PTA 189 unit 1 ch, 1-4 kk


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Unit 1, Chapters 1-4 PTA189 Pathology

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  • In addition, how the person with the pathologic condition is able to participate in his or her family and community is paramount. Current clinical practice must include an emphasis on the person’s activity level, participation, level of supports, and environment. Not just the disease itself.
  • Incidence – number of new cases in a specific time periodPrevalence measures all cases of a condition among those at riskNatural History – how it’s progressed over time
  • Rapid onset, short durationIllnesses that include one or more of the following: permanent impairment or disability, residual physical or cognitive disability, need for long term management – may fluctuate in intensity
  • For example, diabetes can result in impairment (decreased circulation) but not all people with diabetes sustain a disability (vision loss, or amputation).
  • World Health Organization
  • Table 1-1 in your text highlights types of cognitive deficits associated with lesions in specific areas of the brain
  • Most illness, including most cases of cancer are caused by acquired mutations or major change in the DNA of multiple genes. Ethical concerns: concerns have been raised including the use of genes to improve ourselves cosmetically, Increase intelligence, designer babies, or cause permanent changesin the gene pool Genetic engineering is the process where specific malfunctioning cells are targeted and repaired or replaced with correct genes. Gene therapy is being researched for a wide variety of hereditary disorders and diseases, helping injuries heal (i.e. replacing worn out tissue, reducing scar tissue), and to treat patients with inoperable diseases.
  • Biopsychosocial – multiple organs, multiple co-morbidities (SES, genes, social, access to healthcare)Single injury or disease can predispose a person to associated secondary illness
  • Acute - Initial response of tissue to injury or illness
  • Result of persistent injury or repeated episodes of acute inflammation, infection, or foreign body reactionEG: Arthritis, Lupus,
  • What is immunodeficiency? Congenital or acquired failure of one or more functions of the immune system - Acquired: alcoholism, malnutrition, aging, diabetes, steroid therapy, cancer chemo and radiationNeoplasm: malignant tumors produce many locsl and sytemic effects
  • Which would heal more rapidly, a surgical incision in which the edges have been stapled closely together, or a large jagged tear in the skin and subcutaneous tissue? Why?A surgical incision heals rapidly because there is less tissue trauma, less interference with blood vessels, no foreign matter, and the edges are pulled closely together, leaving only a small gap of tissue to be filled in.
  • At the time of fracture tiny blood vessels are torn at the fracture site.Fracture hematoma develops. Fibroblasts, platelets, and other mediators are delivered to the area via the blood secreting growth factors and cytokines. Classified with acute inflammation, evidenced by pain, swelling, heatB. Granulation tissue forms, fibrin meshwork develops and allows the in growth of fibroblasts. C. The reparative phase includes the formation of the soft callus seen around 2 weeks on X-ray, which is eventually replaced by a hard callus. During this phase bone macrophages (osteoclasts) clear away necrotic bone.Once the callus is sufficient to immobilize the fracture site, repair occurs.D. The remodeling phase returns the bone to normal.
  • Pruritus = itching
  • Lymphokines -
  • PTA 189 unit 1 ch, 1-4 kk

    1. 1. Unit 1 Pathology for theChapters Physical Therapist1-4 Assistant Catherine Goodman Kendra FullerKelly King, PT, MACarrington College
    2. 2. OBJECTIVES• Explain and differentiate between concepts of health, illness and disability• Describe genetic aspects of disease• Describe and compare the systemic and local effects of commonly encoutered pathologic conditions
    3. 3. Introduction to Concepts of Pathology • Pathology is defined as the branch of medicine that investigates the essential nature of disease • Changes in body tissues and organs • Cause or caused by disease • Why study Pathology?
    4. 4. Introduction to Concepts of Pathology Terms: • Clinical Pathology • Pathology applied to the solution of clinical problems • Laboratory methods and clinical diagnosis • Pathogenesis • The development and progression of each pathologic (disease) condition • Cellular changes • Manifestation of clinical signs and symptoms
    5. 5. Introduction to Concepts of Pathology• Pathogenesis • Idiopathic disease • Arising spontaneously or from an obscure or unknown cause • Iatrogenic • Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures • Endogenous • Originating within the body or cell (autoimmune or impaired immune system) • Exogenous • Originating outside the body or cell (most infections)
    6. 6. Pathology for the PTA • Clinical pathology • The effects of pathologic processes on the individual’s functional abilities and limitations or impairments • The relationship between impairment and functional limitation is the focus of therapy • Most patients have multiple medical pathologies. This requires knowledge of the impact diseases and conditions have on the neuromusculoskeletal system in order to provide safe, effective treatment.
    7. 7. Concepts of Health, Illness, andDisability • Health – no universally accepted definition • Absence of illness • Physical, mental, and social well-being • Either - or (healthy or ill) • Health – dynamic process dependent on internal and external environments • Homeostasis • Biologic, psychologic, spiritual, and sociologic state • Wellness incorporates all these aspects
    8. 8. Concepts of Health, Illness, andDisability • Illness – often defined as opposite of health, sickness • Disease – biologic or psychologic alteration that results in malfunction • Manifests with specific signs and symptoms (i.e. fever when infection is present) • Cause and effect • Incidence and Prevalence • Natural History
    9. 9. Concepts of Health, Illness, andDisability Terms • Acute • Chronic • Disability – a physical or mental condition that limits a person’s movements, senses, or activities, specific impairment(s)
    10. 10. Classification Models for Disability • Nagi Disablement Model • System to classify the impact of disease or trauma • Pathology produces pain and impairments • Leads to functional limitations and disability • Components • Disease or pathology • Impairment(s) • Functional limitations • Disability
    11. 11. Nagi - Disability • Not all disease leads to impairment • Not all impairment leads to disability • Functional limitations are the result of impairments • Inability to perform the tasks and roles that constitute usual activities for that individual • Disability is patterns of behavior that emerge over long periods of time when functional limitations cannot be overcome
    12. 12. International Classification of Functioning, Disability, and Health (ICF)• International Classification of Functioning, Disability, and Health • The international standard to describe and measure health and disability • Established in 2001• Focus on life vs mortality • How people live with illness and disease • How to provide increased productivity and quality of life• Components: • Body functions (b) • Body structures (s) • Activities and participation (d) • Environmental factors (e) • Personal factors –race, gender, age, education
    13. 13. Cognitive Disability• Dependent on the location of lesion (local change in cells causing abnormal tissue)• Lesions have many etiologic factors • Head injury • Disease • Alcohol abuse • Anoxia or hypoxia (absence or decrease in oxygen)
    14. 14. Cognitive Disability• Cognitive deficits are associated with specific areas of the brain
    15. 15. Implications for the PTA• Physical disability• Cognitive disability• Treatment must be adapted specifically to each patient’s underlying pathology• Treatment areas may need to be modified• Learning styles need to be assessed
    16. 16. Health Promotion and Disease Prevention• Practicing healthy behaviors to decrease precipitating factors• Health Promotion • Self-responsibility • Nutritional awareness • Vit D and Calcium for bone health • Folic Acid and Prenatal vitamins • Stress reduction • Physical fitness
    17. 17. Health Promotion and Disease Prevention • Disease Prevention • Healthy People 2000 • Healthy People 2010 • Healthy People 2020 • Encompass the entire lifespan • Principles: • Self-responsibility • Nutritional awareness • Stress reduction • Physical fitness
    18. 18. Which Preventive Practices Do YouPractice?
