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OVERVIEW OF
PHYSICAL THERAPY ROLE IN
Second Edition 2011
Contents
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Introduction…………………………………………........…..3
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Biological Age Groups and Theories of Aging…….……..….3
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Body Systems Changes in Aging……………….………5
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Assessment of the Geriatric Patient……………….……7
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Balance Disturbance…………………………….……..10
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Geriatric Care…………………………………….……17
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Pressure Sores…………………………………….……23
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Constipation……………………………………………27
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Hypertension...................................................................31
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Orthostatic Hypotension..................................................34
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Introduction
Geriatrics
Geriatrics is the branch of medicine concerned with conditions and diseases of the
aged.
Longevity
It is the average of life span.
Several factors influence longevity:
1- Heredity.
2- Life style; avoiding smoking, healthy weight and diet.
3-Exercises help people avoid disease.
4-Exposure to environmental toxins.
Biological age groups
Young- old: From the age of 65 to 75 years old.
Middle-old : From the age of 75 to 85 years old.
Old- old: older than 85 years old.
Theories of aging
A- Genetic theories
These theories focus on the mechanisms of aging located in the nucleus of the cell.
1-Error catastrophe theory: This theory stated that errors in DNA transcription or
RNA translation lead to error in protein synthesis that can result in accumulation of
mis-synthesized protein leads to genetic errors that promote senescence.
2- Altered protein turns over: It is an alteration in the rate of protein biosynthesis. So,
many proteins are produced more slowly in aged cells that their younger ones.
3-Redundant message theory: Stated that age changes are a result of errors in
functioning genes.
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B- Non-Genetic theories:
These theories focus on the mechanisms of aging represents an accumulation of
stimuli from the environment that produces stress on the organism.
1- Free radical theory: Free radicals are highly reactive chemical compounds having an
unpaired electron in the outer orbit produced during use of oxygen with the cells (oxidative
phosphorylation).These free radicals causes D.N.A. disorders and aging changes. Such
reactions continue until one free radical pairs with another or meet an antioxidant as Vitamin
E or carotene.
2- Connective tissue theory: Focus on changes in collagen and elastin, which are
connective tissues present in most organs. Loss of elastin and collagen physiological
properties causes aging changes. Changes in elastin lead to loss of elasticity of blood
vessels, skin. Lens of the eye and other organs. Changes in collagen in the nose and
ears tend to increase their size.
3- Organ system theory: Certain systems decline with advanced age and their function lost.
The most important systems declined are the neuroendocrine or immune system. Failure of
these systems accelerates dysfunction of the whole organism. Failure of the neuroendocrine
system would be expected to produce profound impairments in homeostatic systems,
including loss of reproductive function and metabolic regulation, which occur with age.
Failure of the immune system would be expected to produce an increased susceptibility to
infection and a decreased ability to reject tumor cells.
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Body System Changes In Aging
Cardiovascular System
1- ↓ contractile strength of the heart.
2- The stroke volume declines.
3-↓ cardiac output and ability of the heart to pump blood.
4- The walls of the heart become thicker (hypertrophy) without an increase in the size
of the atrial or ventricular chambers.
5- Fibrosis develops in the peripheral vascular system, resulting in hypertension,
arteriosclerosis, and decreased cardiac function.
6-The nervous conduction system of the heart degenerates, often causing various
dysrhythmias and degrees of heart block.
Respiratory System
1- Rigid and stiff costal cartilage.
2- Intercostal muscles become atrophied and weak
3- ↓Compliance of the chest.
4- ↓ vital capacity.
5- ↓ number of functioning alveoli.
6- ↓ maximal oxygen consumption (VO2 max.).
Musculoskeletal system
1- ↓ Bone density (bone mass per unit volume) progressively decreases in both sexes,
but more rapidly in women. This process, along with micro architectural deterioration
of the skeleton, leads to enhanced bone fragility and increased risk of fractures, a
condition known as osteoporosis.
2- Loss of muscle bulk (atrophy) and strength, which usually begins between the ages
of 30 and 50 years and becomes noticeable by 60 to 70 years of age.
3- Joint stiffness and limitation of range of motion.
Nervous system
1- ↓ visual and vestibular information changes,
2- Loss of proprioception and vibration sense.
3- ↑ reaction time leads to position instability, gait disturbance and high risk of falling
among elderly people.
4- ↓ the weight of the brain.
5-↓blood flow to the brain.
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6-↓ nerve velocity (speed of impulse conduction) occurs.
7- ↓ pain perceptions, sense of equilibrium and perception of touch and temperature in
addition to .slowed reflexes.
8-↓ ability to perform activities of daily living (ADLs) such as bathing, dressing,
eating, and toileting increase dramatically with age. Similar trends are noted with
instrumental activities of daily living (IADL) such as shopping, preparing meals, and
doing housework and quality of life.
