Exam 2 Breakdown and Recap PDF

exam two  PREVIOUS MATERIAL Inflammation - 1 question Integumentary System - 1 question Cardiovasc...

exam two  PREVIOUS MATERIAL Inflammation - 1 question Integumentary System - 1 question Cardiovascular System - 3 questions Lymphatic System - 2 questions Respiratory System - 3 questions Immune System - 2 questions breakdown Hematologic System - 1 questions Renal System - 2 questions LECTURE 6 50 Multiple Choice Questions from Endocrine System - 12 questions Lectures 1 - 7 Metabolic System - 5 questions GI System - 2 questions 70% Lectures 6 and 7 30: Lectures 1-5 LECTURE 7 Hepatobiliary System - 8 questions Oncology - 8 questions  Normal Endocrine Physiology (to be able to recognize a problem) ENDOCRINE SYSTEM Impact of Aging study recap Major Glands/Hormones Endocrine Health Conditions including differentiating signs, symptoms, and risk factors NOTE: Pay attention to the "Pop Up Physios" when you're studying! Endocrine Anatomy A ND Anterior Pituitary: C ES D U S ES Produces AND Releases: O A PR ELE nes Adrenocorticotropic Hormone R m o r Ho (ACTH) Thyroid Stimulating Hormone (TSH) Luteinizing Hormone (LH) Follicle Stimulating Hormone (FSH) Human Growth Hormone (HGH) STO RE Prolactin (PRL) RE S LEA AND Ho SES rm one s Posterior Pituitary Stores and Releases Antidiuretic Hormone (ADH) Oxytocin (OXY) Key Signs and Symptoms of Endocrine Dysfunction Neuromusculoskeletal Systemic Rheumatoid-like symptoms Excessive or delayed growth Myalgia Polydipsia/Polyruria Arthralgia Altered mental status Fartigue Changes in hair, skin, and Pseudogout body fat distribution PROXIMAL WEAKNESS Changes in vital signs BILATERAL SIGNS Sweating CARPAL TUNNEL Dehydration or fluid retention ADHESIVE CAPSULITIS Hyperpituitarism Oversecretion of one or more hormones Growth Hormone Typically caused by benign Acromegaly pituitary tumors: Gigantism PITUITARY ADENOMAS Adrenocorticotropic Hormone (ACTH) Cushing Disease Thyroid Stimulating Hormone Pituitary tumors will also produce Hyperthyroidism symptoms as they expand within the skull: Prolactin BLURRED VISION Amenorrhea/Galactorrhea/ Gynecomastia Visual Field abnormalities Headaches Somnolence Hypopituitarism Undersecretion of one or more hormones Panhypopituitarism and Dwarfism Generalized condition caused by partial or total failure of all 6 anterior pituitary hormones (ACTH, TSH, FSH, HGH, PRL) Causes: Hypophysectomy Nonsecreting pituitary tumors Postpartum hemorrhage Reversible functional disorders Starvation, anorexia, severe anemia, GI tract disorders  Arthritis in the hands and spine is common Osteophytes and increased joint space from Excess Growth Hormone thick cartilage Stenosis and chondrocalcinosis CTS (bilateral) About half of individuals with acromegaly have In CHILDHOOD In ADULTHOOD back pain - large osteophytes along the anterior longitudinal ligament Pituitary Gigantism Acromegaly Overgrowth of the long bones Increased bone thickness and hypertrophy of Occurs before epiphyseal plates close soft tissue Timely diagnosis and treatment are imperative Develops slowly, after epiphyseal closure Increased mortality with elevated GH or IGF-1 Mostly affects face, jaw, hands, and feet QOL is often reduced Coarse facial features and prognathism, Treated surgically, with drugs, and/or thickened ears, nose, tongue; broad hands radiation Headache, diplopia, blindness, lethargy Develops abruptly Myopathy and reduced exercise tolerance May be associated with other hormonal Osteoarthritis, Chondrocalcinosis, CTS, back changes pain Hyperthyroidism Most common form is GRAVE’S DISEASE Key Symptoms: CNS - tremors, proximal weakness/atrophy, increased DTRs, fatigue Increases T4 production CV - tachycardia, palpitations Untreated, can lead to THYROID STORM MS - atrophy, chronic periarthritis Integumentary - heat intolerance, nail changes, hair loss Potentially fatal Ocular - exophthalmos, eye muscle weakness High fever, severe tachycardia, delirium, GI - weight loss w/ increased appetite, N/V/D, Dysphagia (from goiter) GU - Polyuria, amenorrhea, female infertility dehydration, AMS Treatment Options: Antithyroid medication Radioactive Iodine Surgery Prognosis with treatment is good, but requires lifelong followup