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PHARMACOLOGY AND MEDICAL

CARE CONSIDERATIONS FOR

PHYSICAL REHABILITATION

Cardiopulmonary Conditions and

Diabetes

Douglas DeRitis, RPh, PharmD & Colleen DeRitis, MA, OTR/L

Agenda

• Cardiopulmonary

Conditions

– (Cardiac Disease,

Coronary Artery Disease,

Myocardial Infarction, A-

fibrillation, COPD)

– Pharmacological Issues

and Barriers

– Implications for

Rehabilitation

– Documentation to

support Rehab

Progress/Limitations

• Diabetes

• Medical Considerations

• Sensory Issues (Peripheral

Neuropathy, Vision Problems)

• Foot Inspection and Care

• Pharmacological Issues and Barriers

– Glucose Testing

– Insulin Usage

– Medication Management

– Adaptive Devices

• Implications for Rehabilitation

• Documentation to support Rehab

Progress/Limitations

To review…Process of Pharmacokinetics

• Absorption

• Distribution

• Storage

• Elimination

–Metabolism

– Excretion

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Cardiac Disease

Cardiovascular Disease

• Incidence of heart disease has decreased

• Other conditions present and increase with

age:

– Hypertension

– CHF

– CAD

• Consider co-existing conditions

• Know the classes of cardiac meds

Diagnosis of Cardiac Problems

• Blood serum levels

• Creatine Phosphokinase(CPK)

– Elevated after MI during 4 hrs and peaks at 36 hrs.

• Lactate dehydrogenase (LDH)

• LDH- tissue breakdown

• LDH- MI: peaks in 3 to 4

days, may remain elevated

for up to 10 days.

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Cardiac Output

• Cardiac Output = stroke volume (SV) x heart

rate (HR)

• Influenced by meds that effect heart

• Male 5.6L/min

• Female 4.9 L/min

Factors effecting heart disease• Smoke

• Blood Pressure

• Cholesterol

• Lack of exercise/Inactivity

• Stressors

• Genetics

• Diet

• Diabetes/Other pre-existing conditions

• Age

• Obesity

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Hypertension

• Pharmacology:

– Lowest dose of drug choice

– Diuretics

• Sensitive

• Non-sensitive

• START LOW & GO SLOW!

Blood Pressure Disorders

• High blood pressure, or hypertension

• High blood pressure for adults 140 mm Hg or greater systolic pressure and 90 mm Hg or greater diastolic pressure

• Pre-hypertension- 120 mm Hg – 139 mm Hg systolic pressure and 80 mm Hg – 89 mm Hg diastolic pressure

• Normal=Less than 120 mm Hg systolic pressure and Less than 80 mm Hg diastolic pressure

• Precautions

Coronary Artery Disease

Due to arteriosclerosis process

• Thickening of inner vessels

• Fatty tissue cause

– Decrease in coronary blood flowdecrease

myocardial O2 demand and supply ischemia

– Can also be due to other reasons

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Arteriosclerosis

– Progressive destruction of the arterial structure

– Development of plaque lesions

• Fatty Streak

• Fibrous Plaque (typical)

• Complicated Plaque

– Calcification necrosis

– Hemorrhage

– Thrombus

– Aneurysm

Angina

• Chest pain or discomfort

• Heart muscle does not get enough blood.

• Pressure or a squeezing pain in your chest.

– Indigestion.

– May also feel pain in shoulders, arms, neck, jaw or back.

• Symptom of coronary artery disease (CAD)

• Three types:

– Stable

– unstable

– variant.

• Not all chest pain or discomfort is angina.

Myocardial Infarction

– Heart Attack

– Due to prolonged ischemia

• Symptoms:

– Pain

– Elevated blood serum levels

– Organ involvement

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ArrhythmiaHeart skips a beat… it’s not just love• Any disorder of your heart rate or rhythm.

– too quickly Tachycardia

– too slowly Bradycardia

– with an irregular pattern

• Factors effecting rhythm:– History of heart attack

– Blood chemistry imbalances

– Abnormal hormone levels.