9- Gradual failing in memory capacity.
10- ↓ taste sensation, hearing and visual acuity.
Gastrointestinal tract (GIT)
1- Loss of teeth.
2- ↓ saliva secretions.
3- ↓ gastric acid secretion.
4- ↓ liver size.
5- ↓ colon movement leads to constipation.
Renal System
1- ↓ renal blood flow and glomular filtration rate. These changes may cause fluid and
electrolyte imbalances. Since the kidneys filter out many drugs (including antibiotics),
it is common for the elderly to suffer from drug toxicity.
2- ↑ threshold for renal execration of glucose (normally equal
180mg/dl).
3- In the elderly male patient, the prostate often becomes enlarged (benign prostatic
hypertrophy), causing difficulty urinating or urinary retention.
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Assessment of the Geriatric Patient
Normal physiological changes and underlying acute or chronic illness may make
evaluation of an ill or injured elderly patient a challenge. It is often difficult to
separate the effects of aging from the consequences of disease.
Complicating Factors
1-Often the chief complaint of the elderly patient is vague. Elderly patients often fail
to report important symptoms.
2- Elderly patients often suffer from more than one disease at a time. The presence of
chronic problems may make it more difficult to assess an acute problem. Often, it is
easy to confuse symptoms of chronic illness with those of an acute problem.
3- Pain may be absent, thus causing you and the patient to underestimate to extent of
the injuries.
The following techniques should be used when communicating with older adults
 Always identify yourself.
 Talk at eye level to ensure that the patient can see you as you speak.
 Speak slowly and distinctly.
 Listen closely.
 Be patient.
 Ask one question at a time.
 Do not shout.
 Avoid patronizing the patient (i.e. using terms such as Dear or sweetie).
Physical Examination
The physical examination of the geriatric patient should follow the same general
sequence as for patients in other age groups but certain considerations must be kept in
mind when examining the elderly patient.
When examining the elderly patient the following five points should be considered:
1The patient may fatigue easily.
2- Patients commonly wear many layers of clothing for warmth, which
may
hamper examination.
3- Explain actions clearly before examining all patients, especially those with
diminished sight.
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4- Be aware that the patient may minimize or deny symptoms through fear of being
bedridden or institutionalized or losing self-sufficiency.
5- Try to distinguish symptoms of chronic disease from acute problems. For
example, mouth breathing and loss of skin elasticity can cause dry mucous
membranes that give the false impression of dehydration.
Assessment of the elderly: This is complex and requires time because often there
is multiple pathology. Team work is generally necessary to produce a real picture.
Relatives, friends, neighbors, home helps, policemen, social workers, nurses,
occupational therapists, physiotherapists as well as doctors of varying specialties need
to make a contribution and a true assessment of a patient admitted to an acute unit
may take 2-3 days.
Comprehensive Geriatric Assessment (C.G.A.)
Geriatric assessment team
1- Physician
2- Physical therapist
3- Nurse
4- Occupational therapist
5- Social worker
6-Speech therapist
7-Pharmacist
8-Dietition
9-Psychiatrist
10- Others
Component of C.G.A.
1- Physical assessment
-Traditional History
- Physical examination
2-Mental assessment
- Cognitive assessment
- Depression assessment
3- Functional assessment
- Activities of daily living (A.D.L.)
-Instrumental activities of daily living (I.A.D.L.)
4-Social assessment
-Social history
- Financial status
-Care giver burden
5- Environmental assessment
- Home design
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- Furniture
The elderly are cared in
1-Own home
Theoretically this is ideal for the persons' self- esteem and independence.
2-Family home
A 'granny flat' attached to the house of a son or daughter can work extremely well
because the elderly person's independence plus security can be maintained.
3-Private residential homes
These can be pleasant but expensive, although there can be feelings of rejection
on the part of the elderly person and feelings of guilt on the part of the family.
4-Private, nursing homes
These offer more nursing than residential homes and are highly variable in
standards. Again they can be expensive.
Balance Disturbance
Definition: The term “balance” refers to the ability to maintain the body’s center
of mass over the base of support in order to retain stability.
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The Balance Control Process
Depends on three major components
(1) The sensory system for accurate information about the body position relative to
the environment; the sensory system includes the sense of touch, vision, and inner ear
motion sensors.
(2) The brain's ability to process this information;
(3) The muscles and joints for coordinating the movements required to maintain
balance
Balance sensors.
Assessment of Balance
The most commonly used tools for the measurement of balance are
1- Berg Balance Scale (BBS):
The BBS was developed to measure balance disorders in elderly people and those
with neurological disorders it consists of 14 tasks, as indicated in table (1). These are
scored from 0 to 4, where 0 indicates an inability to perform the task and 4 indicates
the task was performed correctly and independently, i.e. normal performance. The
possible score on this test ranges from 0 (severely impaired balance) to 56 (excellent
balance). Scores below 45 indicate that the subject’s balance is impaired, with an
increased risk of falls.