Hypothyroidism Deficiency of thyroid hormone in adults that Key Symptoms: results in generalized slowed body CNS - slow speech, hoarseness, slow mental functions, fatigue, metabolism headache, cerebellar ataxia, anxiety, depression CV - bradycardia, poor circulation, CHF, severe atherosclerosis Most common disorder of thyroid function in MS - proximal weakness, myalgia, trigger points, stiffness, CTS, the US and Canada decreased DTR Integ - myxedema, thick/cool/dry/scaly skin, cold intolerance, nonpitting edema, poor healing, thin/brittle nails Hematologic - anemia, easy bruising During early treatment, patients may have pseudogout GI - anorexia, constipation, weight gain GU - infertility, menstrual irregularity, menorrhagia Take caution with manual techniques due to fragile skin Respiratory - dyspnea, respiratory muscle weakness If cardiac symptoms have occurred, thyroid hormone dosage must start low and increase slow Treatment Options: Synthetic thyroid hormone Exercise tolerance may be poor Prognosis with treatment is good, especially when caught early; worse once cardiovascular symptoms and myxedema appear Hashimoto’s Thyroiditis Painless, symmetric or asymmetric Autoimmune basis, genetic predisposition enlargement of thyroid Destruction of thyroid gland due to May put pressure on surrounding structures lymphocytes and antithyroid antibodies Most have normal thyroid levels TSH is elevated --> goiter formation 20% are hypothyroid 5% are hyperthyroid (combined Treatment Hashimoto’s and Grave’s) Medication to suppress TSH and correct hypothyroidism Primary Adrenal Insufficiency Primary Insufficiency Key Symptoms Disorder within the adrenal glands causing insufficient cortisol Hypoglycemia and liver glycogen deficiency and aldosterone release Anorexia/Weight loss Known as ADDISON’S DISEASE Nausea/Vomiting Not very common Bronzed/tanned skin in people with lighter skin, slate gray skin in people with darker skin Secondary Insufficiency Hypotension and dehydration Suppression of ACTH by steroid therapy Arrhythmias (from hypokalemia) and possible cardiac arrest Rapid withdrawal of steroid drugs can be life threatening Symptoms are different because only cortisol is impacted Treatment Replace fluids, electrolytes, glucose and cortisol Pathophysiology Synthetic corticosteroids and mineralocorticoids Decreased production of cortisol and aldosterone --> Fatal if untreated metabolic disturbances No feedback for pituitary to stop making ACTH and MSH --> Initially, exercise tolerance is very poor - progress very gradually skin pigmentation Aquatic therapy is CONTRAINDICATED due to demand for cortisol Aldosterone deficiency --> fluid and electrolyte imbalances Vitals need to be monitored closely Secondary Adrenal Insufficiency Secondary Insufficiency Key Symptoms Suppression of ACTH by steroid therapy Arthralgias Rapid withdrawal of steroid drugs can be life threatening Myalgias Symptoms are different because only cortisol is impacted Tendon calcification Pathophysiology Treatment Caused by other conditions outside the adrenals Synthetic corticosteroids and mineralocorticoids Hypothalamic or pituitary tumors Hypophysectomy Hypopituitarism Rapid withdrawal of corticosteroid drugs Long-term exogenous use of corticosteroids Adrenocortical Hyperfunction - Cushing Adipose deposits primarily in the face, neck, and trunk Cushing Syndrome Key Symptoms Adrenal hyperfunction Persistent hyperglycemia - “steroid diabetes” Weakness, fragile capillaries (easy bruising) Excess corticosteroid medication Osteoporosis Cushing Disease Potassium depletion - hypokalemia, arrhythmias Sodium/Water retention - Edema and hypertension Excess ACTH stimulation Hypertension - Left ventricular hypertrophy, CHF, CVA Abnormal fat distribution - Moon-shaped face, dorsocervical fat Pituitary adenoma pad (Buffalo hump), truncal obesity w/ slender limbs, stretch marks Increased infection risk - poor wound healing Mental changes Treatment Restore hormone balance Pituitary irradiation, drug therapy, or surgery High-protein diet to combat muscle wasting Lifelong glucocorticoid replacement if pituitary resected Prognosis depends on cause and ability to control cortisol levels Obesity Definition: An excessive accumulation