    19. 19. Implications for the PTA• Screening programs• Health Promotion• Prescriptive exercise programs to improve health and wellness• Understanding how individual variables affect patient outcomes
    20. 20. Genetic Aspects of Disease• Most illnesses are caused by acquired gene mutations • May be the result of exposure to harmful (toxic) substances • Errors in replication are usually repaired by the body • When the repair process fails, disease or illness results • Acquired gene mutations are not inherited
    21. 21. Genetic Aspects of Disease• Genes are also chemical messengers of heredity• Mutations on the X and Y Chromosomes are passed on to offspring as genetic disorders• Genetic disorders are often manifested in neonatal period• The Human Genome Project allowed complete mapping of DNA sequence and increased understanding of susceptibility to disease, prenatal diagnosis
    22. 22. Genetic Aspects of Disease• Genes are the chemical messengers of heredity• Gene therapy • Introduction of normal genes into living target cells to return cell activity to normal • Requires a vector that can pass the bodies defenses• Genetic engineering • Laboratory practices of manipulating genes • Goal is to remove defective gene and supply a normal one to eliminate genetic defects • Ethical concerns
    23. 23. Genetic Engineering
    24. 24. Genetic Aspects of Disease• Gene doping
    25. 25. Genetic Aspects of Disease• Gene Testing • Identifies people who have inherited a faulty gene • The gene may or may not lead to a particular disorder • Results in earlier monitoring, preventive treatment, and long- term planning• Psychologic implications• Ethical issues and privacy concerns
    26. 26. Benefits of Genetic Testing
    27. 27. Implications for the PTA• Important to eliminate factors in disease susceptibility • Regular exercise can help control diabetes, bone density, immune function, psychologic function and obesity• Understanding of genetic disorders can help therapists understand patient response to interventions and develop individualized plans of care
    28. 28. Review of Terms - Acute Illness • An illness or disease that has a rapid onset and short duration • Often responds to a specific treatment • Usually self-limiting • Return to previous level of functioning
    29. 29. Review of Terms• Subacute Illness • Between acute and chronic. • Present for longer than a few days but less than several months
    30. 30. Review of TermsChronic Illness – characteristics• Permanent impairment or disability• Residual physical or cognitive disability• Need for special rehabilitation and/or long term medical management
    31. 31. Review of Terms• Diagnosis • Identification of disease through evaluation of signs and symptoms, laboratory tests (diagnostic tests), or other tools• Etiology • Causative factors in a particular disease
    32. 32. Review of Terms• Incidence • The number of new cases of a disease in a given population noted within a stated time period• Mortality • Measurement of the number of deaths related to a disease• Epidemic • Higher than expected number of cases within a given area
    33. 33. Review of Terms• Pandemic • Higher than expected number of cases within many regions of the globe• Medical History • Personal and family history of current and prior illness essential for planning appropriate interventions• Predisposing factor • Inherent trait may or may not lead to disease or illness (predisposition to blood clots due to inherited trait)
    34. 34. Review of Terms• Precipitating factor • Causes or contributes to the occurrence of a disorder (long flight – DVT)• Iatrogenic • Disease or illness caused inadvertently by a physician or surgeon or by medical treatment• Complication • New secondary or additional problems that arise after the original disease begins• Prognosis • The probability or likelihood for recovery, expected outcome
    35. 35. Review of Terms• Signs • Objective indicators (manifestations) of disease (fever, rash or lesions)• Symptoms • Subjective indicators (pain, nausea, dizziness)• Exacerbation • Change or increase in severity of chronic condition
    36. 36. Application for the PTA• CJ is having surgery next week to remove a malignant breast tumor, following discovery of a lump in the breast and a biopsy. Her mother and aunt have had breast cancer. CJ is taking medication for high blood pressure.• Match the significant information above to the appropriate term: diagnosis, medical history, etiology, prognosis, neoplasm, signs, complication, treatment, examination of living tissue. Some terms may not be used or may be used more than once.
    37. 37. Application for the PTA• Malignant breast tumor and high blood pressure: diagnosis• High blood pressure and family cancer: medical history• Biopsy: examination of living tissue• Medication: treatment• Surgery: treatment and diagnosis
    38. 38. Pair and Share time
    39. 39. Pathology for the PTA Chapter 2Problems Affecting Multiple Systems
    40. 40. Problems Affecting Multiple Systems • It is important for the PTA to understand systemic, local and functional effects associated with pathological conditions • Why? • What does it mean if something is Systemic?
    41. 41. Inflammation• Acute Inflammation – systemic effects include fever, tachycardia (rapid heart rate)• Can cause changes in blood – elevated serum protein• Can lead to abscess formation• Progressive tissue damage and loss of function
    42. 42. Systemic Effects of Inflammation• Chronic Inflammation – low grade fever, malaise, weight loss, anemia, fatigue, leukocytosis, lymphocytosis, increased erythrocyte sedimentation rates (ESR) • Leukocytosis • Increased white blood cells • Lymphocytosis • Increased lymphocytes (type of white blood cell, disease fighting cells) • ESR • Erythrocyte – red blood cell, high sed. rate indicates inflammation somewhere in body
    43. 43. Systemic Factors of Chronic Infection • Influences on healing • Nutrition • Psychologic well-being • Cardiovascular disease • Hematologic disorders • Infections • Diabetes • Corticosteroids • Immunosuppressive therapy
    44. 44. Other Systemic Factors • Consequences of Immunodeficiency • Failure of the immune system • Predisposed to infection • AIDS • Effects of Neoplasm • Encroaches on healthy tissue • May cause pain, swelling • Symptoms may include muscular weakness, anorexia, anemia, bruising, bleeding, cachexia (wasting)
    45. 45. Implications for the PTA • Careful and close monitoring of vital signs, especially for the patient with multiple system involvement • Modification of physical therapy to minimize risk • Individualized treatment programs • Understanding of the disease process, possible risks for secondary disease, and prognosis
    46. 46. Adverse Drug Reactions (ADRs) • Most patients are taking multiple prescription or over- the-counter (OTC) medications • It is important to know the clinical manifestations of ADRs
    47. 47. Adverse Drug Reactions • ADRs • Unwanted and potentially harmful effects produced by medications or prescription drugs • Mild – no treatment needed • Moderate – may require medication or treatment changes • Severe – potentially life threatening • Lethal – leads to death • Side effects • Predictable effects that can occur within therapeutic dose ranges
    48. 48. Gross Pictures Ahead
    49. 49. Adverse Drug Reactions
    50. 50. Adverse Drug Reactions
    51. 51. Risk Factors for ADRs • Age – most prevalent • Dosages effect • Herbals • Gender • Duration of treatment • Ethnicity • Noncompliance • Alcohol consumption • Small stature • New drugs • Other conditions • Number of drugs
    52. 52. Signs and Symptoms of ADRs • Altered taste • Constipation • Dry mouth • Impaired memory • Anxiety • Fatigue • Dizziness • Headache • Nasal congestion • Vomiting
    53. 53. Clinical Manifestation of ADRs • Rash • Fever • Itching • Burning • Urticaria (hives) • Purpura (red or purple discolorations)
    54. 54. Other Signs and Symptoms of ADRs
    55. 55. Implications for the PTA • Exercise can cause sudden changes in the way drugs are metabolized by the body • Monitor for signs and symptoms of ADRs • Report any suspected ADR to the PT and/or physician • Documentation • Follow the facilities policies for notification of ADRs • May be appropriate to schedule treatment sessions during peak pain relief (2 hrs after oral administration)