Table 1. Berg Balance Scale Test.
Item
1
2
3
4
Description
Sitting to standing
Standing unsupported
Sitting unsupported
Standing to sitting
10
5
6
7
8
9
10
11
12
13
14
Transfer
Standing with eyes closed
Standing with feet together
Reach forward with an outstretched arm
Retrieving object from floor
Turning to back behind
Turning 360 degrees
Placing alternate foot on stool
Standing with one foot in front of the other foot
Standing on one foot
2- Functional Reach Test (FRT):
The functional reach test (FRT) was designed to test the ability to control
movement of the center of gravity over a fixed base of support. It is used as a
dynamic measure of balance to measure the limit of stability in the anterior direction.
It is based on measuring as the maximal distance that subjects could reach forward
horizontally beyond arms length while maintaining a fixed base of support in the
standing position
The distance is measured in centimeters on a tape measure fixed to wall. The
patient, standing with one shoulder close to a wall, is asked to extend the fist along the
wall directly frontward. The subject then leans forward, fist extended in front as far as
possible without taking a step or losing stability. The patient should be able to move
the fist forward a distance of at least six inches; lesser distances indicate a significant
risk for falling.
Function Reach Test.
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3- Get-Up and Go (GUG) and Timed Up and Go tests:
measure, in seconds, the time taken by an individual to stand up from a chair with a
48-cm seat height, walk a distance of three meters to a line on the floor, turn, walk back
to the chair, and sit down again.
Balance Assessment: a Modified Romberg Test
A test for gait/ambulation:
The standing patient performs tasks of increasing difficulty, observing the response
to positional stress, loss of visual input and displacement. The patient assumes different
standing positions, first with eyes open, then with eyes closed. With each successive
maneuver, stability is observed and the patient is asked, "Do you feel steady?”
See graphic below:
1. Feet comfortably apart
2. Feet together
3. Feet semi-tandem (heel-to-instep) 4. Feet tandem (heel-to-toe).
Assessment of Daily Living Activities:
One measure of independence is the capacity to perform functional tasks
necessary to meet the demands of daily life. These activities of daily living (ADLs)
include the basic ADLs, which are necessary for an individual to care for him/herself
within a limited environment. Higher-level activities, or Instrumental (IADLs), are
those abilities necessary to function in the community.
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Table 2. Katz Index of Activities of Daily Living.
1.
2.
3.
4.
5.
6.
Bathing (sponge, shower, or tub):
I: receives no assistance (gets in and out of tub if tub is the
usual means of bathing)
A: receives assistance in bathing only one part of the body
(such as the back or leg)
D: receives assistance in bathing more than one part of the
body (or not bathed)
Dressing:
I: gets clothes and gets completely dressed without
assistance
A: gets clothes and gets dressed without assistance except in
tying shoes
D: receives assistance in getting clothes or in getting dressed
or stays partly or completely undressed
Toileting:
I: goes to "toilet room", cleans self, and arranges clothes
without assistance (may use object for support such as cane,
walker, or wheelchair and may manage night bedpan or
commode, emptying in the morning)
A: receives assistance in going to "toilet room" or in
cleansing self or in arranging clothes after elimination or in
use of night bedpan or commode
D: does not go to room termed "toilet" for the elimination
process
Transfer:
I: moves in and out of bed as well as in and out of chair
without assistance (may be using object for support such as
cane or walker)
A: moves in and out of bed or chair with assistance
D: does not get out of bed
Continence:
I: controls urination and bowel movement completely by
self
A: has occasional "accidents"
D: supervision helps keep urine or bowel control; catheter is
used, or is incontinent
Feeding:
I: feeds self without assistance
A: feeds self except for getting assistance in cutting meat or
buttering bread
D: receives assistance in feeding or is fed partly or
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completely by using tubes or intravenous fluids
I: independent, A: assistance, D: dependent.
Table 3. Instrumental Activities of Daily Living.
1.
Telephone:
I: able to look up numbers, dial, receive and make calls without
help
A: able to answer phone or dial operator in an emergency but
needs special phone or help in getting number for dialing
D: unable to use the telephone
2.
Traveling:
I: able to drive own car or travel alone on bus or taxi
A: able to travel but not alone
D: unable to travel
3.
Shopping:
I: able to take care of all shopping with transportation provided
A: able to shop but not alone
D: unable to shop
Preparing meals:
I: able to plan and cook full meals
A: able to prepare light meals but unable to cook full meals
alone
D: unable to prepare any meals
4.
5.
6.
7.
