II.

Overview of the Different Human Body System

A. Cardiovascular

Heart Disease remains the leading cause of death in industrialized nations. (CVD) or
Cardiovascular disease is responsible for approximately one million deaths annually in the U.S.
and half of these deaths is sudden and unexpected. Effective application of the increased
knowledge regarding CVD and its risk factors will assist health care professionals to educate
clients in achieving and maintaining cardiovascular health.

A1. Cardiac Pathophysiology

Three components of cardiac disease are affecting the ffg:

Heart Muscle - e.g. Coronary Artery Disease (CAD)

Myocardial Infarct (MI)
Pericarditis
Congestive Heart Failure (CHD)
Aneurysms or Disease

Heart Valves - e.g. Rheumatic Fever or

Rheumatic Heart Disease (RHD)
Endocarditis
Mitral Valve Prolapse (MVP)
Congenital deformities

Cardiac Nervous System - e.g. Arrhythmias, Tachycardia, Bradycardia

A2. Clinical Signs & Symptoms

For Heart Muscle

a.) Radiating substernal chest pain or squeezing pressure
b.) Weakness, nausea & light-headedness
c.) Difficulty of swallowing
d.) Shortness of breath
e.) Positional Pain either during movement or without movement

For Heart Values

a.) Easy and profound fatigue
b.) Chest pains
c.) Dyspnea
d.) Palpitations & Skin Rash
e.) Arthralgias for RHD

For Cardiac Nervous System

a.) Subjective report of palpitations
b.) Reduced pulse rate for bradycardia and increased pulse rate for tachycardia
c.) Chest Pain
d.) Restlessness and agitation

B. Peripheral Vascular Disorders & Clinical Signs

B1. Buergers Disease pain, intermittent claudication, cold sensitivity, ulceration

and gangrene, paresthesias.
B2. Reynauds Phenomenon/Disease pallor in the digits cyanotic, blue digits, cold,
numbness of digits, intense redness of digits
B3. Superficial Venous Thrombosis subcutaneous venous distention, palpable cord,
warmth & redness, indurated (hard)
B4. Deep Venous Thrombosis unilateral tenderness and swelling or leg pain, warmth,
positive Homans sign, discoloration, pain with placement of cuff inflated to 160
mmHg.
 B5. Lymphedema edema of the dorsum of the foot or hand, usually unilateral, worse
after prolonged dependency.
B6. Hypertension - occipital headache, vertigo, spontaneous epistaxis, nocturnal
urinary frequency.

Key Points to Remember for Cardiovascular Problems

Fatigue beyond expectations during or after is a red flag symptom.

Be on the alert for cardiac risk factors in older adults, especially women, and begin a
conditioning program before an exercise program.

The client with stable angina typically has a normal blood pressure; it may be low,
depending on medications. BP may be elevated when anxiety accompanies chest pain
or during acute coronary insufficient; systolic BP may be low if there is heart failure.

Cervical disc disease and arthritic changes can mimic atypical chest pain of angina
pectoris, requiring screening through questions and musculoskeletal evaluation.

If a client uses nitroglycerin, make sure she or he has a fresh supply, and check that
the physical therapy department has a fresh supply in a readily accessible location.

Make sure a client with cardiac compromise has not smoked a cigarette or eaten a
large meal just before exercise.

A person taking medications, such as beta-blockers or calcium channel blockers may

not be able to achieve a target heart rate (THR) above 90 beats per minute. To
determine a safe rate of exercise, heart rate should return to the resting level 2
minutes after stopping exercise.

A 3-pound or greater weight gain or gradual, continuous gain over several days,
resulting in swelling of the ankles, abdomen, and hands, combined with shortness of
breath, fatigue, and dizziness that persist despite rest, may be red flag symptoms of
congestive heart failure.

The pericardium (sac around the entire heart) is adjacent to the diaphragm. Pain of
cardiac and diaphragm origin is often experienced in the shoulder, because the heart
and the diaphragm are supplied by the C5-6 spinal segment. The visceral pain is
referred to the corresponding somatic area.