    56. 56. Drug Categories:Nonsteroidal Antinflammatory Drugs • NSAIDS • Reduce inflammation, decrease pain, reduce fever (ibuprofen, Aspirin, Advil, Naproxen) • Tylenol (acetaminophen) • NOT an NSAID – analgesic and antipyretic only • Potential adverse effects of NSAIDs • GI complications, dyspepsia, bleeding, ulcers, per foration
    57. 57. Nonsteroidal Antinflammatory Drugs • Interact with high blood pressure medications • Anti-coagulant, single dose of aspirin limits clot formation for 5-7 days
    58. 58. Implications for the PTA • Widespread use both OTC and prescription • Post op, fever, musculoskeletal pain, arthritis • PTA must observe for any side effects or adverse reactions, especially among elderly • Easy bruising, bleeding • Elevated blood pressure • GI symptoms
    59. 59. Immunosuppressive Agents • Used with organ and bone marrow transplantation • May be used with chronic conditions like RA, psoriasis • Serious side effects and adverse reactions are common • Anaphylactic reactions, renal failure, liver toxicity, neurotoxicity, prone to infection – both fungal and bacterial
    60. 60. Implications for the PTA • Handwashing is essential before contact with immunosuppressed patient • Use of Mask may be appropriate • Do not work with this patient if you are ill
    61. 61. Corticosteroids • Naturally occurring hormones in the body • Glucocorticoids (cortisol) • (hydrocortisone, prednisone, dexamethasone) which affect carbohydrate and protein metabolism • Mineralocorticoids (aldosterone) • Which regulate electrolyte and water metabolism • Androgens • (testosterone) causes masculinization
    62. 62. Glucocorticoids • Effective anti-inflammatory agents • Side effects: • Change in sleep and mood, mild anxiety to psychosis • GI irritation • Hyperglycemia • Fluid retention • Susceptibility to infection
    63. 63. Glucocorticoids • Side effects: • Thinning of subcutaneous tissue • Delayed wound healing • Steroid myopathy: muscle weakness and atrophy • Growth retardation • Osteoporosis
    64. 64. Glucocorticoids A patient with MS has been on prednisolone for the past 4 years. The medication is now being tapered off. This is the third time this year that the patient has received this treatment for an MS exacerbation. The PTA recognizes that possible adverse effects of this medication are:• 1. weight gain and hyperkinetic behaviors• 2. nausea and vomiting• 3. muscle wasting, weakness, and osteoporosis• 4. spontaneous fractures with prolonged healing
    65. 65. Anabolic - Androgenic Steroids • ―Roids‖ • Synthetic derivatives of the hormone testosterone • Used to enhance sports performance or personal (masculine) appearance • Side effects: • HTN • Left ventricular hypertrophy • Liver dysfunction • Sudden and premature death
    66. 66. Implications for the PTA• Harmful side effects of glucocorticoids can be delayed or reduced by exercise• Monitor vital signs due to risk of increased blood pressure both with exercise and with steroid use• Increase use of calcium and vit D
    67. 67. Implications for the PTA• Psychologic considerations • Mood change and irritability • Notify PT or physician when intense changes are seen• Anabolic steroids • Frequent or recurrent tendon or muscle strain • Male pattern baldness • Gynecomastia • Personality changes, ―Roid rage‖ • Depression
    68. 68. Chemotherapy and Radiation • Common treatments for cancer (also other diseases that are non responsive to treatment)
    69. 69. Radiation• Increased risk of cancer after medical radiation: X-ray, CT scan• Radiation can cause: • Causes mutations or alterations in DNA • Damages blood vessels • Bone marrow depression with decreased leukocytes, platelets, and erythrocytes • Epithelial cell damage, erythema, alopecia • Mucosal lining of Digestive tract damaged resulting in nausea and vomiting, diarrhea, bleeding • Fatigue, lethargy, mental depression
    70. 70. Chemotherapy • Chemotherapy • Anti-neoplastic drugs • Interfere with protein synthesis and DNA replication of the tumor cells • Specific drugs are designed for specific types of tumor cells
    71. 71. Chemotherapy and Radiation • Adverse effects of chemotherapy: • Bone marrow suppression • Alopecia • Mucosal inflammation with nausea and vomiting • Fibrosis in lungs • Damage to heart myocardial cells • Neuropathy • Chemicals stimulate the emetic centers of the brain causing vomiting
    72. 72. Implications for the PTA • Patients have a high risk of infection, handwashing is essential • Notify PT or physician of any sigh of infection • Mood swings • Fatigue
    73. 73. Implications for the PTA • Monitor for complaints of pain, burning, numbness, pins and needles, motor deficits (neuropathy) • Possible effects on cardiac and other organs manifests months to years after treatment • Closely monitor patient tolerance to exercise and other physical therapy interventions
    74. 74. Implications for the PTA • Mrs. B.N. is 67 years old and has just completed her recent chemotherapy treatment. She has returned to physical therapy due to her weakness and difficulty walking. • 1. Explain why handwashing is essential when treating Mrs. B.N. • 2. Describe what clinical signs may be expected with Mrs. B.N. • 3. Mrs. B.N. complains of fatigue and requests that her therapy be placed on hold. What is the proper response by the PTA?
    75. 75. Implications for the PTA • Fatigue is common but should not be discounted (consider dehydration, malnutrition, anorexia, sleep disturbances) • Lack of exercise can lead to CRF( cardiac-related fatigue) • PT and PTA team must determine the balance of exercise and rest that is effective for the patient
    76. 76. Pair and Share time
    77. 77. Fluid and Electrolyte Imbalances• Water composes 45-60% of the adult human body (70% for the infant)• Water is the medium in which metabolic reactions and other processes take place• Water is the transportation system for the body • Carries nutrients into cells • Removes wastes from cells • Transports enzymes in digestive secretions • Moves blood cells around the body
    78. 78. Fluid and Electrolyte Imbalances• Fluid is distributed between intracellular fluid (ICF) and extracellular fluid (ECF)• Cell membranes are water permeable • Equal concentrations of dissolved particles on each side of the membrane • Maintaining equal volumes of ECF and ICF • Homeostasis – stable internal environment• What causes the shift of water? • Shifts of water occur due to changes in concentration of ions like sodium
    79. 79. Fluid and Electrolyte Imbalances• The amount of water entering the body must equal the amount of water leaving the body.• Water enters through the ingestion of fluids in liquids and solids• Water exits the body through urine, perspiration, feces, exhaled air• Too much fluid = hypervolemia• Too much fluid loss = dehydration
    80. 80. Implications for the PTA• Patients with CHF should monitor weight gain/loss frequently. Any increase in weight should be reported to PT or physician• Generally, water should be available and offered to patients during rehab, special considerations should be followed for CHF or renal diseased patients• Educate patient on using urine as a gauge for adequate hydration• Dehydration degrades endurance and exercise performance
    81. 81. Electrolyte Imbalances• Sodium • Sodium influences blood volume and pressure, fluid loss or gain • is the primary cation in extracellular fluid• Calcium • Calcium is important for neuromuscular activity, skeletal• Magnesium muscle, bones, kidneys, and GI tract • Magnesium plays a role
    82. 82. Electrolyte Imbalances • Sodium and potassium are essential for producing the membrane potential providing the means for transmission of electrochemical impulses • Sodium influences blood volume and pressure, fluid loss or gain • Potassium is necessary for normal muscle contraction and relaxation (heart, intestines, respiration, neural stimulation of skeletal muscles)
    83. 83. What does this have to do with me, the PTA?