Housework:
I: able to do heavy housework (like scrub floors)
A: able to do light housework but needs help with heavy tasks
D: unable to do any housework
Medications:
I: able to take medications in the right dose at the right time
A: able to take medications but needs reminding or someone to
prepare it
D: unable to take medications
Money:
I: able to manage buying needs, write checks, pay bills
A: able to manage daily buying needs but needs help managing
checkbook, paying bills
D: unable to manage money
I: independent, A: assistance, D: dependent.
Risk factors of fall:
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Falls occur most often in the bathroom, bedroom, and kitchen. About 10% of
falls occur on stairs, with descent being more hazardous than ascent. The first and last
steps are the most dangerous. Common sites of outdoor falls are curbs and steps. In
institutions, the most common sites of falls are the bedside, during transfers into or out
of bed, and the bathroom. The fear of falling is associated with significant
psychological morbidity in the form of high anxiety and depression. This has been
reported to occur in up to 6% of fallers.
The risk factors associated with falling are classified into intrinsic, extrinsic, and
situational.
Table 4. Extrinsic and situational factors contributing to risk of falls and fall-related
injury.
Factor
Examples
Environmental hazard
Slippery or uneven walking
surface, poor lighting
Increased environmental
Using stairs, rising from low
demand
chair
Situational
Changing position, risk-taking
behavior, and recent relocation
to a new nursing home.
Balance therapy:
This is a specialized form of physical therapy. It aims at treating the debilitating
effects of balance disorders. Table (9) describes the items of balance therapy.
Table 5. Items of balance therapy.




Strengthening
Safety awareness
Postural and balance exercises
Gait exercises




Vestibular stimulation
Proprioception tasks
Sensory integration
Patient education
Balance training exercises:
Balance training exercises are indicated for elderly patients at increased risk of
falls as a result of balance disorders. A balanced exercise program should improve
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strength, flexibility, body composition, and cardio-respiratory function. Usually,
balance-training exercises are gradual. Patients begin with the simplest exercises and
advance as appropriate. Low velocity and low-impact designed exercise programs are
preferred to reduce cardiovascular and orthopedic complications, and reduce the risk
of falls by about 10 to 15%. Ball balance and walking training exercises and other
training methods are displayed in the following figures.
Geriatric Care
The care of the elderly subjects is a responsibility of the society, governments and
the family.
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A population-based approach to geriatric care management.
Physical Therapy Care and Intervention
Physical therapy intervention may prevent lifelong disability and restore the highest
level of functioning, through the use of tests, evaluations, exercises, treatments with
modalities, screening programs, as well as educational information.
Goals of exercise programs for elderly:
- Increase general conditioning, especially endurance to assist the subject ADL’s;
- Improve muscle strength to improve the physical activity as walking and outdoor
activities as shopping and driving;
- Minimize risk factor to cardiovascular affection and falling down, which may
lead to fractures especially lower limbs;
- Promote enjoyment, recreation and improve the psychological condition without
causing excessive fatigue;
- Minimize dependence on medication to prevent its side effects on deferent body
systems;
- Maintain a good normal balance as a result of improvement of balance control
system by activities.
Components
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Components on an exercise program include strength and power training,
endurance activities, flexibility, and balance.
Benefits of Physical Activity:
1-Reduces body fat
2-Lowers blood pressure
3-Improves glucose utilization
4-Increases endurance
5-Improves balance and flexibility
6-Improves blood lipid profile
Table 6. Exercise prescription.
Component
Mode
Strength and Isolated muscle group
power
contractions in
movements similar to
real life
Frequency
2-3 times a
week
3 sets per
muscle
group
Endurance
Walking, walking
Daily
uphill, stair-climbing,
step-ups, cycling,
swimming
Flexibility
Static stretch calf,
Daily
hamstrings, hip
abductors
Posture: postural
1-3 times a
awareness, leaning
week
Tai Chi, dance
movements, transfers,
turns
Balance
Intensity
For rapid gains: heavy
intensity, increase
resistance weekly for
slow gains or
maintenance moderate
intensity
Moderate perceived
exertion: Fairly light to
somewhat hard, or
50%-75 of maximum
age-predicted heart rate
Duration
2 or 3 sets each motion
limited by fatigue
Dependent on level of
supervision and
balance function
Variable
Goal: 30 min. per day
of activity, averaged
over a week activity
not necessarily
continuous increase
duration, then increase
intensity
Should elicit feeling of > 15 seconds per
stretch, not pain
muscle group
Environmental modifications:
Environmental modifications can have a major impact on the elderly
person’s ability to function independently or with minimal assistance at home.
Table 7. Home modifications to maximize function.
