia, mild to (2) Most often performed at hip (femoral or moderate spastic CP, and mild ataxia will be pelvic osteotomy). able to ambulate. 8. Medical- urgical, pharmocological interventions C. Myelodysplasia/Spina Bifida for CPo 1. Pathology. a. Management of spasticity. a. Neural tube defect resulting in vertebral and/or (1) Oral medications - presynaptic inhibition spinal cord malformation. Elevated serum or of acetylcholine release. amniotic alpha-fetoprotein, amniotic acetyl- (a) Benzodiazepines, diazepam (valium). cholinesterase in prenatal period and sonogram (b) Baclofen (lioresal). are used for detection. (c) Side effects include sedation, weak- b. Spina bifida occulta - no spinal cord involve- ness, drowsiness, dry mouth. ment, may be indicated by a tuft of hair, dimple (2) Intrathecal Baclofen Pump (ITB) ITB deliv- or sinus. ers drug directly to spinal cord producing c. Spina bifida cystica - visible or open lesion. muscle relaxation with less medication and (1) Meningocele - cyst includes cere- decreased side effects. Pump is implanted brospinal fluid, cord intact. subcutaneously in abdomen with catheter to (2) Myelomeningocele - cyst includes CSF, spinal cord. Programmable doses released. and herniated cord ti ue. Reservoir holds 1-4 month supply. d. Link between maternal decreased folic acid, (3) Selective Dorsal Rhizotomy (SDR). infection, hot tub soaks, and exposure to ter- (a) Surgical transection of EMG selected atogens such as alcohol and valproic acid to dorsal sensory rootlets with the goals neural tube defects. of facilitating or maintaining ambula- e. Hydrocephalus significantly related to clo ure tion or improving ease of caregiving. of neural tube defect. Shunting done to relieve (b) Intensive strengthening program after pressure of hydrocephalus. surgery when ambulation is goal. f. Meningitis common if defect not closed soon (4) Peripheral nerve block. after birth. (a) Injection of phenoUalcohol into peri- g. Foot deformities such as talipes equinovarus pheral nervous system from nerve root (clubfoot) common especially with U,5 level. to motor end-plate. h. Tethered cord may lead to increased severity of (b) Lasts 3-6 months. problems as child grows. (5) Botox injections - minute amounts of bot- i. Latex sensitivity/allergy. ulinum toxin injected into muscle paralyzing 2. Impairments. it for 4-6 months. a. Depends on level of lesion and amount of mal- 9. Orthopedic management of CPo formation of cord (Table 7-2). a. Lengthening procedures. b. Muscle paralysis and imbalance resulting in (1) Muscle/tendon lengthening to correct spinal and lower limb deformities and joint deformity or weak muscle, prevent hip sub- contractures. luxation/dislocation. (1) Kyphoscoliosis. (2) Muscles most often lengthened include (2) Shortened hip flexor and adductors. Achilles tendon, hamstrings, iliopsoas, hip (3) Flexed knees. adductors. (4) Pronated feet. b. Muscle transfers. c. U,S lesion results in bowel and bladder dys- (1) Muscle attachments moved to change function. direction of force to increase function and d. Sensory loss. decrease spasticity. e. Developmental delays.