– Some substances or medicines

• Symptoms of arrhythmias

– Fast or slow heart beat

– Skipping beats

– Lightheadedness, dizziness

– Chest pain

– Shortness of breath

– Paleness

– Sweating

Pacemakers

• Monitors impulses in heart

• Implantable cardioverter

defibrillator

• Life Vest

• Considerations for therapy

Implications for the Pharmacist

• Secondary Prevention

– Long term treatment to prevent recurrent cardiac

morbidity and mortality and to improve quality of

life in people who either have had a prior acute MI

or are at high risk of cardiac events…such as severe coronary artery stenosis, angina, or prior

surgical procedures…– BMJ definitions, May, 2006

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Cardiac Meds

• Grouped by mechanism of action

– Beta-adrenergic receptor antagonists

– Vasodilators

– Diuretics

– Digitalis

– Anti-arrhyhtmic agents

– Statins

• Prevention

– Primary

– Secondary

Meds

• Beta Blockers

• Calcium Channel Blockers

• Antiplatelet therapy

• Aspirin(Bayer, Ecotrin, ECASA, Astrin)

• Ticlopidine (Ticlid): MOA same as clopodogrel

• Clopidogrel (Plavix): inhibit platelet clumping

process by blocking the (ADP) receptor sites

on the platelet cell surface

Beta-Adrenergic Receptor Antagonists

(Beta Blockers)

• Inhibit the sympathetic nervous system

• Minimize bradycardia and depression of

myocardial contractility at rest.

• Decrease in HR, increase Ejection Fraction

• Decrease renin secretion

• Decrease heart O2 demand by

decreasing extracellular volume.

• Incr. carrying capacity of blood.

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-Adrenergic Blockers

• Atenolol/Tenormin

• Carvedilol/Coreg

• Metoprolol/Lopressor

• Nadolol/Corgard

• Propranolol/Inderal

Rehabilitation Considerations:

Beta-Adrenergic Receptor Antagonists

(Beta Blockers)

• Depresses increases in HR and BP

• Patients with ischemia and angina-

– Increase exercise tolerance

• Longer time before angina

• Cannot use Max HR prediction formula

• Base on exercise stress test

-Adrenergic Blockers

Adverse Effects:

- Diarrhea

- Bradycardia

- Hypotension

- Drowsiness, lethargy, fatigue

- Depression

- Bronchospasm

- Weakness

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Anticoagulants

Heparins

-Heparin ( monitor w/ coagulation parameters )

-Low molecular weight Heparins ( monitor anti-

factor XA activity ): use in PE or DVT

-Dalteparin

-Enoxaparin

-Tinzaparin

• Oral

– Warfarin/Coumadin

Rehabilitation Implications:

Anti-Coagulants

Adverse effects:

–Bleeding

– Thrombocytopenia

–Be watchful for hematomas, bruising, etc.

–Patient’s that fall while taking these medications must be monitored very carefully for a possible subdural hematoma.

–Avoid intake of foods high in Vitamin K

Organic Nitrate Dilators

• Venous dilators ( relax smooth muscle )

• Decrease venous pressure, preload, CO

• Decrease O2 demand of the heart

• Increase O2 supply/demand ratio

• Decreasing preload leads to decreasing

ventricular wall stress by decreasing size of

heart.

• Good for angina

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Nitrates

• Types– Isosorbide Dinitrate/Isordil

– Isosorbide Mononitrate/Imdur

– Nitroglycerin

• Rehabilitation Implications– Headache

– Syncope

– Dizziness

– Hypotension

– Bradycardia

Rehabilitation Considerations and

Adverse Effects: Diuretics

• Hypokalemia

• Hyperuricemia

• Hyperglycemia

• Hypomagnesemia

• Hyponatremia

• Lipid abnormalities

Diuretics Classifications

Filtration diuretics Theophyline

Caffeine

Proximal tubular diuretics Mannitol

Acetazolamide Diamox

Loop of Henle Bumetanide Bumex

Furosemide Lasix

Torsemide Demadex

Distal Tubular Thiazides

Chlorthalidone Hygroton

Metolazone Zaroxolyn

Collecting Duct Amiloride Midamor

Triameterene Dyrenium

Spironolactone Aldactone

Indapamide Lozol

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Medication Indication Action

Diuretics Fluid Retention Reduce fluid overload

ACE inhibitors Limit left ventricular

remodeling

Reduce afterload

Digoxin Inotropic incompetence Improve contractility

Beta Blockers Hyper-adrenergic state Autonomic modulation

Medication Action Indication/Effect

Statins Decreased arthrosclerosis

Proangiogenic

Dyslipidemia

Improved pain-free walking

Reduced mortality

Aspirin Antiplatelet aggregation Decreased MI by 18%

Clopidogrel (Plavix) Antiplatelet aggregation Reduced risk of MI/vascular

death by 23.8% more than

aspirin

Beta Blockers

ACE inhibitors

Sympatholytic

Afterload reduction

Reduced risk of MI

Reduced mortality

Reduced ischemic events

Calcium channel blockers

Nitrates

Vasodilation Reduced claudication

Reduced angina

Signs of excessive potassium loss

• Dry mouth

• Increased thirst

• Irregular heartbeats

• Mood changes

• Muscle cramps

• Nausea

• Vomiting

• Tiredness

• Weakness

• Weak pulse

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ACE Inhibitors

• Blocks vasoconstriction by blocks ACE

( angiotensin converting enzyme ).