of fat that contributes to numerous chronic diseases as well as early mortality and morbidity Clinical Manifestations Metabolic Syndrome Waist > 40 in in men, and > 35 in in women High Triglycerides: > 150 mg/dL Low HDLs: < 40 in men, < 50 in women Elevated blood sugar: > 100 mg/dL High blood pressure: > 130/85 mmHg Type 2 DM Liver diseases Osteoarthritis Sleep apnea Atherosclerosis, HTN, Cardiovascular diseases Stroke Asthma - difficulty taking deep breaths Cancer Lymphedema Impaired mobility Obesity - Considerations for Exercise Angina pectoris or MI Excessive rise in BP Aggravation of degenerative arthritis and other joint problems Ligamentous injuries Injury from falling Excessive sweating Skin disorders, chafing Hypohydration and reduced circulating blood volume Heat stroke or heat exhaustion Diabetes Types: Type I: evidence of autoimmune process in the islet cells plus genetic markers Prone to ketoacidosis Require exogenous insulin Cell-mediated autoimmune destruction of beta cells (Decreased utilization of glucose) Increased fat mobilization Impaired protein utilization Type II: combo of cellular insulin resistance and inadequate insulin secretion Usually controlled w/ diet, exercise, and oral hypoglycemic agents Endogenous insulin production is normal, but difficulty utilizing insulin at the cellular level Medications prevent hyperglycemia Associated with obesity and sedentarism Diabetes - Clinical Manifestations Clinical Manifestations Pathophysiologic Bases POLYURIA (excessive urination) Water not reabsorbed from renal tubules because of glucose in the tubules Types 1 and 2 POLYDIPSIA (excessive thirst) Polyuria causes dehydration, which causes thirst Types 1 and 2 POLYPHAGIA (excessive hunger) Starvation from tissue breakdown Type 1 WEIGHT LOSS Glucose not available to cells so body breaks down fat and protein Type 1 RECURRENT BLURRED VISION Chronic exposure of lenses and retina to hyperosmolar fluids Types 1 and 2 KETONURIA Fatty acids broken down so ketones in urine Type 1 WEAKNESS, FATIGUE, DIZZINESS Dehydration --> postural hypotension; energy deficiency Types 1 and 2 OFTEN ASYMPTOMATIC Physical adaptation because rise in blood glucose is gradual Type 2 Diabetes - Hypo and Hyperglycemia Signs Diabetes - Complications Atherosclerosis Hyperglycemia --> fat metabolism --> fat accumulation in vessels Cardiovascular and cerebrovascular changes Cardiovascular Disease Retinopathy and Nephropathy Exercise may be protective NO HIGH INTENSITY OR PLYOMETRICS Infection - Poor wound healing UE Reduced joint mobility and contractures (usually flexor) Bilateral Carpal Tunnel and/or Frozen Shoulder (RED FLAG) CRPS Spine - hyperostosis Arthritis and Osteoporosis Sensory, Motor, and Autonomic Neuropathies Pressure Injuries Cognitive decline Diabetes - PT Implications Exercise is a key component Patients must assess glucose before and after (and figure out how much to eat) With neuropathy - high incidence of injuries (falls, fractures, sprains, cuts, bruises) Resistance exercise has the biggest effect on glycemic control Signs and Symptoms of Hypoglycemia Pale, Sweaty, Goosebumps, Tachycardic, Palpitations, Nervousness, Weakness, Shakiness, Hunger, Headache, Blurred Vision, Slurred Speech, Numbness, Confusion Potential Risks of Exercise Hypoglycemia Worsening hyperglycemia MI, arrhythmia, excessive rise in BP during exercise, post-exercise orthostasis Microvacular disease like retinal hemorrhage or increased proteinuria Degenerative joint disease Orthopedic injury related to neuropathy  METABOLIC Basic Metabolic Physiology SYSTEM (to be able to recognize a problem) study recap Metabolic Bone Conditions including differentiating signs, symptoms, and risk factors NOTE: Pay attention to the "Pop Up Physios" when you're studying! Osteoporosis Clinical Manifestations Loss of height Pathogenesis Postural changes Bone strength depends on bone DENSITY and bone Severe kyphosis Coughing and sneezing can QUALITY Back pain - low back and rhomboids cause compression fractures in osteoporotic bone Density: how many bone cells per square Muscular pain millimeter Trigger points Quality: health of the bone cells Fractures Bone Mineral Density (BMD) Calcium, Phosphate and minerals in