    84. 84. Implications for the PTA • Educate the patient to maintain prescribed sodium restrictions • Elderly have higher incidence of hypokalemia due to the use of diuretics resulting in fatigue, cramping, dizziness, etc. • Ongoing assessment of fluid and electrolyte balance (subjective and objective findings) • Be alert to complaints of headache, thirst, nausea, shortness of breath, muscle strength • Ask about fluid intake and output, body weight changes
    85. 85. Implications for the PTA Assessment of Fluid and Electrolyte Imbalance Area Fluid Excess and Electrolyte Fluid Loss and Electrolyte Imbalance Imbalance Head and neck Distended neck veins, facial Thirst, dry mucous membranes edema Extremities Dependent pitting, edema Muscle weakness, tingling, tetany Skin Warm, moist, taut, cool feeling when edematous Dry, decreased turgor Respiration Dyspnea, orthopnea, productive cough, moist breath Changes in rate and depth of Circulation breathing sounds Hypertension, atrial arrhythmias Pulse rate irregularities, arrhythmia, postural hypotension, tachycardia Abdomen Increased girth, fluid wave Abdominal cramps
    86. 86. Acid-Base Imbalances• Normal function of the body depends on regulation of hydrogen ion concentration, pH• Three systems act to maintain normal pH • Blood buffer systems – immediate buffering by excretion of excess acid • Lungs – excretion of acid (occurs within hours) • Kidneys – Excretion of acid or reclamation of base (occurs within days)
    87. 87. Acid-Base Imbalances • Normal pH level is 7.35 to 7.45 • Cell function is impaired when pH falls below 7.2 or rises to 7.55 or higher. • Below 7.4, more hydrogen ions are present, considered acidic • Above 7.4, fewer hydrogen ions present, considered basic
    88. 88. Acid-Base Imbalances • Acidosis • Excess acid in the body • Acidemia • Excess acid in the blood • Alkalosis • Excess base in the body • Alkalemia • Excess base in the blood
    89. 89. Acid-Base Imbalances• Death occurs if pH level is below 6.8 or above 7.8
    90. 90. Acid-Base Imbalances• Respiratory Acidosis• Respiratory Alkalosis• Metabolic Acidosis• Metabolic Alkalosis• Table 2-7 (pages 44-45) gives an overview of Acid-Base Imbalances
    91. 91. Fluid and Electrolyte Balance
    92. 92. Implications for the PTA• Fruity breath = increased acid levels• Hyperventilation – re-breathing in bag helpful to prevent alkalosis• COPD diagnosis may have frequent changes in O2 and CO2 levels with associated symptoms• CHF- diuretics cause potassium depletion• Notify PT/ MD if signs and symptoms of acid base imbalance develop
    93. 93. Urinary – Renal Disorders • Urinary Tract Infections (UTI) • Very common, men, women, children • Bladder infection – cystitis • Infection of urethra - urethritis • Kidney infection – pylonephritis
    94. 94. Risk Factors of UTI • Age • Immobility, inactivity (impaired bladder emptying) • Catheterization • Increased sexual activity • Use of diaphragm or condom • Uncircumcised penis (first year of life) • Female • Partner of Viagra User • Previous UTI
    95. 95. Chronic Kidney Disease (CKD) • Alteration in kidney function for greater than 3 months • Etiology • Diabetes • Glomerulonephritis • Glomeruli filter waste and fluids from blood • Blood and protein lost in urine • Excessive aspirin or acetaminophen use
    96. 96. End Stage Renal Disease (ESRD) -Renal Failure• Final stage of CKD• May be due to circulatory disruption to kidneys, toxic substances, acute obstruction and trauma• SLE• Uncontrolled hypertension• Uremia – end stage toxic condition
    97. 97. Renal Failure – Red Flags• Multi-system abnormalities and failures • Dizziness, headaches, anxiety, memory loss, inability to concentrate, convulsions and coma • Hypertension, dyspnea on exertion, heart failure • Chronic pain- leg pain and cramps • Edema – peripheral edema • Muscle weakness – peripheral neuropathy • Osteoporosis • Skin pallor, pruritis, dry skin • Anemia, bleeding tendencies
    98. 98. Dialysis • Removal of toxic substances, maintain fluid, electrolyte and acid-base balance • Peritoneal or renal (hemodialysis) • Signs and symptoms often encountered: • Nausea, vomiting, drowsiness, headache, seizures • Dementia – speech difficulties, confusion • Infection at shunt site • Multisystem dysfunction
    99. 99. Dialysis
    100. 100. Implications for the PTA • Renal disease may be induced by interactions of NSAIDS and other analgesics, especially in the elderly • Musculoskeletal changes, osteoporosis, atrophy • Fluid shifts during dialysis • Depression • Susceptibility to infection
    101. 101. Implications for the PTA • Monitor for multisystem dysfunction • Vital signs • Strength • Sensation • ROM • Function • Endurance • Locate shunt – BP at shunt site contraindicated • Locate peritoneal catheters (avoid trauma to these areas)
    102. 102. Implications for the PTA • Functional mobility training as needed • Sit to stand transfers • Ambulation • Toileting • Environmental modifications • Toilet rails, raised toilet seat, etc.
    103. 103. Implications for the PTA • A patient with chronic renal failure is being seen in PT for deconditioning and decreased gait endurance. The patient has been scheduled around dialysis. The patient is also hypertensive and requires careful monitoring. What is the best approach to take blood pressure? • 1. before and after activities, using the nonshunted arm • 2. after activity • 3. before activity • 4. every few minutes during the activity
    104. 104. Urinary Incontinence • Inability to retain urine • Loss of sphincter control • Acute - cystitis • Persistent – stroke, dementia
    105. 105. Urinary Incontinence• Types: • Stress incontinence – cough, laugh, sneeze, weakness and laxity of pelvic floor muscles • Post partum, menopause, nerve damage • Urge incontinence – inability to delay voiding after the bladder is full • Stroke, hypersensitive bladder • Overflow incontinence – leaks due to urinary retention • Functional incontinence – inability or unwillingness to toilet • Dementia, stroke, environmental barriers
    106. 106. Implications for the PTA • Bladder training • Prompted voiding, schedule, intermittent catheterization • Pelvic floor exercises • Kegel exercises – incorporate into every day life, with lifting, coughing, changing positions, etc. • Behavioral training • Record keeping, education on anatomy, muscle weakness, avoiding valsava during activity • Adult diapers, pads • Psychosocial support
    107. 107. Pathology for the PTA Chapter 3Injury, Inflammation and Healing
    108. 108. Objectives• Discuss cell injury and compare/ contrast the factors causing this injury• Differentiate the components of the inflammation reaction• Discuss factors that affect tissue healing and phases of healing
    109. 109. Cell Injury• Understanding cell injury, inflammation and tissue healing serves as a solid foundation for clinical decision making
    110. 110. Injury • Structural and functional changes produced by pathology start with injury to the cells that make up the tissues • Injury can occur as a result of • Ischemia • Infection • Immune reactions • Genetic factors • Nutrition • Physical factors • Chemical factors
    111. 111. Injury • Ischemia: limited blood flow • Decrease in oxygen and nutrients • Decrease in removal of waste products • Causes of ischemia • Atherosclerosis • Clot • MI and Stroke are the leading causes of death (lack of blood flow to heard and brain)
    112. 112. Injury • Infectious agents • Bacteria and viral agents most common • Sepsis occurs when infectious agents are present throughout the body in the blood
    113. 113. Injury • Immune Reactions • Mild allergy to life-threatening anaphylactic reactions • Genetic Factors • Mutations or alterations in DNA • Inherited or acquired
    114. 114. Injury • Nutritional factors • Imbalances can lead to cell injury and death • Iron deficiency can lead to anemia • Vitamin C deficiency can cause scurvy
    115. 115. Injury • Physical factors • Trauma • Incision • Excision • Excessive heat • Excessive cold • Pressure • Radiation
