Clinical Medicine Test 1 9/14/11

branch of medicine that investigates the changes in body tissue caused by diesease

Application of pathology (the investigation of changes in body tissue due to disease) in solving clinical problems

• Impairments
• Physical limitations
• Ability to participate fully in one individual social structure

spectrum from optimal level of function to death

psychological, sociological, and spiritual well being-- along with indiviual physiology

_(Traditionally thought of as absence of disease)_

biological process; a deviation from the normal physiological homeostasis

Individual's perception of being unwell

Identification of a specific disease

Cause of a disease

"causative factors"

Tendencies that promote development of a disease in an individual--makes them more susceptible

• Examples:
• -obesity
• -diabetes

development of the disease

develops quickly, marked signs, short term

-- more predictable

Often milder, develops gradually, persists longer (maybe forever)

Pathologic changes occur, no obvious manifestations

--not enough to seek medical attention, feel differently, but nothing is present that can be identified--

No symptoms or clinical signs are evident

• Early development of a disease
• Signs are non-specific or absent

Signs & symptoms of disease

• Collection of signs & symptoms
• Often affecting more than one organ

Manifestions of the disease subside or are absent

Condition that triggers an acute episode

New Secondary or additional problems

--inability to swallow=secondary condition/complication of Parkinson's Disease--

Treatment measures to promote recovery or slow the progress of a disease

Unwanted outcomes of primary condition

Period of recovery

• Probability for recovery or for other outcomes
• --prediction--

Maximizing function of diseased tissues

Science of identifying the causative factors and tracking the pattern/occurrence of disease

Indicates the # of people w/ a disease wi/in a group

(ex)--Native Americans have high morbidity rate for alcoholism

Indicate the # of deaths resulting from a particular disease within a group

--some cancers have and higher or lower mortality rate--

Occur when a higher than expected number of cases of an infectious disease occur within a given area

--public health sense rise in a disease, creates vaccine

Involve a higher number of cases in many regions of the globe

--moves geographically

Tracked by incidence & prevalence

Number of new cases in a given population within a specified time period

Number of new and old or existing cases in a specific population and within a specified time period

• Decrease in the size of cells
• --Results in reduced tissue mass (creates less force & less strength)

• Increase in cell size
• --Results in enlarged tissue mass

• Increased number of cells
• --Results in enlarged tissue mass

Mature cell type is replaced by a different mature cell type (teeth)

Cells vary in size & shape within a tissue

Undifferentiated cells with variable nuclear & cell structures

"New Growth"--commonly called tumor

Deficit of oxygen in the cells

--vey common--

Reduced oxygen in tissues

• Excessive heat or cold
• Radiation exposure

Pressure or tearing of tissue

--lacerations, cuts, bruises

• Exogenous-- from environment (ex) toxins you breath or touch; asbestus
• Endogenous-- from inside the body (ex) bacterial infection releases toxins into the blood

• Bacteria & Viruses
• --Fungi--lethal (happens usually under imunosupression)

• Genetic disorders
• Inborn errors of metabolism
• Altered metabolism

need supplements

complecation of burns

• Biopsychosiocial models of disability are widely accepted
• These models provide a framework for identifying the consequences of disease, disorder and injury

• Pathology-disease process
• Impairment-structural change
• Functional Limitation-task oriented
• Disability-social oriented

--widely used by rehab professionals for many years--

• Developed by the World health Organization (WHO)
• most important classification model
• Aims to represent how individuals live with thier health conditions
• Considers a number of factors that impact the behavior of an individual
• has a global/ multi-cultural focus

• Difficult to diagnose in some
• Impact patients & their families significantly
• May impact PT treatment & goal setting

• Public health concepts
• Prevention and wellness
• Role of the PT/PTA

• Many pathologies commonly treated in physical therapy impact multiple body sytems
• Systemic effects of many diseases can have significant impact on function

--the more body systems involved, the more likely to impair function--

Acute initial response to injury

--more often demonstrates local response but may include systemic response

• has many causes but the most commonly seen in PT are:
• --Persistant injury (carpal tunnel)
• --Immune Response

• Age
• Nutrition
• Multiple Co-Morbities (more illnesses, harder to recover)
• Psycho-social status (poor, minority, "not educated"- all leads to difficult recovery)

• Malnutrition
• Age
• Autoimmune Disease
• Chemotherapy
• Substance addiction
• HIV/AIDS

Cancers that have spread (metastisis) impact various body systems by encroaching on health/disturbing normal function

• Cell injury & causes of injury
• Inflammation as a response to injury
• Tissue healing and repair

• Ischemia
• Infection
• Immune Reactions
• Genetic Factors
• Nutritional Factors
• Physical Factors
• Mechanical Factors
• Chemical Factors

• Blood flow LESS than the minimum necessary to maintain cellular health
• --Reduction in blood flow results in reduced oxygen to the tissues
• --Frequently a result of arterial disease

• Most often caused by viral or bacterial invasion
• --It is the job of the immune system to attack and destroy infected cells

• A spectrum of abnormal responses from mild allergy to life threatening responses
• --Abnormal immune responses are the cause of many of the pathologies that we treat in physical therapy

A variety of conditions related to the number and structure of chromosomes

• Malnutrition impacts the protein synthesis necessary for cellular growth and maintenance
• --Excessive levels of certain nutrients can also have adverse effects on cells

Trauma or the presence of physical agents can lead to cellular injury and death

• Changes in size and shape of cells caused by increased or decreased load that fall outside of average for that particular tissue
• --Repetitive strain disorders (carpal tunnel-median nerve compressed)