the Vertebral compression fractures are meshwork of bony tissues most common Mass of minerals per volume of bone Functional impairment Peak bone mass achieved in the 3rd decade of life Disability If peak is low, OP and fractures are likely Decreased QOL Mechanical stimuli may be the only stimuli capable Treatment of inducing modeling in mature bone Medication This is why activity and exercise are so important PHYSICAL THERAPY Emphasize NEUTRAL AND EXTENSION Most common cause in women is ESTROGEN POSTURES DEFICIENCY Paget Disease Clinical Manifestations Pain - headaches, myalgias, arthritis, radiculopathy Increased bone resorption by osteoclasts and excessive and disorganized formation of new bone by Skeletal - bone pain and deformities osteoblasts Femur is most commonly affected bone Bone marrow gets replaced by vascular/fibrous tissue Kyphoscoliosis is most common deformity Overall result is enlarged bones that are weak, leading to: Neurologic - nerve compression, impaired cognition Deformity CV - increased cardiac output, heart failure Fracture Arthritis, pain Miscellaneous: fatigue, tinnitus, dizziness/vertigo Pathogenesis Exercise Cause is unknown Recommended for people with Paget Disease Considered an osteoclastic disorder, but also heavily Poor joint mechanics due to bone growth can be helped involves osteoblasts via strengthening Unrestrained proliferation of osteoclasts kicks it off Pain from Paget usually leads to sedentary behavior Osteoblasts can’t keep up Multi-dimensional Ex-Rx: stretching, strengthening, Initial resorption stage followed by abnormal endurance, aerobics, balance, and coordination regeneration Therapist involved in management of deformities via New bone is coarse, irregularly thickened, orthotics rough, and pitted GASTROINTESTINAL SYSTEM Impact of Aging study recap GI Health Conditions (GERD) including differentiating signs, symptoms, and risk factors NOTE: Pay attention to the "Pop Up Physios" when you're studying! Gastrointestinal System Gastroesophageal Reflux Disease Aging: Heartburn - burning sensation in stomach ORAL CHANGES: Tooth enamel and dentin wear, and rising into the chest tooth decay and loss, Decreased taste buds, Can radiate to chest, throat, or back Decreased sense of smell, Salivary secretion Typically 30-60 minutes after eating decreased Chest pain UPPER GI CHANGES: Acid regurgitation Reduced stomach acid: Belching Iron malabsorption Dysphagia Small bowel bacterial overgrowth Nausea, Vomiting B12 deficiency Early Satiety Pancreatic secretions reduced LOWER GI CHANGES Older Adults more likely to have Prolonged transit time (reduced atypical/severe symptoms Remain upright at least 3 hours after meals neurotransmitters and receptors) Extra-Esophageal Symptoms: asthma, cough, Can impact PT POC Constipation laryngitis Less diverse microbiata SCHEDULE THERAPY AWAY FROM MEAL TIMES Pro-inflammatory state Lying down usually worsens symptoms  Normal Hepatobiliary Physiology HEPATOBILIARY (to be able to recognize a problem) SYSTEM study Impact of Aging recap Hepatobiliary Health Conditions including differentiating signs, symptoms, and risk factors NOTE: Pay attention to the "Pop Up Physios" when you're studying! Hepatobiliary System - Anatomy LIVER PANCREAS Albumin and plasma proteins Exocrine secretion of digestize enzymes Bile production and pancreatic juices, transported Conversion/excretion of bilirubin through pancreatic duct to duodenum Produces clotting factors Secretion of glucagon and insulin by Stores vitamins islets of Langerhans GALLBLADDER Stores and concentrates bile (reservoir) Expels bile into the duodenum when food is present Bile alkalinizes intestinal contents and emulsifies, absorbs, and digests fat Cholecystokinin causes gallbladder to contract Hepatobiliary System - Aging Decreased response to drugs depending Liver contains many immune cells and on liver function, affecting multiple produces proteins associated with acute systems. inflammatory response. Age-related cell changes impact immunity. Dose must be modified with age Liver function tests (AST, ALT, ALP, GTP, Liver volume decreases 20-40%, and and serum bilirubin) remain unchanged blood flow decreases up to 35% with age Signs and Symptoms of Hepatic