• Decrease BP, controls HTN

• Increases Na+ and H2O excretion which

decreases blood volume, holds onto K+

• Decreases release of aldosterone ( decreases

Na+, Cl-, H2O retention, decreases BP )

• Decreases release of vasopressin (pituitary)

ACE Inhibitors• Benazepril

• Captopril

• Enalapril

• Fosinopril

• Lisinopril

• Moexipril

• Quinapril

• Ramipril

• Trandolapril

Rehabilitation Implications and

Adverse Effects:

ACE Inhibitors

• Hypotension

• Rash

• Angioedema

• Cough

• Taste disturbance

• hyperkalemia

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Calcium Channel Blockers

• Amlodipine: dihydropyridine

• Diltiazem: benzothiazepine

• Nicardipine: dihydropyridine

• Nifedipine: dihydropyridine

• Verapamil:

phenyalkylamine

Calcium Channel Blockers

• Non-dihydropyridines: decrease force of

contraction of myocardium. This is called

negative inotropic effect. ( e.g. verapamil,

diltiazem )

• Dihydropyridines: slow down conduxtion of

electrical activity within the heart. This is

called negative chronotropic effect. ( e.g.

amlodipine, nifedipine, isradipine ); for a-fib,

a-flutter where rate control is essential.

Statins- HMG-CoA Reductase

Inhibitors

• Pravachol ( pravastatin )

• Zocor ( simvastatin)

• Lipitor ( atorvastatin )

• Crestor ( rosuvastatin )

• HMG-CoA plays a key role in

production of cholesterol in

the liver.

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HMG-CoA Reductase Inhibitors

• Muscle problems (rhabdomyolysis)

• Elevated liver enzymes

• Myalgias

• Less Common:

- neuropathy

- cognitive loss

- hepatic and pancreatic dysfunction

- sexual dysfunction

Heart Failure

• Types

– Right Ventricular Failure

– Left Ventricular Failure

– Non-Specific

• Symptoms

• Signs

Heart Failure

Stage A: identifies the patient who is at high risk for developing HF, but has no structural disorder of the heart.Stage B: patient with a structural disorder of the heart, but has never presented with symptoms.

Stage C: patient with past or current symptoms of HF associated with underlying structural heart disease.

Stage D: patient with end-stage disease who require specialized treatment strategies ( e.g. mechanical circulatory support, hospice ).

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Rehabilitation Implications:

Heart Failure

• Reduced exercise tolerance

• Impaired quality of life

• Reduced life expectancy

Heart Failure-Class of Drugs to Avoid

• Anti-arrhythmic agents: can exert cardio-depressant and pro-arrhythmic effects. ( only amiodarone has been shown not to adversely affect survival ).

• Calcium channel blockers: have been shown to be associated with an increased risk of cardiovascular events.

• NSAID’S: can cause sodium retention and peripheral vasoconstriction.

Medications in Heart Failure

Management

• Combination of 4 types of drugs

• Diuretic

• ACE Inhibitor

• Beta-blocker

• Digitalis (Digoxin)

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Cardiac Rehabilitation

• “sum of activity required to ensure cardiac patients the best possible physical, mental,

and social conditions so…they may…regain as normal as possible a place in the community

and lead an active life.”

Rehabilitation Implications

Monitoring Physical Activity

• HR

• BP

• Abnormal signs and symptoms

• Electrocardio-radiography

• Measurements

– Pre-exercise baseline

– 2-3 minute interval

– 5-6 minutes

• Ability to perform exercise

– Duration

Metabolic Equivalent (MET) Level

• How hard one is working to do the activity

• Estimates the amount of oxygen used by the body during physical activity

• 1 MET = the energy (oxygen) used by the body as you sit quietly, perhaps while talking on the phone or reading a book.

• The harder your body works during the activity, the higher the MET.

• 3 to 6 METs = moderate-intensity physical activity.