f. Abnormal tone - may have low tone which Pediatric Physical Therapy 247 will lead to poor strength and/or spasticity in upper extremities. c. Facilitation of functional motor development including appropriate developmental activities, g. 0 teoporosis. primary or voluntary movement as well as h. Cognitive impairments including mental retar- reactive and anticipatory postural adjustments. dation, learning and perceptual disabilities, d. Educate parents regarding shunt malfunction. language disorders. Signs include increased irritability, increased 3. Functional limitations. muscle tone, seizures, vomiting, bulging a. Very variable depending on level of lesion fontanelle, headache, redness along shunt tract. (Table 7-2). b. Weakne or paralysis of hip flexors (high lum- e. (Table 7-2). bar level Ie ion) makes ambulation possible D. Brachial Plexus Injury only with reciprocating gait orthosis (RGO). c. Problems with learning, communication. I. Pathology. 4. Medical-surgical management of spina bifida. a. Traction or compression Injury to unilateral a. If open defect, surgical closure within 24-48 brachial plexus during birth process or due to hours. cervical rib abnormality. b. Ventriculoperitoneal shunt performed for (I) Erb's Palsy involves C5-6, upper arm paral- hydrocephalus. ysis, may involve rhomboids, levator scapulae, c. Orthopedic surgeries similar to cerebral palsy serratus anterior, deltoid, supraspinatus, (refer to above). infraspinatus, biceps brachii, brachioradialis, 5. Physical therapy examination in spina bifida. brachialis, supinator and long extensors of a. Physiological homeostasis in infants, breathing, wrist fingers, and thumb. oxygenation. (2) Klumpke's Palsy involves C8-Tl,lower arm b. Gross and Fine Motor Development (refer to paralysis, involves intrinsic muscles of hand, tests above) including reflex and behavioral flexors and extensors of wrist and fingers. examination of infant. (3) Erb-Klumpke Palsy, whole arm paralysis. c. Communicate with parents, family members b. Nerve sheath is torn and nerve fibers com- about concerns, goals for intervention. pressed by hemorrhage and edema, although d. Functional abilities using PEDI or WeeFIM. total avulsion of nerve is possible. e. Active and passive ROM. f. Muscle strength: may do so from observation 2. Impairments. of developmental abilities if child under 3 a. Sensory deficits of upper extremity. years of age. b. Paralysis or paresis of upper extremity. g. Sensation: stroke skin and note response, c. Characteri tic position for Erb's Palsy of upper record by dermatome. extremity is adduction, internal rotation of h. Skin: check for skin breakdown, suture of clo- shoulder with extension of elbow, pronation of sure, skin over shunt line. forearm and flexion of the wrist. 6. Interventions, goals, and prognosis in spina bifida. a. Teach parent proper positioning, handling, 3. Functional limitations. and exerci e, keeping physiological flexion of a. Dependent on severity of injury. the newborn. Include prone positioning to (I) Erb's Palsy results in decreased shoulder girdle avoid shortening of hip flexors, as well as hip function with I: I hurneroscapular movement. ROM, low tone, and osteoporosis in mind. (2) Klumpke's Palsy results in decreased wrist b. Use of adaptive equipment/orthoses such as and hand function. spinal orthoses for alignment, adaptive chairs b. Traction injuries resolve spontaneously. for sitting (if needed), parapodium for early c. Avulsion injuries may require surgical nerve standing, LE orthoses and ambulation assistive repair if not resolved within three months. devices, and or wheelchair as needed. d. Shoulder subluxation, and contractures of mus- cles may develop. 4. Physical therapy examination for brachial plexus injury. a. Observe infant posture and arm position and movement. b. Test reflexes: Moro, biceps, radial reflexes are not present, grasp is intact.