Room
Modification
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Kitchen
Bathroom
Living room
Bedroom
Laundry
room
- Lower work surfaces, e.g. place cutting board on top of
a drawer
- Hang items vertically to be easily reached
- Use cookie sheet for carrying items
- Store heavy things on lower shelves
- Stagger four burners on stove top to reduce danger of
reacting over fire and burning self
- Use narrow wheelchairs for easier maneuverability and
access, elevate toilet seat three to six inches to ease
transfer
- Install non-slip grab bars to ease transfers
- Clear all obstructions in path to toilet
- Install a single lower faucet for easy temperature
regulation and elimination of twisting movements
- Install an extending handheld shower
- Use a tub seat
- Check chairs for stability and use only those with arms
and proper seat height
- Place telephone by bedside
- Locate bed so person can see window or hallway
- Provide firm mattress for ease of transfers
- Use a sliding board for transfers
- Provide easy access to switches for lighting and heat
- Use easy-care permanent press clothing
- Use long-handled tongs to retrieve items from frontloading washer for wheelchair access
Mobility and assistive aids:
Senior people must be trained on and encouraged to use assistive devices to help
in independent mobility.
Canes
1- Typically support 15% to 20% of the body weight.
2- The tips, handles, materials, and lengths of canes vary. As the number of tips
increases, the degree of support also increases.
3- The cane tip is fitted with a rubber tip with a concentric ring to prevent slipping.
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4-The handle of the cane may be curved or have a pistol grip; the pistol grip offers
more support.
5- Canes can be made of a variety of materials, but most are made of wood or
lightweight aluminum.
6-The length of the cane is important for stability. Some canes are adjustable.
Three methods may be used to evaluate the proper cane length:
A- Measuring the distance from the distal wrist crease to the ground when the patient
is standing erect (This is the preferred method).
B- Measuring the distance from the greater trochanter to the ground.
C- Measuring the distance between the ground 15 cm in front of and to the side of the
tip of the shoe and the elbow flexed at 30 degrees.
Crutches
1- Can support full body weight, but are seldom used with older persons.
2- Require good arm strength.
3-There is a risk of brachial plexus injury.
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Walker
1- It is prescribed when a cane does not offer sufficient stability.
2-Walker types include pickup and wheeled walkers.
3- The pickup walker is lifted and moved forward by the patient, the result is a slow
gait. It requires both strength to repeatedly pick up the walker and cognitive ability to
learn the necessary coordination.
4- A wheeled walker allows for a smoother, coordinated and faster gait. The most
commonly used type is the two-wheeled walker.
Wheelchair
1- Suitable for Patients who cannot safely use or are unable to ambulate with an
assistive device
2- This must be fitted according to the patient’s body built, weight and disability.
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3- Incorrect fit may result in poor posture, joint deformity, reduced mobility and
pressure sores.
4- The use of a wheelchair commonly requires home modifications as wide doorways.
Therapeutic and Assistive Devices
Splints
1-are fitted to prevent deformity or to promote function.
2-Static hand splints may be applied to maintain the wrist in a neutral position, the
fingers in extension, and the thumb in opposition to prevent flexion deformities.
3-A wrist cock-up splint supports the wrist in extension but leaves the fingers free.
4- A foot drop splint helps maintain ankle flexion.
Self-help assistive devices
1- Are used to promote safety or to compensate for specific impairments.
2- The most commonly used assistive devices are canes, reachers, Raised toilet seats
and Cups with lids.
3- Memory aids include automatic dialing telephones, drug organizers and reminders,
and pocket devices that record and play back messages (reminders, instructions and
lists) at the appropriate time.
Pressure Sores
Pressure sores are a major problem for those who have neurological impairments
of weakness and sensory loss, as well as other chronically ill and debilitated patients.
The incidence is from 25% to 85% and that this complication accounts for 7% of
deaths. Prevention of pressure sores should be of high priority.
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The classification currently used by the National Spinal Cord Data
Collection System utilizes four grades:
Grade I: limited to superficial epidermis and dermal layers.
Grade II: involving the epidermal and dermal layers and extending into the adipose
tissue.
Grade III: extending through superficial structures and adipose tissue down to and
including muscle.
Grade IV: destruction of all soft tissue structures down to bone. There is
communication with bone or joint structures or both.
Factors Contributing To Pressure Sores
1- Pressure
Pressure causes tissue damage by closure of blood vessels resulting in ischemic
necrosis.
Initially, reactive hyperemia or redness of the skin occurs over the compressed
skin and subcutaneous tissue. Usually within 24 hours the skin will return to normal.
More prolonged pressure is followed by the formation of edema and a vascular
inflammatory response that precedes the ulceration by two to four days.
2- Sensory and motor Impairment
Individual is unaware of discomfort resulting from prolonged pressure.
Because the patient has difficulty shifting weight due to weakness and is unaware of
the need to relieve pressure due to lack of sensation, continued pressure may lead to
ischemic necrosis of the tissue.