Disease GI symptoms Edema/Ascites Any patient with undiagnosed/untreated jaundice Dark urine and Light stools must be referred back to a physician. Right upper quadrant abdominal pain Avoid intense exercise when liver is Skin changes compromised Jaundice (from elevated bilirubin) Bruising Spider angioma & palmar erythema (from elevated estrogen) Neurologic involvement (from ammonia buildup) Confusion Sleep disturbances Muscle tremors Hyperreactive reflexes Asterixis** Musculoskeletal pain - midscapular pain, right shoulder/upper trap/subscap, thoracic, Hepatic osteodystrophy - manifests as osteomalacia/osteoporosis  If underlying cause of jaundice is treated, it Jaundice typically resolves in 4-6 weeks. Once normal coloration returns along with normal stool and urine colors, exercise can Overproduction of Bilirubin be resumed. Hemolysis Reabsorption of hematoma Blood transfusion Decreased Uptake or Conjugation in Bilirubin Metabolism Hepatocyte Dysfunction Hepatitis Chronic Hepatic DIsease Impaired Bile Flow Cholethiasis Primary sclerosing cholangitis Pancreatic cancer Pancreatitis Ascites PT Implications Abnormal accumulation of fluid in the peritoneal cavity Positional intolerances 85% of cases associated with decompensated liver Semi to High Fowler’s positions are cirrhosis usually well tolerated Fluid accumulates due to portal hypertension Breathing techniques Monitor for signs of Spontaneous Signs and Symptoms Bacterial Peritonitis Clinically detectable once more than 500 mL has Edema can mask muscle wasting accumulated Close monitoring of fluid intake/output Weight gain Abdominal distention Increased abdominal girth Peripheral edema Dyspnea when fluid displaces the diaphragm Cirrhosis NOTE: Combination of aerobic and resistance exercise is recommended Chronic, progressive inflammation of the liver Treatments #1 cause: viral hepatitis Based on complications Transplant is best for long-term survival Cycles of inflammation, and healing with Mortality rate is high (life expectancy 6 formation of fibrous bands of connective tissue months or less once decompensated/end-stage liver disease IRREVERSIBLE PT Implications Clinical Manifestations Detecting edema/ascites Interference with liver functions Report any and all signs of blood loss to Processing amino acids, carbs, lipids, and MD immediately vitamins Prevent increased abdominal pressure Metabolizing cholesterol, hormones, High risk for sarcopenia vitamins, meds, and toxins Cirrhosis Look for the following integumentary signs on your patients with history of liver issues: Spider Angiomas Nail changes Dupuytren’s contracture  AVOID Isometric Exercises as Portal Hypertension these are likely to increase abdominal pressure Clinical Manifestations Gastroesophageal Varices Portal: area where blood vessels enter the liver Very serious - accounts for 1/3 of deaths Venous blood from stomach, large and small related to cirrhosis and bleeding intestine, pancreas, and spleen transported via Endoscopy needed for everyone with portal vein to liver cirrhosis to screen Pressure increases when pressure in portal vein Usually treated prophylactically with beta is higher than pressure in inferior vena cava blockers Usually related to cirrhosis Bleeding Structural changes Hyperdynamic vascular responses PT Implications Ultimately, blood backs up in stomach, Portal pressure highest at night, after eating, esophagus, umbilicus, and rectum and with coughing, sneezing, and EXERCISE Engorged vessels Pressure surge can lead to variceal bleeding Varices Interventions to reduce abdominal pressure Bleeding - education for exercise  Any direct contact with infected blood/body fluids requires treatment (immunoglobulin) Enteric precautions required for treating people with Hep A & Hepatitis: Hep E - GOWN and GLOVES Acute or chronic inflammation of the liver from a virus, a chemical, a drug reaction, or alcohol abuse HEP A HEP B HEP C HEP D HEP E 75-85% of acute infections become Coinfection of HBV and HDV Acute, self-limiting Acute infection only; 25% of people with HBV die leads to more acute disease infection; doesn’t progress chronic; 10-20% Morbidity doesn’t progress or prematurely from cirrhosis; progress to cirrhosis; to chronic; High