• > 6 METs = vigorous-intensity physical activity.

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METS values- ADL

Activity METS (min) METS (max)

Bed making 2 6

Carrying groceries 5 7

Cleaning windows 3 4

Cooking(standing) 2 3

Dressing 2 3

Eating 1 2

Sexual Intercourse 3 5

Showering 3 5

Walking up stairs 4 7

Watching TV 1 2

METS values- Leisure

Activity METS (min) METS (max)

Cycling 5mph 2 3

10mph 5 6

Dancing Ballroom 4 5

Aerobic 6 9

Swimming Freestyle 9 10

Tennis 4 9

Walking 1mph 1 2

2mph 2 3

3mph 3.4 4

Rehabilitation Implication

General-Cardiac Medications• Effect on heart or vascular system

– Altering myocardial oxygen consumption

– Peripheral blood flow

– Cardiac pre-load or afterload

• Increase/decrease exercise capacity

• Alter expected changes in heart rate/BP

• Controls abnormality at rest only

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Exercise Response

• Altering factors that determine myocardial

oxygen demands/delivery

• Imbalance between heat production and

dissipation

• Interfere with glycogenolysis or fatty acid

mobilization and oxidation

Pulmonary Conditions

Pulmonary Considerations

Millions people diagnosed with COPD

– bronchitis

– emphysema

– not diagnosed

• Large number of MD office visits, ER, and

hospitalizations

• Functional limitations

• Economic considerations

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Chronic Obstructive Pulmonary Disease

• COPD

• Airways are obstructed

• Causes

– Smoking

– Pollutants

A disease by any other name…

• COPD also known as:

– Chronic obstructive airway disease

– Chronic obstructive lung disease

• Includes:

– Emphysema

– Chronic Bronchitis

– Asthma

COPD

• Inflammation, fibrosis and narrowing of small

airways

– Increased airway resistance and obstruction

• Bronchial changes

• Emphysematous changes

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Stages of COPD

• Mild: FEV 80 % or greater, no abnormal signs,

cough +/- sputum, little or no dyspnea

• Moderate: FEV 50-79, breathessness ( +/-

wheeze on moderate exertion), cough +/-

sputum, general reduction in breath sounds,

presence of wheezes, hypoxemia may be

present

Stages of COPD

• Severe: FEV 30-49

• Very Severe: FEV < 30

• Dyspnea with any exertion or at rest

• Wheeze and cough often prominent

• Lung hyperinflation usual; cyanosis, peripheral

edema and polycythemia in advanced disease

• Hypoxemia and hypercapnia are common

Causes of COPD

• Smoking

• Pollutants

• Chemicals

• Dust

• Second-hand smoke

• Genetics

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What Are the Signs and Symptoms of

COPD?

• Cough

• Sputum

• SOB

• Wheezing

• Chest tightness

• Cough that doesn’t go away

Emphysema• Lung defect

– Permanent enlargement of

air spaces

– Destruction of alveolar walls

– Obstruction and airway

collapse occur on expiration

• Adaptation

– Use accessory muscles

– Prolonged expiratory phase

Chronic Bronchitis

• Excessive mucous production and secretion

– Airway obstruction

• Due to inflammation and edema

• Inflammation and edema of mucosa

• Copious sputum

– Recurrent infections

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Asthma

• Airway obstruction

– Reversible

• Airway inflammation

• Increased airway responsiveness to stimuli

• Episodic symptoms

• Pathophysiology

How Is COPD Treated?

• Quit smoking

• Pulmonary rehab

• Exercise

• Education

• Oxygen

• Surgery

Goals • Symptom management

• Decrease disability and slow

progression

• Exacerbations

• PFTs as close to normal

• Avoid adverse effects of

medication

• Prevent fixed, irreversible

airway obstruction and

damage

• Avoid mortality

• Functional Activity

• Increase participation in

physical/social activity

• Quality of life

• Bronchodilation

• Decreased inflammation

• Mucous mobilized

• Pharmacotherapy

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Respiratory disease Types Mechanisms

Peripheral muscle dysfunction Deconditioning, steroid myopathy, ICU

neuropathy, malnutrition, decrease lean

body mass, fatigue, hypoxemia, electrolyte

abnormalities

Respiratory muscle dysfunction Hyperinflation, malnutrition, diaphragmatic

fatigue, steroid myopathy, electrolyte

abnormalities

Nutritional Issues Obesity, cachexia, decreased lean body

mass

Skeletal disease Osteoporosis, scoliosis

Sensory deficits Medications

Psychosocial Anxiety, depression, guilt, panic,

dependency, cognitive deficits, sleep issues,

sexual dysfunction

COPD Medications

• Bronchodilators

• Inhaled Steroids

• Flu Shots

• Pneumonia vaccine

Pharmacological Considerations

• Theophylline ( aminophylline, theophylline )