248 d. Muscle testing, may use observation of devel- opmental postures and movements if child c. Sensory testing of affected UE. under 3 years of age. 5. Physical therapy intervention and prognosis. e. Functional level. a. Partial immobilization of limb across upper 5. Physical therapy interventions, goals and prognosis abdomen for 1-2 weeks to avoid further injury. in Down Syndrome. b. Gentle ROM after initial immobilization to a. Minimize gross motor delay. avoid contractures. (1) Facilitate gross and fine motor development c. Elicit muscle activity with age appropriate through appropriate positioning, posture and functional movements of upper extremity. movement activities. d. May use gentle constraint of unaffected arm to (2) Increase strength and stability by manipu- facilitate use of affected UE. lating gravity and resistance in a graded manner. e. Prognosis depends on severity of nerve injury, favorable in most instances. If recovery does b. Encourage oral motor function. not occur, surgery is indicated. (1) Facilitate lip closure and tongue retrusion. (2) Short, frequent feeding sessions for energy E. Down Syndrome (Trisomy 21) conservation. 1. Pathology. a. Chromosomal abnormality caused by breakage c. Avoid hyperexten ion of elbows and knees during and translocation of piece of chromosome onto weight bearing activities. normal chromosome. b. Milder form with some normal cells inter- d. Prognosis may be correlated with tone, the lower spersed with abnormal called mosaic type. the tone the more significant the motor delay. c. Brain weight decreased when compared with normal. e. All children with Down Syndrome will eventu- d. Cerebellum and brain stem lighter than normal. ally become ambulatory. e. Smaller convolutions of cortex. 2. Impairments. 6. Medical-surgical management of Down Syndrome. a. Hypotonia. a. Yearly radiographs to rule out atlanto-axial b. Decreased force generation of muscles. subluxation. c. Congenital heart defects. b. Medical-surgical correction of cardiac problems. d. Visual and hearing losses. e. Atlanto-axial subluxation/dislocation could F. Traumatic Brain Injury (TBI) possibly be due to laxity of transverse odontoid 1. Pathology. ligament. a. Primary brain injury due to mechanical forces (1) Signs include decreased strength, ROM, that occur at initi.al impact. DTR's, and sensation in extremities. This is (1) Acceleration dependent injuries when force a medical emergency. is applied to movable head such as coup- f. Cognitive deficit (mental retardation). contrecoup and rotational injury. 3. Functional limitations. (2) Nonacceleration dependent injuries include a. Gross motor developmental delay. skull depres ion into brain ti sue and vibration. b. Difficulties in eating and speech development (3) May be accidental or due to child abuse because of low tone. such as \"shaken baby syndrome\" which c. Forceful neck flexion and rotation activities causes TBI. should be limited due to atlanto-axial ligament b. Secondary brain injury due to processes initiated laxity. as a result of initial trauma. d. Cognitive and perceptual deficits may result (1) Cerebral edema increases intracranial in delay of fine motor and psychosocial devel- pressure and may lead to herniation, cere- opment. bral infarction, brain tem injury and 4. Physical therapy examination in Down Syndrome. coma. a. Developmental test for gross and fine motor. (2) Epidural hematoma due to bleeds of middle b. Test of tone by passive range of motion. meningeal artery, vein, or venous sinus c. Active and passive ROM. bleeds into epidural pace. (3) Subdural hematoma due to lacerated cortical blood vessels.

c. Evaluation of traumatic brain injury. Pediatric Physical Therapy 249 (1) Imaging such as CT scan and MRI to deter- mine extent of initial and secondary injury. (1) Facilitate gross and fine motor development (2) Monitoring intracranial pressure. through appropriate positioning, postures (3) Behavioral scales such as the Glasgow and movement activities. Coma Scale, and the Rancho Los Amigos scale assess the child's orientation to time (2) Increase strength and stability by manipu- and place and the ability to respond to var- lating gravity and resistance in a graded iou stimuli. Infant coma scale used for manner. non-verbal infant. d. Parent/family or caregiver education. 