    116. 116. Injury• Mechanical factors • Soft tissue stress • Repetitive or forceful tasks• Chemical Factors • Chemotherapy and other toxins, topical and metabolic • Taken in large amounts most medications can be toxic
    117. 117. Cell Injury• Reversible • Cell injury or stress is short duration and cell is able to recover• Chronic • Sub lethal stress remains present over a period of time causing the cell to adapt but survive (atrophy, hypertrophy, hyperplasia, metaplasia, and dysplasia)• Irreversible • Results in cell death and necrosis
    118. 118. Cell Injury • Tissue Calcification • Calcium is deposited into the area of damaged tissue, T.B, atherosclerosis, calcific tendinitis – can be treated with pulsed US
    119. 119. Implications for the PTA• Signs and symptoms differ depending on the stage of cell injury and the type of organ or tissue involved• Understanding injury processes and implications
    120. 120. Tissue Healing • Resolution • Minimal tissue damage, cells recover and tissue returns to normal (sunburn) • Regeneration • Damaged tissue restored to original form, replaced by same type of cell (liver) • Repair • (Replacement)- functional tissue replaced by highly collagenous scar tissue, loss of function • Collagenous scar tissue forms when the injury is extensive, extends beneath the epidermis or cells are unable to undergo mitosis (brain, cardiac cells)
    121. 121. Components of Tissue Healing • Collagen: most important protein, provides structural support and tensile strength for almost all tissues • Tendon strength • Flexibility of skin • Rigidity of bone • Elasticity of blood vessels
    122. 122. The Healing Process • Four phases of healing for acute wounds caused by trauma or surgery • Hemostasis and degeneration • Inflammatory phase • Proliferation and migration • Remodeling and maturation • Phases often overlap and can take months to years to complete
    123. 123. The Healing Process - Hemostasis• Hemostasis: • blood clotting • Platelets clump together forming a loose clot • Platelets release chemical messengers, growth factors that summon inflammatory cells promote cell healing
    124. 124. The Healing Process - Hemostasis• Degeneration: formation of hematoma, necrosis of dead cells, and start of inflammatory process• Repair of tissue occurs after the removal of dead cells
    125. 125. Defense Mechanisms • Non-specific: • First line of defense: • Skin/ mucous membranes • Block entry of bacteria or other harmful substances • Saliva, tears have enzymes and chemicals that inactivate or destroy pathogens • Second line of defense: • Phagocytosis • Process by which neutrophils (a leukocyte, WBC) and macrophages engulf and destroy bacteria, cell debris and foreign matter (pathogens) • Inflammation limits the effects of injury
    126. 126. Defense Mechanisms • Specific • Third line of defense • Immune system • Specific immune cell responses • Lymphocytes, macrophages, etc. • Provides protection by stimulating the production of antibodies
    127. 127. Inflammation • Initial response of vascularized living tissue to injury • After cell injury, the body reacts with the process of inflammation • Normal defense mechanism in the body intended to localize and remove an injurious agent • Not the same as infection, but infection is one cause of inflammation • Disorders are named using the ending –itis
    128. 128. Inflammation is Triggered By Cell Injury •Ischemia •Nutrition •Infections •Tissue Necrosis •Immune Reactions •Mechanical Factors •Genetic Factors •Excessive Heat •Physical Factors •Excessive cold •Incision •Pressure •Excision •Irritant and corrosive chemicals
    129. 129. The Inflammatory Response• 8&feature=fvwrel
    130. 130. Wound Pictures Ahead!
    131. 131. Inflammation is Triggered By • Incision
    132. 132. Inflammation is Triggered By • Excision
    133. 133. Inflammation is Triggered By • Tissue Necrosis
    134. 134. Inflammation is Triggered By • Excessive Heat
    135. 135. Inflammation is Triggered By • Excessive Cold
    136. 136. Inflammation is Triggered By • Pressure
    137. 137. Inflammation is Triggered By • Infection
    138. 138. Inflammation is Triggered By • Chemical Burn
    139. 139. Clinical Manifestations of Inflammation • Redness and warmth • Due to increased blood flow (vasodilation) to damaged area • Swelling (edema) • Shift of protein and fluid into the interstitial space • Pain • Increased pressure of fluid on nerves; release of chemical mediators – i.e., bradykinins • Loss of function • May develop if cells lack nutrients; edema may interfere with movement
    140. 140. Acute Inflammation • Three major components • Dilation of blood vessels and increased blood flow • Mast cell changes allowing proteins to leave the cell • Migration of proteins to the area of injury
    141. 141. Acute Inflammation • Events that occur • Vascular events – blood vessels • Cellular events – mast cells • Chemical events - mediators and complement factors (proteins)
    142. 142. Inflammation (Cont’d) • Acute inflammation • Self-limiting • Essential part of the healing process (not a disease) • Lasts 3-7 days • Edema and blood clotting usually occur • Platelets are activated • Platelet plug is formed and stabilized • Thrombus (blood clot) formed • Increased capillary permeability causes protein and water to escape into compartment or tissue causing edema
    143. 143. Inflammation (Cont’d)• Edema • Fluid and protein in tissue causes leukocytes (WBC) to accumulate • Lukocytes are attracted to site of inflammation • (WBC) • Leukocytosis – increased WBC count in blood
    144. 144. Inflammation (Cont’d)• Acute inflammation • Bacteria killed by neutrophils • White blood cells that clean up and eliminate pathogens, dead cells and other cellular debris • Limited number of Monocytes/macrophages • Also provide phagocytosis but with increased role in chronic inflammation
    145. 145. Inflammation (Cont’d) • Chronic inflammation • Fibrocytes/fibroblasts - play a critical role in wound healing, create collagen and other cellular material • Endothelial cells – important role in controlling inflammation, release cytokines (Stimulate the release of inflammatory mediators from other cells), line blood vessels and create lymphatic drainage
    146. 146. Inflammation (Cont’d) Page 66 Factors affecting bloodflow Vasodilation + Histamine increased vascular Serotonin permeability = Bradykinins Edema Leukotrienes/prostaglandins Factors leading to inflammation Lack of adequate bloodflow Production of Damaged tissue inflammatory Acute inflammation cellular Cancer infiltrate mediators Platelets Infectious biologic organisms Foreign material Neutrophils Chemicals Monocyte/macrophage Physical agents Fibrocytes/fibroblasts Factors attracting and Endothelial cells Heat stimulating cells Cold C5a Radiation Lipooxygenase products Chronic inflammation cellular Lymphokines infiltrate Monokines Monocyte/macrophage Lymphocyte Fibrocytes/fibroblasts Endothelial cells
    147. 147. Inflammation (Cont’d) • Chronic inflammation • Not self-limiting • Must be resolved and replaced by acute inflammation for healing to occur • Production of specific antibodies or cell-mediated immunity
    148. 148. Local Effects of Inflammation • Effusion • General term referring to the escape of fluid into a compartment or tissue (edema) • Exudate • Any fluid that filters from the circulatory system into lesions or areas of inflammation • Serous exudate • Watery, generally clear, contains small amounts of protein and white blood cells (common with allergies, runny nose, etc.) • Fibrous exudate • Thick and sticky, high cell and fibrin content
    149. 149. Local Effects of Inflammation• Purulent exudate • Thick , yellow-green in color, contain leukocytes, cell debris and microorganisms. (Bacterial infection, referred to as ―pus‖)• Abscess • Localized pocket of purulent exudate in a solid tissue (around a tooth, in the brain)• Hemorrhagic exudate • Blood, present if blood vessels are damaged