• Beta Agonists ( albuterol, salmeterol )

• Mast cell stabilizers ( Nedocromil )

• Leukotriene modifiers ( Montelukast,

Zafirlukast, Zileuton )

• Corticosteroids ( Betamethasone, Fluticasone )

• Anticholinergics ( Ipratropium, Tiotropium )

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Pharmacological Considerations

• Theophylline: relaxes bronchial smooth

muscle.

• Increases heart muscle contractility

– (+ inotropic), HR, BP, renal blood flow

• Narrow therapeutic index

• Headache CNS excitation, dizziness, nausea,

diarrhea

• Interacts ( cimetidine, quinolones, e-mycin )

Pharmacological Considerations

• Beta-Agonists: smooth muscle relaxation,

may see insomnia, tremor, anxiety.

• Mast Cell Stabilizers: prevent/control certain

allergic disorders; treat asthma and hay fever.

• Leukotriene Modifiers: reduce inflammation;

less effective than corticosteroids.

• Corticosteroids: reduce inflammation that

constrict airways.

Side effects and reactions

• Drug interactions ( theophylline)

• GI Upset ( theophylline; CNS excitatory effects)

• CNS ( headache; tremor, irritability,

anxiousness, tremor )

• Cardiac ( increase BP, HR ): theophylline, beta-

agonists

• Serum levels: theophylline– monitor levels

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Pulmonary Rehabilitation

• Definition

– Multidisciplinary, comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing manifestations of the disease

– American Thoracic Society(ATS) Statement on Pulmonary Rehabilitation(2006)

Living With COPD

• Symptom management

• Smoking cessation

• Home clean

• Medical follow up

• When to get help

Indications for rehabilitation

• Symptomatic

• Limitations with exercise capacity

• Loss of independence

• Lung volume reduction surgery

• Transplant

• Nutritional issues

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Patient Education Resources

• Ready, Aim, Improve Tools (www.medqic.org)

• Living Well with Chronic Lung Disease: A

Guide for Pulmonary Rehabilitation (Krames)

• COPD: Exercise and Daily Activity (Krames)

Benefits of pulmonary rehabilitation

Reduced areas Use of medical resources

Hospitalizations

ER visits

MD visits

Respiratory symptoms

Psych symptoms

End of life issues Health care proxy

Living will

Use of chronic ventilation

Improved QOL

Exercise tolerance

Physical activity

Return to work

Knowledge about disease

Independence

Control of symptoms

Beck depression inventory (0-16)

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Diabetes

Diabetes Mellitus

• Prevalence

• Insulin functions:

– Increase uptake of glucose by muscle and fat

– Increase liver glycogen stores

– Decrease glycogen breakdown by liver

– Increase synthesis of fatty acids

– Decrease breakdown fatty acids into ketone bodies

– Promote incorporation amino acids into protein

Types of Diabetes

• Type I– Little or no insulin produced in

pancreas

– Cells are starved

– May see weight loss and dehydration

– Usually <20 years old

– More common in white people

– Equally effects women and men

– Managed with insulin

– Rapid onset

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Types of Diabetes• Type II

– Insulin resistance

– Over age 40 with gradual onset

– Unknown etiology

– People at risk include• Family history

• History of gestational DM

• Overweight or obese

• High triglycerides

• Hypertension

• Inactive

– Managed with:• Exercise

• Meal Planning

• Oral Agents

• Insulin

Labwork and Monitoring Diabetes

• Blood Glucose

• HbA1c

• Parameters

Insulin

Fast Lispro Humalog

Aspart Novolog

Regular

Med NPH

Lente

Slow Ultralente

Glargine Lantus

Continuous Subcutaneous

Insulin Infusion

Lispro

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Insulin Adverse Effects

• Hypoglycemia

– Glucagon

– Glucose

• Lipoatrophy

• Lipohypertrophy

• Figure out cause and correct

Diabetes Medications

• Sulfonylureas ( glyburide, glipizide, glimepiride

chlopropamide )

• Thiazolidnediones ( rosiglitazone, pioglitizone )

• Biguanide ( metformin)

• Meglitinide ( repaglinide, nateglinide )

• Alpha-glucosidase Inhibitors: ( acarbose, miglitol )

• DDP-4 Inhibitors: ( sitagliptin, saxagliptin )

• GLP-1 agonists: exenatide, liraglutide

Diabetes Medications

• Sulfonyureas: sensitize Beta cells to glucose.