3- Shear Pressure
When the upper layers of tissue area slide against the lower layers with an
angular force, this, shear pressure may lead to ulcer.
4- Spasticity, Moisture, Infection
The increased muscle tone subsequent to recovery from spinal shock will result
in spasticity. This may cause problems with hygiene, may increase shear pressure, and
may be intensified by infection or other noxious stimuli including, a preexisting
pressure sore.
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5- Anemia and Hypoalbuminemia
Anemia contributes to tissue breakdown and plays a role in delaying wound
healing.
Decreases in serum albumin below 3.0-3.5 g/cm3 are quite common in
patients with pressure sores, even when body weight is normal.
Table 8. Risk factors for development of pressure sores.
Usual Sites of Pressure Sores
The three most common sites are the sacrum, heels and ischium (The most
common locations Grades III and IV). Over 50% of all Grade III and IV pressure
sores occur in the sacral area. Below are listed the vulnerable sites.
The common locations of severe pressure sores are Sacrum, Greater trochanters,
Lateral malleolus; Back of the heels, Ischial tuberosity, Knees,
Olecrenon, Spine
of the Scapulae and Occipit.
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Most common locations of severe pressure sores
(Grades III and IV).
Prevention
1. Frequent inspection of skin for possible pressure problems
and
proper cleansing technique:
Skin care includes careful inspection, which must be done as frequently as every
two hours while the patient is in bed and more often if a new activity such as sitting or
transfers with a sliding board is initiated. As a minimum, inspection should be done
in the morning and evening on a daily basis by the patient alone or with some
assistance. The skin must also be cleansed promptly of urine and feces with a mild
soap and water. Perspiration may be excessive and require frequent attention, but the
patient should be kept dry with cleansing to prevent maceration of tissue.
2. Use of appropriate pressure relief:
Bony prominences are the areas most prone to breakdown, and proper bed
positioning is essential to relieve pressure to these sites. Relief of pressure and
avoidance of friction or shear depend on anticipation and use of appropriate methods
of turning and shifting and on proper equipment. When a patient is turned or assisted
in transfer, he must be lifted and not dragged across sheets or other surfaces.
Heels should be protected with foam blocks. Use of mattresses filled with air-or
foam is not a substitute for turning. A number of cushioning products are on the
market, varying from cushions filled with air, water, or plastic material
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3. Awareness of potential hazards to the skin:
Excessive exposure to heat or cold may cause damage to insensate skin. Safety
precautions are the mainstay of a prevention program. Use of hot water when bathing
can be a hazard and water temperature should be monitored and regulated.
Management of Pressure Sores
Principles of treatment:
1-Pressure relief must be accomplished.
2- Good nutrition and adequate hemoglobin and albumin levels are also essential for
healing.
3-The debridement of necrotic tissue and local cleansing are essential.
4- The majority of ulcers will heal with conservative methods and do not require
surgery, given the proper circumstances. Grade IV sores, however, will usually
require surgery, particularly if located over the ischial tuberosities. Grade IV pressure
sores in other areas may heal without surgery.
The management of pressure sores based on severity is as follows:
Grade I: Cleanse the wound, relieve pressure, and monitor change by weekly
measurement of size and depth.
Grade II: Cleanse the wound, pack with gauze for drainage, perform sharp and/or
enzymatic debridement of necrotic tissue, relieve pressure, measure and grade weekly.
Grades III and IV: Clean the wound, pack with gauze, debride necrotic tissue,
relieve pressure, measure and grade weekly. However, patient should also be referred
to a spinal cord injury center or skilled plastic surgeon.
Surgical Management
The indications for surgical intervention involve failure of pressure sores to heal
spontaneously, poor quality of the skin following healing, and the need to mobilize the
patient.
Physical Therapy Management: By use of
1. Ultraviolet rays. 2. Laser Therapy (He-Ne and IR Laser).
Constipation
Definition
Constipation means reduction in frequency of defecation (less than 3 times /
week, a constant sensation of rectal fullness with incomplete evacuation of feces and
sometimes painful defecation due to hard stools.
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The lower digestive tract
Common causes of constipation are:1- No enough fiber in the diet
2- No enough liquids
3- Lack of exercise
4- Medications
5- Changes in life or routine such as pregnancy, older age, and travel
6- Abuse of laxatives
7- Ignoring the urge to have a bowel movement
8- Specific diseases such as stroke (by far the most common)
9- Problems with the colon and rectum
10- Problems with intestinal function (chronic idiopathic constipation).
11- Environmental factors.
Complications of constipation:1- Hemorrhoids caused by straining to have a bowel movement and it will treated by
use warm tub baths, ice packs, and application of a special cream to the affected
area.
2- Anal fissure (Tears in the skin around the anus) caused when hard stool stretches
the sphincter muscle. As a result, rectal bleeding may occur and it treated by
stretching the sphincter muscle or surgical removal of tissue or skin in the
affected area.