C. Overview of Pulmonary Signs and Symptoms

Key Points to Remember:

Pulmonary pain patterns are usually localized in the substernal or chest region over
involved lung fields that may include the anterior chest, side, or back.

Pulmonary pain can radiate to the neck, upper trapezius, costal margins, thoracic
back, scapulae, or shoulder.

Shoulder pain caused by pulmonary involvement may radiate along the medial aspect
of the arm mimicking other neuromuscular causes of neck or shoulder pain.

Pulmonary pain usually increases with aspiratory movements, such as laughing,

coughing, sneezing, or deep breathing.
Shoulder pain that is relieved by lying on the involved side may be autosplinting, a
sign of a pulmonary cause of symptoms.

Shoulder pain that is aggravated when lying supine (arm/elbow supported) may be an
indication of a pulmonary cause of symptoms.
 For anyone presenting with pain patterns described above, especially in the absence
of trauma or injury, check the clients personal medical history for previous or
recurrent upper respiratory infection or pneumonia.

Central nervous system (CNS) symptoms, such as muscle weakness, muscle atrophy,
headache, loss of lower extremity sensation, and localized or radicular back pain,
may be associated with lung cancer.

Any CNS symptom may be the silent sensation of a lung tumor.

Posterior leg or calf pain postoperatively may be caused by a thrombus and must be
reported to the physician before physical therapy begins or continues.

Always follow guidelines for preventing transmission of tuberculosis.

Hemoptysis or exertional/at rest dyspnea either unexplained or out of proportion to

the situation or person, is a red flag symptom requiring medical referral.

Any client with chest pain should be evaluated for trigger points and intercostals
tears.

D. Overview of Hematologic Signs and Symptoms

Key Points to Remember

Anemia may have no symptoms until hemoglobin concentration and hematocrit fall
below one half of normal.

Weakness, fatigue, and dyspnea are early signs of anemia.

Exercise for anemic clients must be instituted with physician approval and gradually
per tolerance and/or perceived exertion levels.

Platelet level below 20,000/mm3 (thrombocytopenia) can be lethal. Multiple bruises

and petechiae may be the only sign.

For clients with known thrombocytopenia, exercise programs must avoid the Valsalva
or bearing down movement, and caution must be used to avoid further injury by
bumping against objects.

During the inspection/observation portion of the objective examination, screen both

hands for skin or nail bed changes indicative of hematologic involvement.

For the client with hemophilia, bleeding episodes must ne treated early with factor
replacement and point immobilization during the period of pain. Never apply heat to
a bleeding or suspected bleeding area.

Pain may be the only symptom of a joint or muscle bleed for the client with
hemophilia. Any painful symptom in this population must be screened medically.

The National Hemophilia Foundation (NHF) publishes therapists treating hemophiliacs:

Physical Therapy in Hemophilia (1986), written by S. Cotta et al. This can be ordered
by calling the NHF at (212) 219-8180.
E. Overview of Gastrointestinal Signs and Symptoms

Key Points to Remember

Gastrointestinal disorders can refer pain to the sternum, shoulder, scapula, low back,
and hip.

The membrane that envelops organs (visceral peritoneum) is insensitive to pain so

that, except in the presence of inflammation/ischemia, it is possible to have
extensive disease without pain.

Clients may not relate known GI disorders to current (or new) musculoskeletal
symptoms)

Sudden and unaccountable changes bowel habits, blood in the stool, or vomiting red
blood or coffee-ground vomitus are red flag symptoms requiring medical follow-up.

Antibiotics and NSAIDs are the drugs that most commonly induce GI symptoms.

Kehrs sign (left shoulder pain) occurs as a result of free air or blood in the abdominal
cavity causing distention (e.g., trauma, ruptured spleen).

F. Overview of Renal and Urologic Signs and Symptoms

Key Points to Remember

Renal and urologic pain can be referred to the shoulder or low back.