There is a increase in the amount of

endogenous insulin secreted due to an

increase of intercellular calcium.

• Thiazolidnediones: regulates glucose/fat

metabolism promoting better use of glucose

by cells.

• Biguanide: reduce hepatic glucose output;

increase uptake of glucose by periphery

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Diabetes Medications

• Meglitinide: helps pancreas produce insulin;

closes K+ channels in pancreatic B-cells; opens

Ca++ channels. This will lead to enhanced

insulin secretion.

• Alpha Glucosidase Inhibitors: slow the

digestion of starch in the small intestine;

glucose from starch enters the bloodstream

more slowly; insulin can match the amount of

glucose more effectively.

Diabetes Medications

• GLP-1 agonists: agents bind to a membrane

on the GLP receptor. Results in an increase in

insulin secretion. Suppressed pancreatic

release of glucagon in response to eating.

• DDP-4 Inhibitors: prevents breakdown of GLP-

1 by DDP-4. As a result, more insulin is

released from Beta cells in pancreas.

Hypoglycemia

• Headache

• Nervousness

• Irritability

• Hunger

• Faintness

• Diaphoresis

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Hyperglycemia

• Confusion

• Weakness

• Fruity Breath

• Polyphagia

• Polydypsia

• Polyuria

• Nausea

• Vomiting

Additional Complications of

Diabetes

• Neuropathy

• Retinopathy/Vision Changes

• Renal Disease /Dialysis

• Risk for Skin Changes

• Heart Disease and Stroke

Rehabilitation Implications

• Skin inspection

• Foot screening

• Sensation

• Vision changes

• Balance/Proprioception

• ADL’s and Safety issues

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Blood Glucose Guidelines

• A. <100 mg/dl: 15-30 grams of Carbohydrates. Recheck after 30 minutes. Do not exercise if still < 100

• B. 100-150 mg/dl: 15 grams of Carbohydrates for each 1/2 hour of exercise.

• C. 150-200 mg/dl: No need to eat before exercise. Blood glucose must be checked after.

• D. > 200 mg/dl: No need to eat unless exercise is prolonged.

• E. > 300 mg/dl: Do not exercise patient. Contact MD/Nurse.

Simple assessment strategies for you

related to Medications:

• Ask them to read you something

• Can they open a medication?

• Can they use both hands together?

• Can they prepare simple meals following

dietary regulations?

• Can they tell time?

• When did they eat their last meal?

Devices for Diabetic Management

C.McCaul, MA, OTR/L,

2004

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AND STILL MORE…

C.McCaul, MA, OTR/L,

2004

COUPLE MORE…

C.McCaul, MA, OTR/L,

2004

Exercise benefits for people with

Diabetes

• Lowers Blood Glucose*

• Improves Insulin Utilization

• Lowers BP*

• Helps improve HDL

• Improves Sleep

• Relieves Stress

• Maintain Healthy Weight

• Prevents onset of Type II Diabetes

• Improves/Maintains Strength and

Flexibility

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Diabetic Foot Screening

• 11 question screen

• Foot ulcer history

• Toes

• Nails

• Calluses

• Temperature

• Swelling

• Shoes

Diabetic Foot Screening

• Is there a history of foot ulcers?

• Is there a foot ulcer now?

• Is there an abnormal shape of the foot?

• Is there a toe deformity?

• Are the toenails thick or ingrown?

• Is there callus buildup?

• Is there swelling?

• Is there elevated skin temp?

• Is there muscle weakness?

• Can the pt see the bottom of feet?

• Is the pt wearing improperly fitting shoes?

Monofilament Testing

http://ndep.nih.gov/diabetes/pubs/Feet_Kit_Eng.pdf

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Therapy Implications

• Document patients’ physiological response during ADL/activities

• Watch use of isometrics

• Old habits die hard

• Dropout rates: Cardiac Rehab especially

women>men

– Transportation

– Medical co-morbidities

– Psychosocial impairments

Therapy implications

• Lifestyle modification

• Weakness

– Prolonged bedrest AKA deconditioning

• Fear

– Resuming life

– Return to work

• Can enhance life

• Perspective on what’s important

Questions?