2. Impairment . e. Prognosis depends on severity of injury, rate of a. Depend on the severity and location of the initial and secondary injuries. recovery, social and physical supports available. b. Level of consciousness and cognitive level may 6. Medical-surgical management for TBI. be impaired temporarily or permanently. c. Spasticity, loss of functional range of motion, a. Mechanical ventilation, if needed. contractures and deformities. b. Pharmacologic agents to control intracranial d. Weakness, balance, and coordination problems. e. Heterotopic ossification - pathologic bone pressure including sedatives, paralytics, diuretics formation around joint due to increased tone and barbiturates. around joint, immobility and coma. c. Intracranial pressure monitored by intracranial press.ure bolt. 3. Functional limitations. d. Surgical evacuation of hematoma. a. Decrea ed mobility skills. b. Cognitive and perceptual difficulties. VII. Pediatric Neuromuscular Problems c. Developmental process may be affected result- ing in abnormal development or developmental A. Duchenne's Muscular Dystrophy (pseudohyper- delay. trophic Muscular Dystrophy) I. Pathology. 4. Physical therapy examination of traumatic brain a. X-linked recessive, inherited by boys, carried by injury. recessive gene of mother. Diagnosi confirmed a. History, MRI, CT, EEG results, current med- by clinical examination, EMG, muscle biopsy, ications. DNA analysis and blood enzyme levels. b. Level of consciousness (Children's Coma b. Dystrophin gene missing results in increased Scale, Rancho Los Amigos Coma Scale). permeability of sarcolemma and destruction of c. Active and passive ROM. muscle cells. d. Muscle strength, observe spontaneous move- c. Collagen, adipose laid down in muscle leading ments if MMT not possible. to pseudohypertrophic calf muscles. e. Sensory testing. 2. Impairments. f. Balance and coordination testing, developmen- a. Progressive weakness from proximal to distal tal testing if appropriate. beginning at three years of age to death in late g. Determination of muscle tone (modified adolescence or early adulthood. Ashworth Scale). b. Positive Gower's sign because of weak quadriceps h. Cranial nerve testing. and gluteal muscles, child must use upper i. Functional level testing. extremities to \"walk up legs\" to rise from prone j. Integumentary examination, checking for pres- to standing. sure sores. c. Cardiac tissue also involved. d. Contractures and deformities develop due to 5. Interventions, goals and prognosis. muscle imbalance especially of heelcords and a. Maintain or improve joint flexibility by posi- tensor fascia latae, as well as lumbar lordosis tioning, erial casting, range of motion. and kyphoscoliosis. b. Stimulate/arouse level of consciousness 3. Functional impairments. through sensory stimuli. a. Developmental milestones may be delayed. c. Minimize gross and fine motor delay. b. Ambulation ability will be lost necessitating use of wheelchair eventually. c. Progressive cardiopulmonary limitations. 4. Examination in muscular dystrophy. a. Muscle strength - MMT, dynamometer.

250 a. Supine standers when more support needed posteriorly. b. Active and passive ROM. c. Functional testing. 2. Sidelyers decrease effects of TLR, put hands in d. Skeletal alignment (check for lordosis, scolio- visual field. sis, kyphosis). 3. Adaptive seating customized to meet the specific e. Respiratory function, chest excursion during support and posture needs of the the individual. breathing or spirometer. 4. Abductor pad at hips often used in positioning f. Assess for need for adaptive equipment. equipment to decrease scissoring extension pattern 5. Interventions, goals and prognosis. of hip extension, adduction, with knee extension a. Maintain mobility as long as possible by and plantar flexion of ankles. encouraging recreational and functional activi- B. Equipment for Therapeutic Exercise ties to maintain strength and cardiopulmonary 1. Balls of different sizes to promote strengthening, function. balance, coordination, and make motor learning fun. b. Maintain joint range of motion through the use 2. Wedges to facilitate or increase muscle contraction of active and passive ROM exercises, positioning needed depending on po ition of wedge. devices such as prone standers or standing 3. Bolsters combine characteristics of ball and frames. Gastrocnemius and tensor fascia lata wedge. shorten first. Night splints may be used. 4. Swings to promote sen ory integration. c. Electrical stimulation of muscles for younger 5. Scooter boards for prone tability/mobility work. children has been able to increase contractile 6. Others include toys, modified tricycles, music, ability. pets, and family member . d. Educate and support parents and family in a sensitive manner. C. Lower Extremity Orthotics e. Do not exercise at maximal level, may injure 1. Ankle foot orthosis (AFO) to provide support