Lesions outside the ureter can cause pain on movement of the adjacent iliopsoas
muscle.

Radiculitis can mimic ureteral colic or renal pain, but true renal pain is seldom
affected by movements of the spine.

Low back, pelvis, or femur pain may be the first symptom of prostate cancer.

Inflammatory pain may be relieved by a change in position. Renal colic remains

unchanged by a change in position.

All the possible pain patterns discussed in this chapter are presented as follows.

G. Overview of Hepatic and Biliary Signs and Symptoms

Key Points to Remember

Primary signs and symptoms of liver diseases vary can include GI symptoms, edema,
ascites, dark urine, light-colored or clay-colored feces, and right upper abdominal
pain.

Neurologic symptoms such as confusion, muscle tremors, and asterixis may occur.

Skin changes associated with the hepatic system include jaundice, pallor, orange or
green skin, bruising, spider angiomas, and palmer erythema.

Active, intense exercise should be avoided when the liver is compromised (jaundice or
other active disease).

Anti-inflammatory and minor analgesic agents can cause drug-induced hepatitis.

Non-viral hepatitis may occur postoperatively.
 When liver dysfunction results in increased serum ammonia and urea levels,
peripheral nerve function is impaired. Flapping tremors (asterixis) and
numbness/tingling (carpal tunnel syndrome) can occur.

Musculoskeletal locations of pain associated with the hepatic and biliary systems
include thoracic spine between scapulae, right shoulder, right upper trapezius, right
interscapular, right subscapular areas.

Referred shoulder pain may be the only presenting symptom of hepatic or biliary
disease.

H. Overview of Endocrine and Metabolic Signs and Symptoms

Key Points to Remember

Clients with a variety of endocrine and metabolic disorders commonly complain of

fatigue, muscle weakness, and occasionally muscle or bone pain (Louthrenoo and
Schumacher, 1990)

Muscle weakness associated with endocrine and metabolic disorders usually involves
proximal muscle groups.

Periarthritis and calcific tendinitis of the shoulder is common in endocrine clients.

Symptoms usually respond to treatment of underlying endocrine pathology.

Carpal tunnel syndrome (CTS), hand stiffness, and hand pain occur with endocrine and
metabolic diseases.

There is a correlation between hypothyroidism and fibromyalgia syndrome (FMS)

which is being investigated. Any compromise of muscle energy metabolism aggravates
and perpetuates trigger points (TPs).

Exercise for the diabetic client must be carefully planned, because significant
complications can result from strenuous exercise.

Exercise with the insulin-dependent diabetic client should be coordinated to avoid

peak insulin dosage whenever possible. Any diabetic client who appears confused or
lethargic must be tested immediately by fingerstick for glucose level. Other
precautions for the physical therapist are covered in the text.

When it is impossible to differentiate between ketoacidosis and hyperglycemia,

administration of some source of sugar (glucose) is the immediate action to take.

Early osteoporosis has no visible signs and symptoms. History and risk factors are
important clues.

Cortisol suppresses the bodys inflammatory response, masking early signs of

infection. Any unexplained fever without other symptoms should be a warning to the
physical therapist of the need for medical follow-up.

I. Overview of Oncologic Signs and Symptoms

Key Points to Remember

Spinal cord compression from metastases may present as back pain, leg weakness,
and bowel/bladder symptoms.

Back pain may precede the development of neurologic signs and symptoms in any
person with cancer.
 Signs of nerve root compression may be the first indication of cancer, in particular,
multiple myeloma, or cancer in the lung, breast, prostate, or kidney.

The five most common sites of metastasis are the lymph nodes, liver, lung, bone, and
brain.

The presence of jaundice in association of any atypical presentation of back pain may
indicate liver metastasis.

Lung, breast, prostate, thyroid, and the lymphatics are the primary sites responsible
for most metastatic bone disease.