3- Retention of urine.
4- Fecal incontinence.
5- In old age cardiac dysfunction will occur.
Evaluation
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Most people with constipation do not need extensive testing and can be treated
with changes in diet and exercise.
Medical History
Ask a patient to describe his or her constipation, including:1-Duration of symptoms,
2-Frequency of bowel movements,
3-Consistency of stools,
4-Presence of blood in the stool, and toilet habits.
N.B.
A record of eating habits, medication, and level of physical activity or exercise
will also help to determine the cause of constipation.
Physical Examination
A physical exam may include a rectal exam with a gloved, lubricated finger to
evaluate the tone of the muscle that closes off the anus (anal sphincter) and to detect
tenderness, obstruction, or blood. In some cases, blood and thyroid tests may be
necessary to look for thyroid disease and serum calcium or to rule out inflammatory,
neoplastic, metabolic, and other systemic disorders.
Treatment
Treatment depends on the cause, severity, and duration, in most cases dietary and
lifestyle changes will help relieve symptoms of constipation and help prevent it.
I. Conservative treatment
A. Diet
A diet with enough fiber (20 to 35 grams each day) helps form soft, bulky stool.
High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and
vegetables. For people prone to constipation, limiting foods that have little or no fiber,
such as ice cream, cheese and meat.
B. Lifestyle Changes
Include drinking enough water and other liquids such as fruit and vegetable juices
and engaging in daily exercise as brisk walking may help stimulate bowel motility,
pelvic floor exercises, upper and lower extremities exercises and regular daily walking
for about 20- to 30-minute walk every day, aerobic exercise and reserving enough
time to have a bowel movement.
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C. Laxatives
Most people who are mildly constipated do not need laxatives. However, for
those who have made diet and lifestyle changes and are still constipated, doctors may
recommend laxatives or enemas for a limited time. These treatments can help retrain a
chronically sluggish bowel.
D. Enemas
Can be used when fecal impaction is present. Plain tap water enemas can be used.
E. Physical therapy modalities
People with chronic constipation caused by anorectal dysfunction can use:
1-Biofeedback to retrain the muscles that control release of bowel movements.
Biofeedback involves using a sensor to monitor muscle activity that at the same
time can be displayed on a computer screen, allowing for an accurate assessment
of body functions. A health care professional uses this information to help the
patient learn how to use these muscles.
2-Massage as connective tissue massage and manual massage for the abdomen.
3- The Interferential therapy.
4- Acupuncture therapy
5-Hot rolls: Hot rolls are hot fomentation applied on the abdomen and on the lower
back region which will help to stimulate colon so it must be applied on the same
direction of colon, also it increase the relaxation in the spasmed muscles, but it must
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be not used when there is an inflammation in the abdomen or at time of menstruation
and pregnancy.
6-Physical exercises: As brisk walking, pelvic floor exercises and upper and lower
limbs training. Also, ask patient to walk daily about 20-30 minutes
II. Surgical treatment: Operative treatment includes removal of the colon may be an
option for people with severe symptoms caused by colonic inertia. However, the
benefits of this surgery must be weighed against possible complications, which
include abdominal pain and diarrhea.
Patient Education and advices:
1. Eat more fiber.
2. Drink plenty of water and other liquids such as fruit and vegetable juices and clear
soups.
3. Get enough exercise, 20- to 30-minute walk /day may help.
4. Allow yourself enough time to have a bowel movement.
5. Don't ignore the urge to have a bowel movement.
6. Use laxatives only if a doctor says you should.
7. Check with your doctor about any medicines you take.
Hypertension
Definition
Persistent elevation of arterial pressure above 150\90 mmHg in persons aged below 50
or above 160\100 mmHg in persons more than 60 years, under basal conditions.
Aetiology of hypertension
A- Essential hypertension: (of unknown cause) more than 80% of cases of
diastolic hypertension.
B-Secondary hypertension
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A cause for hypertension can be identified in only 5% of cases. The commonest cause
is pregnancy, oral contraceptive agents and renal diseases.
Management
I - Clinical picture of hypertension
A) Uncomplicated hypertension:
- There may be no symptoms, or the patient may complain of headache, epistaxis,
dizziness, tinnitus, vertigo or irritability.
- Examination: A persistently high blood pressure above 160\95 is detected. Per
cordial examination may show no abnormality or may show signs of left ventricular as
hypertrophy, aortic ejection systolic click and murmur.
B) Complicated hypertension (2 categories).
- Complications as a result of the mechanical stress of the hypertension directly e.g.
cerebral hemorrhage, left ventricular failure, and renal damage.
- Complications as a result of accelerated atherosclerosis as coronary artery disease
and cerebral arterial occlusion.
