Special Conditions In

Aging Women
Lets revise
1. What will be the advised period of time to regain preoperative
shoulder ROM for a women who has undergone mastectomy?
A. 2 Mon
B. 3 Mon
C. 4 Mon
D. 5 Mon
2. When Should the breast self exam be performed?
Learning Objectives
- Assess and apply physical therapy
management in females with
osteoporosis and osteoporotic
fractures.
- Physical therapy management of
women with long-term physical
disabilities
- Understand the DSM IV classifications
of psychosocial disorders and the
implications for screening, referral,
and intervention
Osteoporosis
Pathophysiology of osteoporosis
• Osteoporosis is defined as low
bone mineral density caused by
altered bone microstructure
ultimately predisposing patients to
low-impact, fragility fractures.
• Osteoporotic fractures lead to a
significant decrease in quality of
life, with increased morbidity,
mortality, and disability.
• Over 50% of postmenopausal
white women will have an
osteoporotic-related fracture.
What are the risk factors
for Osteoporosis?
Diagnosis
• Who should I assess for osteoporosis and fracture risk?
• Post menopausal women and men over age 50
• Individuals over age 50 who have experienced a fragility fracture
• How do I assess for osteoporosis and fracture risk?
• detailed history and a focused physical examination to identify risk factors for
low bone mineral density, falls and fractures
The clinical investigation of patients
• Osteoporosis is asymptomatic
• patients usually first come to clinical attention after sustaining a fragility
fracture, the primary manifestation of the disease
• signs and symptoms due to any one of the many disorders that cause
secondary osteoporosis should be sought e.g.
• malabsorption (e.g. due to coeliac or inflammatory bowel disease),
• hyperthyroidism,
• hyperparathyroidism,
• Cushing's disease,
• hypogonadism,
• rheumatoid arthritis,
• alcoholism and chronic obstructive pulmonary disease
Investigations
• DEXA (Dual energy X-Ray Absorptiometry- Standard test)
• CT
• laboratory investigations
• Calcium
• CBC
• Creatinine
• Alkaline phosphatase
• TSH
• Serum protein electrophoresis ( with vertebral fractures)
• 25- Hydroxy Vit D (after 3-4 months of supplementation)
• bone turnover markers
DEXA
- Simple test that measures bone
mineral density.
- Spine and hip, including femoral neck
- It is similar to an X-ray, but uses much
less radiation.
DEXA
• the criterion standard for the evaluation of BMD.
• DXA provides the patient’s T-score, which is the BMD value compared
with that of control subjects who are at their peak BMD.
WHO Definition of Osteoporosis Based on BMD Measurements
by DXA
Assessment
Risk factors
• Gender • Inadequate calcium intake or
• Race impaired calcium absorption
• Family history • Alcohol
• Age • Caffeine
• Low body weight • Smoking
• Early menopause (including surgical) • Nullipara
• Loss of menstruation (induced by
anorexia or exercise)
• Glucocorticoid use
• Low physical activity levels and • Rheumatoid arthritis
immobilization • Lactation
Fracture types that allow a diagnosis of
osteoporosis
• a low-trauma hip fracture, with or without BMD test
• A low-trauma clinical vertebral fracture, proximal humerus fracture,
or pelvis fracture
• a low-trauma distal forearm fracture in a person with osteopenia at
the lumbar spine or hip by BMD testing
Assessing the 10-year fracture risk
• FRAX is a World Health Organization-sponsored, country-specific
fracture risk assessment tool that combines BMD at the femoral neck
(or total hip) with a group of well-validated and weighted clinical risk
factors for fracture that are largely independent of BMD
• Recommended primarily for individuals with a BMD finding of
osteopenia
Clinical manifestations
Management
• Patient education
• Lifestyle Modification
• Pharmacotherapy
• Calcium and Vit-D
• HRT
• Vertebral Fractures Management
• PT Management
Patient Education and lifestyle
modification
Patient Education:
• Risk factors
Lifestyle modification
• Pain management including self-
help techniques
• Exercise
• Nutritional information
Increasing weight-bearing Ca2+,
and muscle-strengthening
Vit-D, Anti fracture therapy
• Prevention of falls
exercise
• Other professionals’ help
How can one reduce
the risk of falls?