Substances that are toxic to cells lead to cellular death

• Injury to a cell causes a loss of its homeostasis
• Cells become challenged to alter their mechanisms in order to regain homeostasis
• Cell injury is considered reversible if it is small in magnitude or short in duration
• This allows the cell to recover after removal of the injuring factor

• Mechanical Defenses
• Cellular Defenses
• Systemic Immune Defenses

• Inflammation is the body's response to tissue injury
• A coordiniated series of physiological events
• --eliminating the insult
• --replacing damaged tissue
• --promoting the restoration of normal structure and function
• Three phases of inflammation and repair. They occur in sequence but with varying degrees of overlap and duration
• --inflammation
• --proliferation
• --repair

• Eliminating the insult
• Replacing damaged tissue
• Promoting the restoration of normal structure and function

• 1) Inflammation
• 2) Proliferation
• 3) Repair

• The body's immediate protective response that attempts to eliminate the cause of injury
• Characterized by significant vascular response and the release of chemical mediators
• --Transient vasoconstrictors (stop bleeding)
• --Significant vasodilation (WBC's transported to injury sight)
• --Increased capillary permeability
• A significant increase in the presence of both red and white blood cells are noted in the area
• White blood cells- remove debris and enhance the healing process (phagocytes)
• Red blood cells assist in clotting
• Local inflammation is characterized by the CARDINAL SIGNS of inflammation:
• --Heat (warmth)
• --Redness
• --Swelling (edema)
• --Pain
• Leading to loss of function
• Systemic signs of infection include:
• --Fever (pyrexia)
• --Changes in blood chemistry

• Characterizes LOCAL inflammation
• --HEAT
• --REDNESS
• --SWELLING
• --PAIN

• --FEVER (pyrexia)
• --CHANGES IN BLOOD CHEMISTRY

• Leukocytosis-Increase in the number of white blood cells
• Differential-altered proportion of various types of white blood cells
• --Neutrophils: bind to microorganisms and control their growth
• --Monocytes
• --Phagocytes
• C-reactive protein: a protein not normally seen in the blood but appears in response to tissue damage
• Increased ESR: Elevated plasma proteins
• Cell Enzymes: Released from damaged cells into the blood stream

Increase in the number of white blood cells

• Altered proportions of various types of white blood cells
• --neutrophils: bind to microorganisms and control their growth
• --Monocytes
• --Phagocytes

Protein not normally seen in the blood but appears in response to tissue damage

• Erythrocyte Sedimentation Rate
• --Blood test used to measure time it takes for RBC's to separate from plasma and drop to the bottom of the tube (mm/hr)

released from damaged cells into the blood stream

• Rebuilding of damaged tissue covering and strengthening of injery site
• --Epitheliazation: reestablishment of superficial tissue covering the injury sight
• --Collagen Production: fibroblasts migrate to the area to produce new collagen
• --Wound contracts: edges grow together
• --Neovascularization: new blood supply forms to nourish newly formed tissue

Reestablishment of superficial tissue covering the injury sight (thin covering)

Fibroblasts migrate to the area to produce new collagen

Edges grow together

New blood supply forms to nourish newly formed tissue

• Longest Phase with durations varying according to size and severity of the wound
• Collagen Synthesis and Lysis- primitive collagen is replaced by more permanent collagen
• Collagen is aligned according to function
• --Induction Theory: collagen mimics the tissue it is healing
• --Tension Theory: collagen structure is determined by function

Primitive Collagen is replaced by more permanent collagen

Collagen mimics the tissue it is healing

Collagen structure is determined by function

• Occurs with mild tissue damage. Damaged cells recover & return to normal structure and function within a short time
• (ex) papercut

Damaged cells are replaced with identical new ones by the proliferation of nearby cells

Takes place when there is extensive tissue damage or when cells are incapable of regeneration

Occurs when the edges of a wound are held close together (surgical wounds that are sutures)

Occurs when there is a large break in the skin with a greater inflammatory response and formation of significant scar tissue

• Active Inflammation that does not resolve and causes prolonged tissue destruction
• May be caused by
• --Failure to resolve causative factor
• --Abnormal immune response to injury

• Type, Size & Location of injury
• Infection
• Vascular supply
• Physical Agents: electric stimulation
• Co-morbitities: diseases
• Movement
• Age
• Medications
• Nutrition

• Pharmacological Management
• --Asprin
• --Ibuprofen (advil/motrin)-musculoskeletal relief
• --Naproxyn (sodium, alieve)
• --Prednisone (corticosteroid)-acute inflammation, allergic reactions
• --Cox-2 (enzymes secreted by iflammated tissue)
• Celebrex (short term management of pain--10 days)

• Physical Therapy
• --Physical Agents

• Cartilage: heals poorly due to low vasular supply
• Tendons: demonstrate regeneration if surgically repaired and immobilized. Functional outcomes implacted significantly by rehabilitation
• ~~~Bone Healing~~~
• Primary Intention: surgical fixation
• Secondary Intention: Immobilization
• Four Stages of Healing in Bone
• --Inflammation
• --Soft Callus
• --Hard Callus
• --Remodeling

Surgical Fixation

Immobilization

• 1) Inflammation
• 2) Soft Callus
• 3) Hard Callus
• 4) Remodeling

• Advanced age
• Poor nutrition
• Anemia
• Diabetes (#1 most commong problem w/ healing because of a compromised circulatory system)
• Infection
• Immunocompromise