Degrees
* Mild hypertension: if diastolic pressure is 95 - 110 mmHg.
* Moderate hypertension: if diastolic pressure is 110 - 125 mmHg.
* Severe hypertension: if diastolic pressure is 125 - 135 mmHg.
* Malignant hypertension: if diastolic pressure is above 135 or 140 mmHg and
papilledema must be present.
Treatment
1) Surgical: for curable cases.
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2) Non surgical: for primary hypertension and for the non curable forms of
secondary hypertension.
A - Advices:
* Weight reduction in obese.
* Dietary sodium restriction.
* Regular aerobic exercise.
* Limiting alcohol intake, discouraging smoking and caffeine.
* Relaxation therapy.
* Fish oil intake, potassium and calcium supplement.
B- Drug therapy:
1) Volume depletes (Diuretics).
2) Adrenergic inhibitors:
* Peripheral as reserpine.
* Central as aldomet.
* Alpha receptor blocker as Beta receptor blocker or combined Alpha and Beta.
* Vasodilators: Direct, calcium blockers or converting enzyme inhibitors.
C- Non pharmacological treatment.
1- Weight reduction: It increases sensitivity to salt and to antihypertensive agents.
2- Infrared: infrared increases peripheral circulation so reduces blood pressure so
applying infrared in cervical spine for 15 minutes leads to 10 mmHg decrease in
systolic blood pressure and 8mmHg decrease in diastolic
3- Shiatsu: It is the pressure by the ball of thumb, balls of fingers and palm of hand
for 5-7 seconds in every point except in neck points every one of them needs only 3
seconds.
* The pressure of these points stimulates the generation of own power to prevent
illness.
* Examples:
A- With the bulb of the thumb, gently press the first point below the jaw as you count
to ten, repeat 3 times on right and left side.
B- Use three fingers of each hand to press the root of the occipital bone and three
points above it, repeat 3 times.
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C- Apply a strong pulling pressure to the left middle finger and then to the right
middle finger.
4- Biofeed back
A) EMG or muscle tension feedback: sensory are placed over the muscle site which
can detect changes in myoelectric potential these signals are magnified and converted
to varying sounds or needle movements on an indicator help to relief stress.
B) Thermal biofeedback: Thermal biofeedback utilizes a sensitive thermistor which
senses extremely small differences in skin temperature, changes in skin temperature
are thought to be a function of changes in blood volume in the peripheral vascular, this
biofeedback proved to be effective in management of vascular headache, peripheral
vascular disorder and control of hypertension.
c) Skin potential response biofeedback: Based on the electro dermal activity of the
skin in response to stress.
5- Aerobic exercise: (decrease weight, increase glucose tolerance, decrease blood
lipids)
* Mode: Brisk walking, jogging or swimming
* Frequency: at least 4 time\ week for 30- 45 min.\ session.
* Intensity: 70 - 85 % MHR.
* Duration: 6 - 8 weeks (2 -8 months).
Orthostatic Hypotension
Definition: It is a sudden fall in blood pressure that occur when a person assume
standing position. With fall in systolic blood pressure of ≥ 20 mmHg or fall in
diastolic blood pressure of ≥10mmHg & that occur within 3 min. of standing.
Symptoms
1- Dizziness
2- Faintness which appear only on standing and caused by low blood pressure.
Causes of Orthostatic Hypotension
1-The heart is the central pump, & a weak or irregular it causes orthostatic.
Conditions such as arrhythmia, heart failure, & pregnancy are example where the
heart may not be up to the task of providing an adequate blood pressure.
2- Hypovolemia is the decreased amount of blood in the body which may results
from the excessive use of the diuretics or from dehydration.
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3- Vasodilators or other types of drugs.
4- Prolonged bed rest.
5-In the elderly, decreased baroreceptor responsiveness, coupled with decreased
arterial compliance. The decreased baroreceptor responsiveness delays the tachycardia
response.
Evaluation
Record supine and standing blood pressure. Abnor al if blood pressureBlood Pressure
drops >20/10
Non-pharmacological Treatment of Orthostatic Hypotension
1- Take in extra amount of salt (about 10 gm/day total). also avoid dehydration.
2- Sleep with head of bed elevated about 15-20 degrees.
3-eat frequent small meals (because eating lower blood pressure). Avoid sudden
standing after eating due to postprandial dilation of splenic vessel beds.
4- Avoid straining at stool (because that may lower blood pressure).
5- Avoid hot shower or excessive heat. Use air conditioner.
6- Get up gradually at the morning.
7- Avoid prolonged standing (dilation of skeletal muscle beds).
8- Make slow careful change in position and repeat feet
dorsiflexion several times before standing.
9- Wear compression stocks which help to prevent pooling the venous blood then the
venous blood flows more quickly up the leg toward the heart.
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