to muscle tissue (overwork injury). foot, ankle, knee to provide a stable base of support, f. Supervise use of adaptive equipment as needed. and to reduce effects of spasticity and hypoexten- g. Disease is progressive leading to respiratory sibility of muscles. insufficiency and death in the young adulthood. a. Ankle set at 5 to 10 degree dorsiflexion to 6. Medical-surgical management of Duchenne's decrease genu recurvatum. Muscular Dystrophy. b. Articulating ankle AFO controls amount of a. Palliative and supportive, treating symptoms as dorsiflexion and plantar flexion. they occur. c. Tone reducing AFO may be polypropylene or b. Steroids (prednisone) increases life expectancy plaster cast, bivalved. by decreasing pulmonary dysfunction. (1) Decreases effects of pa ticity including Antibiotics for pulmonary infections. scissoring by maintained tretch. c. Orthopedic surgery for scoliosis (spinal instru- (2) Stretches and maintains length of heelcord mentation), muscle lengthening of gastrocne- to prevent or lessen contracture. mius. (3) Provides good mechanical base of support B. Refer to Chapter 1, Musculoskeletal Physical for standing and ambulation. Therapy for additional pediatric conditions, e.g., 2. Knee-ankle-foot orthosis (KAFO). deformities! disorders of hip, knee, ankle/foot and a. For standing or ambulation. spine b. Reciprocal or swing-through gait. c. Knee may be solid at 0 to 5 degrees flexion or VIII. Pediatric Adaptive Equipment hinged. d. Used by children with spina bifida or muscular A. Positioning Equipment: used to maintain skeletal dystrophy. alignment, prevent or reduce development of contrac- 3. Hip-knee-ankle-foot orthosis (HKAFO). tures and deformities and to facilitate functional abilities a. For standing and ambulation. 1. Standers give the child weight bearing experience b. Swing-through gait. which maintains hips, knees, ankles and trunk in c. Used by children with spina bifida or spinal optimal position, facilitates formation of acetabulum cord injuries. and aids bowel and bladder function.

4. Reciprocating gait orthosis (RGO). Pediatric Physical Therapy 251 a. HKAFO with molded body jacket. b. Cable system allows forward step with lateral IX. Family, Early Intervention and the weight shift. Education Setting c. Used by children with thoracic level spinal bifida or spinal cord injuries. A. Family 1. Family is the single most important constant and 5. Pavlik harness. environmental factor. a. For infants with congenital hip dysplasia. 2. PT must collaborate with child and family. b. Hips held in flexion and abduction to maintain 3. Family Centered Approach begins with child's and femoral head in acetabulum. family's strengths, needs and hopes, and results in a service plan which responds to the needs of the D. Mobility Aids whole family. Role of PT is to support, encourage 1. Wheelchairs. and enhance the competence of parents or caretakers a. Must be the correct size for the child. in their role as caregivers. b. Posture, movement, strength, endurance, 4. Parents of children with developmental disabilities abnormal tone, contractures are important in often suffer from chronic sorrow due to the loss of determining custom features of a wheelchair the typical potential of their child. including method of mobility, seating stability. c. Stroller type chairs limit independence of B. Early Intervention Programs (EIPs) child. 1. Mandated by public law. d. Scooter/three wheelers require fair (3/5) sitting a. To provide comprehensive, multidisciplinary balance and upper extremity control. EIP. 2. Walkers. b. For infants and children from birth to three a. Rollator walkers with wheels usually used. years. b. Forward walker (anterior rollator walker). c. Multidisciplinary assessment. (1) Encourages forward trunk leaning. d. Individual Family Service Plan (IPSP) developed. (2) Provides maximum anterior stability. e. Family is a member of the team. c. Posterior walker (Posture control walker). (1) Encourages trunk extension. C. School System: Individual Education Plan (IEP) (2) Encourages shoulder depression, elbow 1. Mandated by public law. extension, neutral wrist which may a. Free and appropriate public education for all decrease scissoring in lower extremities. children with disabilities. d. Gait trainers offer maximum support to upper b. For children three to twenty-one. extremities and trunk. c. Multidisciplinary assessment. 3. Crutches. d. Right to related services such as PT is related a. Require more postural control than walkers. to educational need. b. Axillary and Lofstrand crutches available. e. Least restrictive environment.