Monitoring physiologic responses (vital signs) to exercise is important in the

immunosuppressed population. Watch closely for early signs (dyspnea, pallor,
sweating, and fatigue) of cardiopulmonary complications of cancer treatment.

To determine appropriate exercise levels for clients who are immunosuppressed,

review blood test results (WBCs, RBCs, hematocrit, platelets).

Besides the seven early warning signs of cancer, the physical therapist should watch
for idiopathic muscle weakness accompanied by decreased deep tendon reflexes.

Any woman presenting with chest, breast, axillary, or shoulder pain of unknown
etiology must be screened for breast cancer.

Changes in size, shape, tenderness, and consistency of lymph nodes raise a red flag.
Supraclavicular nodes and inguinal nodes are common metastatic sites for cancer.

No reliable physical signs distinguish between benign and malignant soft tissue
lesions; all soft lumps that persist or grow should be reported immediately to the
physician.

J. Overview of Immunologic Signs and Symptoms

Key Points to Remember

Pain in the knees, hands, wrists, or elbows may indicate an autoimmune disorder;
aching in the bones can be caused by expanding bone marrow.

Any change in cough, pain, or fever, or any change or new presentation of symptoms,
should be reported to the physician.

Physical therapist in every clinical setting must be familiar with universal precautions
(see Appendix to Chapter 8).

Be alert to any warning signs of hypersensitivity response (allergic reaction) during

therapy and be prepared to take necessary measures (e.g., graded exercise to client
tolerance, control of room temperature, client use of medications).

Immediate emergency procedures are required when a client has a severe allergic
reaction (anaphylactic shock).

For the client with Guillain-Barr syndrome, active exercise must be at a level
consistent with the clients muscle strength. Overstretching and overuse of painful
muscles may result in prolonged or lack of recovery.

For the client with multiple sclerosis, treatment should take place in the coolest
(temperature) setting possible.

For the client with early stage myositis, muscle fibers are fragile and could be
damaged further by exercises other forms of physical therapy. Maintain close contact
 with the physician for laboratory test results to determine the most opportune time
for each level of the exercise program.

For the client with ankylosing spondylitis the risk of fracture from even minor trauma
and the development of atlanto-axial subluxation necessitate the use of extreme
caution in treatment procedures. The most common site of fracture is the lower
cervical spine.

K. Systematic Origins of Musculoskeletal Pain: Associated Signs and Symptoms

Key Points to Remember

Clients may inaccurately attribute symptoms to a particular incident or activity, or

they may fail to recognize causative factors.

Any person presenting with musculoskeletal pain of unknown cause and/or past
medical history of cancer should be screened for medical disease. Special Questions
for Men and Women may be helpful in this screening process.

When symptoms seem out of proportion to the injury, or if they persist beyond the
expected time for the nature of the injury, medical referral may be indicated.

Pain that is unrelieved by rest or change in position or pain/symptoms that do not fit
the expected mechanical or neuromusculoskeletal pattern should serve as red flag
warnings.

When symptoms cannot be reproduced, aggravated, or altered in any way during the
examination, additional questions to screen for medical disease are indicated.

Shoulder pain aggravated by the supine position may be an indication of mediastinal

or pleural involvement. Shoulder or back pain alleviated by lying on the painful side
may indicate autosplinting (pleural).

Trigger points should always be considered as a possible cause of a presentation like

systemic symptoms.

Chest pain can occur as a result of cervical spine disorders because nerves originating
as high as C3, C$ can extend as far as the nipple line.

Postoperative infection of any kind may not present with any clinical signs/symptoms
for weeks or months.

Muscle weakness without pain, without history of sciatica, and without a positive
straight leg raising (SLR) is suggestive of spinal metastases.

Sciatica may be the first symptom of prostate cancer metastasized to the bones of
the pelvis, lumbar spine, or femur.

Sacral pain, in the absence of a history of trauma or overuse, that is not reproduced
with pressure on the sacrum (client is prone) is a red flag presentation indicating a
possible systematic cause of symptoms.