mortality in cause cirrhosis Associated with liver cancer *can only get Hep D if already Associated with liver pregnant women infected with Hep B* cancer Parenteral, sexual contact, Parenteral, vertical, contact with blood Fecal-oral; food and hemodialysis, vertical, Parenteral, Sexual contact, Transmission or open sores Same as Hep A water blood before 1987, perinatal (rare) HEALTHCARE WORKERS organs before 1992 AT HIGH RISK Symptoms Malaise, Fatigue, Mild Fever, Nausea, Vomiting, Anorexia, RUQ discomfort, Diarrhea, Jaundice, Dark urine, Clay-colored stools Supportive care; Acute: supportive prevention with Acute: supportive; Chronic: Treatment Chronic: combination Interferon alfa2a or b None; preventive measures vaccine; most recover interferon and antivirals therapy in 3 months Hep B vaccine can prevent Not in US; vaccine approved Vaccine YES YES NO Hep D in China in 2012  Definitions and Tumor Grading ONCOLOGY Risk Factors, Pathogenesis, study and Clinical Manifestations General and specific to lung, breast, and colorectal recap PT Implications for treatment Impact of Pain and Metastases NOTE: Pay attention to the "Pop Up Physios" when you're studying!  MOST COMMON TYPES OF CANCER Oncology - Definitions Men: prostate, lung/bronchus, colon/rectum Women: breast, lung/bronchus, and colon/rectum Cancer: uncontrolled cell proliferation and spread of abnormal cells Differentiation: Normal cells undergo physical/structural changes as they form body tissues and have different physiologic functions In malignant cells, differentiation is altered Dysplasia: Disorganization in cells in which adult cell varies from its normal size, shape, or organization; Can reverse itself or progress to cancer Metaplasia: First level of dysplasia; reversible and benign (but can progress) Ex. epithelial metaplasia where columnar cells change to squamous Hyperplasia: Increased number of cells, leading to increased tissue mass Can be normal (ex. wound healing) or neoplastic (tumor forming) Tumor: Abnormal growth of new tissue with no useful purpose and can harm the host organism Primary Tumor: arises from cells normally local to the structure Secondary Tumor: metastisized cells from another part of body Cancer - Staging and Grading Staging Carcinoma in situ (premalignant, Stage 0 preinvasive) Early stage, cancer is usually localized Stage I to primary organ Increased risk of regional spread Stage II because of tumor size or grade Local cancer has spread regionally, Stage III but may not be disseminated to distant regions Cancer has spread and disseminated Stage IV to distant sites  PT Role in Pain Management: Cancer - Pain Positioning, Adaptive Equipment, Assistive Devices Gentle functional mobility training NOTE: Most physical agent modalities are contraindicated/not recommended for people with cancer (ultrasound, TENS, heat) PT Considerations for Cancer Pain: Mild to moderate pain: Common Patterns of Pain Referral Hypertension, Tachycardia, Tachypnea Severe or visceral pain may also cause: Pain Mechanism Lesion Site Referral Site Hypotension C7, T1-5 vertebrae Interscapular area, posterior shoulder Bradycardia Shoulder Neck, upper back Nausea, Vomiting Somatic Tachypnea L1, L2 vertebrae SI joint and hip Weakness Hip joint SI and knee Fainting Heart Shoulder, neck, upper back, TMJ Spinal compression Radicular back pain Back, inguinal region, anterior thigh, and Urothelial tract Leg weakness genitals Visceral Change or loss of bowel/bladder control Pancreas, liver, spleen, gallbladder Shoulder, midthoracic, or low back Back pain may precede neuro signs and Peritoneal or abdominal cavity Hip pain from abscess of psoas or symptoms (inflammatory or infectious process) obturator muscle Hepatobiliary obstruction/Liver mets: Anywhere in distribution of peripheral Jaundice with atypical back pain Nerve or plexus nerve Immobility and inflammation can lead to pain Neuropathic Nerve root Anywhere in corresponding dermatome Inflammation can lead to infection, necrosis, Anywhere in region of body innervated and sloughing of tissue CNS by damaged structure  Primary cancers that typically spread to specific bones Cancer - Metastases should serve as red flags during evaluation and treatment of patients with