    150. 150. Systemic Effects of Inflammation • Fever – pyrexia • Common if inflammation is extensive. If caused by infection, fever can be severe depending on the microorganism. • High fever can be beneficial. Impairs the growth and reproduction of pathogenic organisms. • Caused by release of pyrogens – fever producing substances • Pyrogens circulate in blood, cause hypothalamus to reset temperature control system at higher level • Malaise • Feeling unwell, fatigue, headache • Anorexia • Loss of appetite
    151. 151. Potential Complications ofInflammation• Infection • Microorganisms can more easily penetrate edematous tissues.• Deep ulcers • Result of severe or prolonged inflammation• Skeletal muscle spasm • Protective response to pain• Local complications • Depend on site of inflammation but may include obstruction, loss of sensation, and decreased cell function
    152. 152. Granulation Tissue
    153. 153. Absence of Granulation Tissue
    154. 154. Danger Signs • Base of wound becomes increasingly moist, changes from healthy red or pink to yellowish or grey tissue • Discharge changes from clear to purulent • Unpleasant odor is present
    155. 155. The Healing Process • Epithelial cells are activated, undergo mitosis and extend across the wound from the outside edges inward • Fibroblasts enter and produce collagen (basic component of scar tissue) • Fibroblasts and macrophages produce growth factors (cytokines), stimulate epithelial cell growth, development of new blood vessels (angiogenesis)
    156. 156. The HealingProcess
    157. 157. Wound Healing
    158. 158. The Healing Process • Healing by first (primary) intention • Clean wound, free of foreign material and necrotic tissue, edges are held close together, minimal gap between edges • Healing by second (secondary) intention • Large break in tissue, more inflammation, longer healing period, formation of more scar tissue
    159. 159. Fracture Healing • Immediate vascular response with hematoma and inflammation • Granulation tissue and fibrocartilage formation – soft callus • Bony callus replaces soft callus to immobilize the fracture site • Repair – bone union occurs when hard callus replaces soft callus • Non-union occurs without proper immobilization • Remodeling occurs until the bone returns to normal • Time frame varies – minimum 6 weeks
    160. 160. Tendon and Ligament Injury• Sprain • Stretching or tear in a ligament• Strain • Stretching or tear in a musculotendinous unit• Tear – inflammation – granulation tissue – collagen - repair
    161. 161. Tendon and Ligament Injury• Most tendons and ligaments require surgical intervention• Adhesions are common• Aggressive motion and muscle contraction should be avoided after surgical repair for at least 8 weeks• High rate of impaired function, re-injury, joint osteoarthritis
    162. 162. Tendon and Ligament Injury• Not all heal at the same rate• ACL does not heal as well as the MCL• Tensile strength is only 50-70% of original strength 1 year later• Torn ligament ends must be in contact with each other to heal
    163. 163. Tendon and Ligament Injury• Surgical vs. nonsurgical • Depends on degree of injury • Involvement of supporting tissues • Heal by way of scar tissue proliferation and not ligament regeneration • Untreated ligament tears are biomechanically inferior
    164. 164. Tendon and Ligament Injury• Progressive, controlled stress must be applied to the healing tissues during healing• However, must be protected against excessive forces during remodeling phase
    165. 165. Tendon and Ligament Injury• Grades of Injury • Grade I: microscopic tearing of the ligament without producing joint laxity • Grade II: Tearing of some ligament fibers with moderate laxity • Grade III: complete rupture of the ligament with profound instability and laxity
    166. 166. Tendon and Ligament Injury• Grades of Injury • Grade I and II are most common • Can be treated with protective bracing and rehab with strengthening to provide dynamic muscular support and proprioception • Usually good to excellent results anticipated in 90% of cases treated non-surgically
    167. 167. Tendon and Ligament Injury• Grades of Injury • Grade III • 15% of all knee sprains • Frequently requires repair of associated tissues • Cartilage (meniscus) and MCL, LCL, or PCL injury often seen with ACL grade III injury
    168. 168. Ligament andTendon Injury– Phases ofHealing• Inflammatory phase 3-5 days• Proliferative phase 2-3 weeks • Protection, immobilization, irregular collagen formation• Maturation phase and remodeling occur around 3 weeks post injury • Irregular and immature collagen replaced by mature collagen aligned along lines of stress• Final phase - 8-12 weeks • Maximum muscle contraction forces should be avoided for at least 8 weeks
    169. 169. Tendon and Ligament Injury -Treatment• For a Grade 1-2 sprain, use R.I.C.E (rest, ice, compression and elevation):• Rest your ankle with weight bearing as tolerated• Ice should be immediately applied. It keeps the swelling down.• Compression dressings, bandages or ace- wraps immobilize and support the injured ankle.• Elevate your ankle above your heart level for 48 hours.
    170. 170. Tendon and Ligament Injury -Treatment• For a Grade 3 sprain/strain• Treatment similar to grade 2 but over a longer period• Remodeling can take 8-12 weeks (some reports say 16 weeks) before higher levels of stress can be applied• May require surgical reconstruction• Normal strength 40-50 weeks postoperatively
    171. 171. Ligament Sprain
    172. 172. Ligament Injury
    173. 173. Ligament Injury - Dislocation
    174. 174. Potential Complications ofInflammation• Chronic, long-term inflammation can stop wound healing, damage DNA and promote neoplasm (cancer)
    175. 175. Treatment of Inflammation • Acetylsalicylic acid (ASA) • Aspirin • Acetaminophen • Tylenol • Non-steroidal anti-inflammatory drugs (NSAIDs) • Ibuprofen • Glucocorticoids • Corticosteroids
    176. 176. Scar Formation • Loss of function • Result of loss of normal cells and specialized structures • Hair follicles • Nerves • Receptors • Contractures and obstructions • Scar tissue is non-elastic • Can restrict range of movement • Adhesions • Bands of scar tissue joining two surfaces that are normally separated
    177. 177. Scar Formation (Cont’d)• Hypertrophic scar tissue • Overgrowth of fibrous tissue • Leads to hard ridges of scar tissue or keloid formation• Ulceration • Blood supply may be impaired around scar • Results in further tissue breakdown and ulceration at a future time
    178. 178. Complications of Scar Tissue
    179. 179. Factors Promoting Healing • Youth • Good nutrition: protein, vitamins A and C • Adequate hemoglobin • Effective circulation • Clean, undisturbed wound • No infection or further trauma to the site
    180. 180. Factors Delaying Healing • Advanced age (reduced cell development, mitosis) • Poor nutrition, dehydration • Anemia (low hemoglobin) • Circulatory problems • Presence of other disorders such as diabetes or cancer • Irritation, bleeding, or excessive mobility • Infection, foreign material, or exposure to radiation • Chemotherapy treatment • Prolonged use of glucocorticoids
    181. 181. Implications for the PTA • Inflammation is necessary for healing but must be controlled for recovery to proceed • Edema causes muscle inhibition so must be effectively treated • Client education needed regarding weight bearing and activity level to promote healing
    182. 182. Implications for the PTA• Prevention of re-injury• Understanding healing time-lines• Immobilization followed by mobilization, DVT assessment• Modalities: pain control• Physician approved surgical protocols
    183. 183. Case Study • M.H., age 6, fell while running down stairs and hurt his wrist and elbow. His are was scraped and bleeding slightly, and the elbow became red, swollen, and painful. Normal movement was possible, although painful. • 1. Explain why the elbow is red and swollen. • 2. Suggest several reasons why movement is painful. • 3. State two reasons why healing may be slow in this scraped area on the arm, and two factors that encourage healing in this boy.