Calcium and Vit-D
• Total daily intake of elemental calcium > 50 years = 1200 mg
• Healthy adults at low risk of vitamin D deficiency = 400–1000 IU (10–25 μg)
• Adults > 50 at moderate risk of vitamin D deficiency = 800–1000 IU (20–25
μg)
• To achieve optimal vitamin D status > 1000 IU (25 μg) /day
• Upto 2000 IU/day are safe and do not necessitate monitoring
• For individuals receiving pharmacologic therapy for osteoporosis,
measurement of serum 25-hydroxyvitamin D should follow three to
four months of adequate supplementation and should not be
repeated if an optimal level (≥ 75 nmol/L) is achieved
HRT
• Oestrogen (with or without progesterone) can be used to prevent loss
of bone density if administered at or near to menopause
• QOL improvement
• Reduces fracture risk in post-menopausal women
Vertebral Fractures Management
• Bed rest and activity limitation… harmful in long term
• Need for hospitalization may vary
• Home support services
• Manage pain and mobility
• Verbal cues are very important
 PT Management
The main problems faced by
the patient are:
• Pain Goals for the PT include
• Fear of movement • To reduce or minimize pain during or after
• Depression exercise
• Early mobilization
• Activation of the major trunk stabilizers
• The maintenance of the patient-physiotherapist
relationship
 PT Management
Mobility and Transfers Pain Management
• Motivation
• Individual position of comfort • Education
• Ice
• Mattress suitability • Superficial heat
• Bed positions • Electrotherapy
• Soft tissue manipulation
• Movement and exercise • Spinal mobilization techniques
• Record via activity charts • TENS
• Bracing-spinal orthotics
• VAS • Hydrotherapy
• Cognitive and behavioral strategies
• Assistive devices • Rest
• Relaxation therapy
Exercise
• “movement” better word than
“exercise” in initial phase
• Pain reduction
• Spinal extension exercises
• Static exercises
• Prone lying encouraged
• Exercising peripheral
musculature
• Hydrotherapy
• Weight-bearing exercise
• Resistance exercise
• High intensity, low-repetition
muscle-strengthening program
with HRT
• Aerobic exercise
• Aerobic exercise with weight
training
A progression of neck, back and
shoulder exercises and postures
Long term Management
• To maintain, slow the loss of or increase bone density in patients at
risk of osteoporosis, those with diagnosed osteoporosis and no
fracture or those with osteoporotic fracture
• To reduce pain if it exists
• To prevent spinal deformity and vertebral fractures
• The prevention of falls and the maintenance of mobility and
independence
• Education
Activity: Lets discuss the
exercise guidelines for
postmenopausal women.
Women With Long-term
Physical Disabilities
Models of Disablement
An Approach to Patient Care
• Disablement models allow you to think beyond the physical presentation of
the injury
• Appreciates unique needs of patients by respecting Differences
• Values
• Needs
• Preferences
And
• By Listening
• Communicating
• Educating
Managing Females With Long Term
Disabilities
promising model of care developed specifically for people with multiple
conditions is the guided care model (Aliotta et al 2008).
• self-management and carer support, comprising several hours of training for
patient and carer alike, focusing on managing multi morbidity
• home-based assessment of patient
• transitional care, comprising close, structured support through
• transitions in care (for example, after discharge from hospital)
• care managers trained in motivational interviewing
• predictive modelling, to identify multi-morbid patients
DSM IV classifications of psychosocial
disorders and the implications for
screening, referral, and intervention
Common Psychosocial Disorders in women
through life stages
• Anxiety
• Depression
• PMS
• PMDD
Postpartum depression
• Menstrual psychosis
• PTSD
• Phobias: excessive fear of a specific object, circumstance or a situation.
• Eating disorders
• BPD
Mood Disorders
• Major depressive disorder is characterized by one or more major
depressive episodes (at least 2 weeks of depressed mood or loss of
interest in usual activities accompanied by at least four additional
symptoms of depression).
• Bipolar disorder is characterized by at least one manic or mixed episode
(mania and depression) with or without a history of major depression.
• Dysthymic disorder is essentially a chronically depressed mood that
occurs for most of the day for more days than not over a period of at
least two years, without long, symptom free periods. Symptom-free
periods last no longer than 2 months.
Depression VS Mania
Anxiety Disorders
• Social Anxiety: Involves the fear of social situations including
situations involving scrutiny or contact with strangers.)
• Generalized anxiety Disorder: excessive anxiety or worry about
several events or activities for most days during at least 6-month
period.
• PMS: affects a woman's emotions, physical health, and behavior during certain
days of the menstrual cycle, generally just before her menses. PMS is a very
common condition. Its symptoms affect more than 90 percent of menstruating
women.
• PMDD: Severe form of PMS
• Menstrual Psychosis: this is a particular kind of psychosis that occurs following
the menstrual period, usually described as the time frame between 3 days
before and 3 days after the first day of the menses.
• PTSD: a psychiatric disorder that may occur in people who have experienced or
witnessed a traumatic event such as a natural disaster, a serious accident, a
terrorist act, war/combat, or rape or who have been threatened with death,
sexual violence or serious injury.
Lets check our anixeties
• https://patient.info/doctor/generalised-anxiety-disorder-assessment-
gad-7
• https://nationalsocialanxietycenter.com/liebowitz-sa-scale/
Resources
• https://osteoporosis.ca/health-care-professionals/clinical-practice-gui
delines/exercise-recommendations/video-series-on-exercise-and-oste
oporosis/
• https://www.webmd.com/osteoporosis/video/exercise-osteoporosis
• https://www.youtube.com/watch?v=LcCH5F22lY4&t=10s