cancer history Site of Mets Symptoms Pulmonary mets are most common of all mets because venous drainage of most of the body is through SVC and IVC into the heart; lungs are the first organ to filter malignant cells Lungs Parenchymal mets are asymptomatic until they obstruct the bronchi or reach parietal pleura (pain fibers) Dry, persistent cough, pleural pain, dyspnea, pleural effusion, hemoptysis Most ominous signs of advanced cancer; filters blood coming from GI tract, so it’s a primary metastatic site for tumors of stomach, Liver colorectum, and pancreas Abdominal and/or RUQ pain, general malaise and fatigue, anorexia, early satiety, weight loss, low grade fevers Bone is one of the three most favored sites of tumor mets (lung, breast, prostate, thyroid, kidney, lymphoma, melanoma) Bone PAIN (deep pain, worse with activity), neurologic symptoms, pathologic fractures Life threatening and emotionally debilitating Brain Increased ICP, obstruction of CSF, change mentation, reduced sensory/motor function Anterior cord compression, nerve root compression, distal weakness and sensory changes, progressive central or radicular Spinal Cord back pain (worse in reclined position, when sneezing, coughing, or Valsalva maneuvering; relieved by sitting; change in bowel/bladder function Lymphatic System Lymphedema Cancer - Exercise Precautions for Survivors Survivors with anemia: Delay exercise until after a medical evaluation Survivors with compromised immune function or marrow transplant Avoid public gyms and other public places until WBC counts are safe This can take a year or more Severe fatigue may prevent exercise Stretch daily 5-min increments of mild activity (like walking) is encouraged Avoid exposure of irradiated skin to chlorine No swimming until medically cleared Survivors with catheters: Avoid water or other microbial exposures Avoid resistance training of muscles that can dislodge catheter Recumbent stationary biking may be better than treadmill walking to survivors with peripheral neuropathies or gait disturbances Lung Cancer - most frequent cause of cancer death in the US Small Cell Rapid growth, early mets Poor prognosis Strongly associated with smoking Non-Small Cell Squamous Cell - slow growth, rare mets; curative treatment is more likely Adenocarcinoma - slow to moderate growth, early mets Large Cell - rapid growth, early and widespread mets Risk Factors Environment - smoking, occupational exposure, radon, vehicle exhaust, air pollution Nutrition Genetics Age Family history Medical history Lung Cancer - Clinical Presentation Early Stage: Similar to pulmonary symptoms associated with smoking - cough, dyspnea, sputum production Lung CA is often an incidental finding on a routine chest x-ray General Symptoms: Persistent cough with hemoptysis and hoarseness Weight loss Shortness of breath Fatigue and weakness Persistent pulmonary infections Small Cell Lung Cancer Non Small-Cell Lung Cancer Obstructed airflow - dyspnea, stridor, wheezing Localized, sharp, severe pleural pain (worse on Persistent, new, or changing cough inspiration, limiting lung expansion) Hemoptysis Cough and dyspnea Chest pain Pleural effusion Paraneoplastic Syndromes PANCOAST TUMORS - invades brachial plexus, phrenic nerve Hormone overproduction Digital clubbing, skin changes, joint swelling Lung Cancer - PT Implications Prehab: Can reduce post-op pulmonary complications Decrease hospital LOS Improve exercise capacity Improve FVC Be on the lookout for: Signs of bone mets - bone pain, back pain, chest, shoulder, arm pain If a PT can’t find a mechanical cause or patient doesn’t progress, return to MD for further workup PANCOAST TUMORS Presents like thoracic outlet syndrome Sharp, pleuritic pain in axilla, shoulder (radiates in ulnar nerve distribution) May also present like subacromial bursitis Breast Cancer Types: Ductal Carcinoma in Situ: confined to the duct; does not always need treatment Invasive Ductal Carcinoma: invades through duct wall into stromal tissue; can mets via lymphatic or circulatory system Invasive Lobular Carcinoma: grows through lobule and spreads; poorly visualized on mammogram (doesn’t form a lump) Inflammatory Breast Cancer: very aggressive, rapidly progressive; cancer