    184. 184. Pathology for the PTA Chapter 4 The Immune System
    185. 185. Objectives• Compare/ contrast the different types of immunity• Discuss the effect of physical activity and exercise on the immune system• Compare immunodeficiency diseases
    186. 186. Immunology• The study of the physiologic mechanisms that allow the body to recognize materials as foreign and to neutralize or eliminate them.• The immune system protects the body from infection and disease• Excessive immune system activity can result in hypersensitivity (i.e. allergies)
    187. 187. Immunity• Natural (innate) immunity • Species specific • The viruses that cause leukemia in cats or distemper in dogs dont affect humans. Innate immunity works both ways because some viruses that make humans ill — such as the virus that causes HIV/AIDS — dont make cats or dogs sick
    188. 188. Active or Passive Immunity• Active innate immunity • Natural exposure to pathogen—chicken pox • Development of antibodies or immunoglobulins• Active artificial immunity • Pathogen purposefully introduced to body • Stimulation of antibody production • Immunization----measles • Booster immunization
    189. 189. Immunity (Cont’d)• Passive innate immunity • Transferred from mother to fetus • Across placenta • Through breast milk • Protection of infant for the first few months of life or until weaned• Passive artificial immunity • Injection of antibodies----antiserum • Short-term protection
    190. 190. Immunity (Cont’d)• Primary immune response • First exposure to antigen • 1 to 2 weeks for antibody titer to be effective• Secondary immune response • Repeat exposure to the same antigen • More rapid response with effectiveness in 1 to 3 days
    191. 191. Components of the Immune System• Lymphoid structures • Lymph nodes • Spleen • Tonsils • Intestinal lymphoid tissue • Lymphatic circulation• Immune cells • Lymphocytes • Macrophages
    192. 192. Componentsofthe ImmuneSystem
    193. 193. Components of the Immune System (contd)• Tissues involved in immune cell development • Bone marrow • Origination of immune cells • Thymus • Maturation of immune cells
    194. 194. Components of the Immune System (Cont’d)• Spleen – large lymphatic organ • Generates response to bloodborne antigens • Removes foreign matter and old or defective blood cells• Lymph vessels – filters fluids to lymph nodes
    195. 195. Components of the Immune System (Cont’d)• Lymph nodes • Help body recognize and fight germs, infections, and other foreign substances, dependent on type of problem and body parts involved. Contain lymphocytes• Tonsils • Part of the immune system to filter germs, bacteria and viruses when they enter the body through the nose and mouth
    196. 196. Components of the Immune System(Cont’d)• Thymus • Responsible for development of T lymphocytes (T cells)• Bone Marrow • Source of stem cells, leukocytes, and the maturation of B lymphocytes (B cells)• Lymphocyte • WBC, determine the immune response to foreign substances (B and T cells)
    197. 197. Pathogen• Infectious organism that causes disease• Recognized as being foreign by the body• Single celled microorganisms • Virus • Bacteria • Yeast – unicellular fungus• Multicellular parasites • Fungi • Worms
    198. 198. Pathogen • Antigen • Protein on the surface of a cell • Pathogens have antigens on their surface • Antigens trigger the immune response and the production of antibodies
    199. 199. Pathogenesis • How pathogens (infectious organisms) cause disease • Secretion of toxins • Endotoxins • Direct killing of host cells • Physical blockage
    200. 200. Pathogenesis • Secretion of toxins • Bacteria produce toxins which cause pathology and disease • Neurotoxin from Clostridum bacteria causes tetanus • Shigalla dysenteria bacteria causes dysentery
    201. 201. Pathogenesis • Endotoxins • Located in cell wall of pathogens • Cause fever, lower blood pressure, inflammation • Direct killing of host cells • Replication within the cell by pathogens can kill the cell, causes release of replicated pathogens to infect other cells • Physical blockage • Size of pathogen can block tissues
    202. 202. Pathogenesis Pathogenesis of Rheumatoid Arthritis
    203. 203. How Does the Body Fight Pathogens?
    204. 204. Immunoglobulins—Y shaped proteins• IgG – most common antibody in the blood, crosses placenta producing passive immunity in newborn• IgM – bound to B lymphocytes, forms natural antibodies, first antibody secreted by B cells• IgA – found in tears, saliva, colostrum, provides protection for newborn• IgE – Binds to mast cells, causes release of histamine resulting in inflammation• IgD – attached to B cells, activates B cells (Humoral Immunity)
    205. 205. Cells - Macrophage• Macrophage – mature from monocytes • Means large eaters • Essential first step in immune system is engulfment of pathogen by macrophage • Pathogen is introduced to lymphocytes by macrophage
    206. 206. Cells - Lymphocytes• Primary cells of the immune system are Lymphocytes• B Lymphocytes • Responsible for production of antibodies - humoral immunity (immunoglobulins) • Mature in bone marrow • Become plasma cells producing specific antibodies • B-memory cells are also formed and provide repeated production of antibodies
    207. 207. Cells - Lymphocytes (Cont’d)• T-Lymphocytes • From bone marrow stem cells • Further differentiation in thymus • CMI – cell mediated immunity • T-killer cells –cytotoxic, release enzymes or chemicals to destroy foreign cells • Helper T cells – activate B and T cells, control or limit specific immune response • Memory cells – remember antigen and quickly stimulate immune response on re-exposure
    208. 208. Development of Cellular and Humoral Immunity
    209. 209. The Immune System • EMg
    210. 210. Factors That Alter Immunity • Aging • Sex and hormonal influences • Nutrition and malnutrition • Environmental pollution • Exposure to toxic chemicals • Trauma • Sleep disturbances
    211. 211. Factors That Alter Immunity • Presence of concurrent illness and diseases: • Malignancy • Diabetes mellitus • Chronic renal failure • Human immunodeficiency virus (HIV) infection • Medications, immunosuppressive drugs • Hospitalization, surgery, general anesthesia • Splenectomy • Stress, psycho spiritual well- being, socioeconomic status
    212. 212. What does this have to do with PTA?
    213. 213. Implications for the PTA • Intense or strenuous exercise may be detrimental to the immune system in young subjects • It takes 6 to 24 hours for the immune system to recover from the acute effects of severe exercise • A lifetime of moderate exercise and physical activity enhances immune function
    214. 214. Implications for the PTA • Intense or strenuous exercise has no detrimental effect on immune function or rate of infections in older adults. • Relatively intense exercise programs may be prescribed to maximize cardiopulmonary and musculoskeletal function without impairing immune function in frail elderly people. • Intense exercise during any infections episode should be avoided
    215. 215. Immunodeficiency• Partial or total loss of one or more immune system components• Increased risk of infection and cancer
    216. 216. Immunodeficiency (Cont’d) • Primary deficiencies • Basic developmental failure somewhere in the system • Secondary or acquired immune deficiencies • Loss of the immune response due to specific causes • Can occur at any time during the lifespan • Infections, splenectomy, malnutrition, liver disease, immunosuppressant drugs, radiation, chemotherapy (cancer)
    217. 217. Immunodeficiency (Cont’d) • Predisposition to the development of opportunistic infections • Caused by normal flora • Usually difficult to treat due to immunodeficiency • Prophylactic antimicrobial drugs may be used prior to invasive procedures
    218. 218. Acquired Immunodeficiency Syndrome(AIDS)• AIDS – chronic infectious disease caused by the human immunodeficiency virus (HIV)• HIV destroys helper T-cells - lymphocytes• Loss of immune response• Increased susceptibility to secondary infections and cancer• Development may be suppressed by antivirals
    219. 219. AIDS (Cont’d)• HIV positive • Virus is known to be in the body. • No evidence of immune suppression• AIDS • Marked clinical symptoms, multiple complications• Individual is often identified as HIV positive before the development of AIDS. • Current therapies start if HIV infection is diagnosed in the early stages.
    220. 220. Clinical Manifestations of AIDS • Musculoskeletal • Myalgia and arthralgia • Musculoskeletal pain and wasting • Pelvic pain • Tuberculosis • Delayed healing
    221. 221. Clinical Manifestations of AIDS • Cardiopulmonary • SOB • Cough • Frequent infections of respiratory system • Cardiomyopathy • Integumentary • Alopecia • Basal cell carcinoma • Mucocutaneous ulcers • Rash • Delayed wound healing
    222. 222. Clinical Manifestations of AIDS • Neurologic and Neuromuscular • HIV encephalitis: • Gait disturbance • Intention tremor • Dementia • Behavioral: Apathy, lethargy, social withdrawal, irritability, depression • Cognitive: Memory impairment, confusion, disorientation • Motor: Ataxia, leg weakness, los of fine motor, incontinence, paraplegia • Radiculopathy
    223. 223. Treatment of AIDS• No cure• Antiviral drugs reduce the replication of viruses but do not kill the virus (AZT)• Frequent mutations require ―cocktails‖ of additional drugs• HAART therapy (highly active antiretrovirus therapy)• With treatment, the prognosis is much improved, decades• Without treatment, death occurs within several years
    224. 224. AIDS
    225. 225. Implications for the PTA • Primary role of Physical Therapy is assisting the patient with the management of physical dysfunctions common with this chronic disease • Strength training • ADL and energy conservation • Treatment of neuropathy or radiculopathy • Balance and gait training • Body mechanics and posture • Breathing exercises • Individualized exercise based on stage of disease
    226. 226. Implications for the PTA• Hand washing, standard precautions, disinfection important for all patients• Critical for the immuno-deficient patient • Pulmonary complications common • Susceptibility to infection • Often debilitated and easily fatigued• Frequent mobility and body positioning enhance gas respiration and promote comfort while maintaining strength• Individualized programs
    227. 227. Chronic Fatigue Syndrome (CFS)• Result of a combination of factors• Unexplained fatigue of greater than 6 months• Thought to be result of neuroendocrine system abnormality• No known cure
    228. 228. Implications for the PTA • Monitor vital signs • Because blood pressure and pulse remain low • Avoid overexertion, reduce stress, gentle stretching • Borg Scale of Perceived Exertion can be helpful in grading exercises at the sub-maximal level
    229. 229. Borg Rate Perceived Exertion Scale • 6 No exertion at all • 7 Extremely light (7.5) 8 • 9 Very light • 10 • 11 Light • 12 • 13 Somewhat hard • 14 • 15 Hard (heavy) • 16 • 17 Very hard • 18 • 19 Extremely hard • 20 Maximal exertion 9 corresponds to "very light" exercise. For a healthy person, it is like walking slowly at his or her own pace for some minutes 13 on the scale is "somewhat hard" exercise, but it still feels OK to continue. 17 "very hard" is very strenuous. A healthy person can still go on, but he or she really has to push him- or herself. It feels very heavy, and the person is very tired. 19 on the scale is an extremely strenuous exercise level. For most people this is the most strenuous exercise they have ever experienced.
    230. 230. Hypersensitivity Reactions (Cont’d)  Type I hypersensitivity – allergic reactions (Cont’d)  Hay fever/allergic rhinitis • Nasal mucosa  Food allergies • Digestive tract mucosa  Atopic dermatitis/eczema • Skin  Asthma • Bronchial mucosa
    231. 231. Type I Hypersensitivity (Allergy)
    232. 232. Anaphylaxis/Anaphylactic Shock• Severe, life-threatening• Systemic hypersensitivity reaction• Decreased blood pressure due to release of histamine• Airway obstruction• Severe hypoxia• Can be caused by: • Latex materials • Insect stings • Nuts or shellfish; various drugs
    233. 233. Anaphylaxis (Cont’d) • Signs and symptoms • Generalized itching (pruritus)or tingling especially in oral cavity • Coughing • Difficulty breathing • Feeling of weakness • Dizziness or fainting • Sense of fear and panic • Edema around eyes, lips, tongue, hands, feet • Hives • Collapse with loss of consciousness
    234. 234. Signs and Symptoms of Anaphylaxis
    235. 235. Treatment for Anaphylaxis • Requires first aid response: • Administer EpiPen if available • Call 911 (many paramedics can start drug treatment and oxygen) • Treatment in Emergency Department: • Epinephrine • Glucocorticoids • Antihistamines • Oxygen • Stabilize BP
    236. 236. Type II – Cytotoxic Antibody-DependentHypersensitivity• Blood typing depends on the particular glycoprotein• 3 variants A, B and O• Individual can be O, A, B, or AB• Will have antibodies to the type of glycoprotein they do not have
    237. 237. Type IV – Cell-Mediated or DelayedHypersensitivity• Occurs only after exposure to antigen• Delayed response by sensitized T-lymphocytes• Release of lymphokines - help regulate the immune system and activate macrophages• Inflammatory response• Destruction of the antigen• Examples: • Tuberculin test • Contact dermatitis • Allergic skin rash
    238. 238. Autoimmune Disorders• Development of antibodies against own cells/tissues• Auto-antibodies are antibodies formed against self- antigens – loss of self-tolerance• Disorder can affect single organs or tissues or can be generalized
    239. 239. Autoimmune Disorders Organ Specific Disorders Systemic Disorders Addison’s disease Amyloidoisis Crohn’s disease Ankylosing spondylitis Chronic active hepatitis Multiple sclerosis Diabetes mellitus Myasthenia gravis Hemolytic anemia Polymyalgia rheumatica Thrombocytopenia Scleroderma Polymyositis, Psoriasis dermatomyositis Reiter’s syndrome Postviral Rheumatoid arthritis encephalomyelitis Sarcoidosis Primary biliary cirrhosis Systemic lupus Thyroiditis erythematosus (SLE) Graves’ disease Hashimoto’s disease Ulcerative colitis
    240. 240. Systemic Lupus Erythematosus (SLE) • Chronic inflammatory disease • Affects a number of organ systems • Characteristic facial rash – ―butterfly rash‖ • Affects primarily young women • Incidence is higher in African Americans, Asians, Hispanics, Native Americans
    241. 241. ―Butterfly Rash‖ Associated with SLE
    242. 242. ―Butterfly Rash‖ Associated with SLE Rash can vary from a rosy blush to thickened epidermis with scaly patches
    243. 243. SLE (Cont’d)• Signs and symptoms vary due to organ involvement but commonly include: • Arthralgia, fatigue, and malaise • Cardiovascular problems • Polyuria – increased production of urine• Diagnostic test • Serum antibodies; other blood work• Treatment • Usually treated by a rheumatologist • Prednisone (glucocorticoid) • Non-steroidal anti-inflammatory drugs
    244. 244. Implications for the PTA • Functional limitations of patients with SLE vary according to severity of the disease • Exercise may be limited during exacerbation of disease • Gradual resumption of activities must be balanced with rest periods • Energy conservation, pacing of activities • Joint protection • Prevention of skin breakdown • Observe for complications of high dose corticosteroids – avascular necrosis of hip, knee
    245. 245. Fibromyalgia • Disorder characterized by pain and stiffness affecting muscles, tendons, and surrounding soft tissues • Eighteen specific tender or trigger points • No obvious signs of inflammation or tissue degeneration
    246. 246. Fibromyalgia
    247. 247. Fibromyalgia• Diagnosis made after elimination and review of medical history• Patients often told their pain is ―all in their head‖• Chronic and complex condition often recognized in physical therapy after multiple prior interventions
    248. 248. Implications for the PTA • Primary treatment for fibromyalgia is exercise (to tolerance) • Increased cardiovascular fitness has been shown to decrease pain and improve function • Stretching exercises reduce fatigue • Aquatic therapy often very helpful • May initially require short exercise sessions with the goal of 30 minutes daily • Avoid pushing through the pain
    249. 249. Autoimmune disorders•
    250. 250. Autoimmune Disorders (cont’d) RA Joint Protection
    251. 251. Challenge Question • Explain three reasons why the immune system might not respond correctly to foreign material in the body. The immune system does not recognize the foreign material: • Deficit of lymphocytes, stem cells or macrophages • Antibody is not produced • Lymphoid tissue is damaged • Genetic immune deficiency is present