cells obstruct lymphatics causing redness and swelling; usually diagnosed at Stage 4 Paget Disease of Breast: rare form of ductal carcinoma with itching, tingling, pain, and rash Pathogenesis Estrogen is the likely the promotor (not the source) of most breast cancers Clinical Manifestations Lumps or increased tissue density typically behind areola or in upper outer quadrant Masses tend to be firm and irregular and painless if carcinoma versus smooth and rubbery if benign As cancer becomes invasive, breast tissue can become fibrotic and fixed causing significant asymmetry Change in contour or texture Nipple changes - discharge, retraction, inversion Local skin dimpling, erythema, rash, or ulceration Swollen axillary lymph nodes Inflammatory breast cancer causes warmth, redness, swelling, itching, and pain Breast Cancer - PT Implications When treating someone with a history of breast cancer: Be alert for signs and symptoms for recurrence or metastasis (new lump or mass, changes near shoulder and lymph nodes) Mets to lymph nodes can cause compression and referred pain to shoulder Bone mets occur in up to 70% of women with advanced breast cancer New onset or increased bone pain, especially at night or with weight bearing should be carefully assessed BP cannot be assessed on the side of mastectomy Side Effects of Cancer Treatment that can impact rehab Chemo: fatigue, nausea, mouth sores, neutropenia, neuropathy, “chemo brain” Radiation: skin redness, blistering, fatigue, tissue scarring, poor wound healing, lymphedema, ischemic heart disease; radiation to left breast more associated with cardiovascular problems Hormone Therapy: decreased bone density, joint pain Post-Operative Considerations Potential complications - pain, sensory changes, infection, necrosis, seroma, hematoma, local swelling Goals - restore ROM, strength, endurance Assess and treat lymphedema (very common if axillary lymph nodes were removed) Exercise During Cancer Treatment - aerobic and resistive exercise during treatment is beneficial Aerobic exercise can maintain functional ability and reduce fatigue (moderate intensity (40-70% of HRmax)) Exercise After Cancer Treatment (recommendations from the American Cancer Society) Avoid inactivity and return to normal daily activities as soon as possible following diagnosis Aim for at least 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week Include strength training exercises at least 2 days per week; emphasize strength training for women treated with adjuvant chemotherapy or hormone therapy Colorectal Cancer Types: Adenocarcinoma: Begins in cells that make and release mucus and other fluids (most common type) Carcinoid: begin in the hormone-producing cells of the intestine GI Stromal: begin on colon wall cells Lymphomas: cancers of immune cells that start in lymph nodes, colon, or rectum Sarcomas: start in muscle and connective tissue in wall of colon (very rare) Clinical Manifestations (unfortunately, few early warning signs - often asymptomatic until metastasis) Common Symptoms Occult blood loss (with anemia and iron deficiency) Melena, Hematochezia Abdominal pain Weight loss Change in bowel habits Bright-red blood from the rectum is a cardinal sign, but needs further assessment to rule out other causes Liver Mets - right upper quadrant pain Abdominal bloating Early satiety Intestinal obstruction, GI bleeding, perforation Anemia Ascites Distant mets (to lungs, bone, brain) Colorectal Cancer - PT Implications Impaired posture is common due to adaptive shortening of abdominals after surgery Inability to lie supine Low back pain Altered body mechanics Removal of abdominal/pelvic lymph nodes can cause lymphedema Metastatic Implications Prostate mets - dull, vague, aching pain in sacral or lumbar regions Pulmonary mets - chest, shoulder, arm, or back pain with pulmonary symptoms Liver mets - low back pain and abdominal pain at the same level as the back pain (refer back to MD immediately) Anemia Rehabilitation Can improve QOL, tolerance of cancer treatment and recovery of function Movement to stimulate gastric system and help flow of abdominal contents may begin same day of surgery Pelvic floor PT should be recommended Multi-system approach is recommended