Key Takeaways
- Lymphedema management uses Complete Decongestive Therapy (CDT): manual lymphatic drainage, compression bandaging, exercise, and skin care
- Diabetes effects on PT: Type 1 (insulin-dependent, autoimmune) and Type 2 (insulin resistance); exercise lowers blood glucose; monitor for hypoglycemia during exercise
- Hypoglycemia signs during exercise: shakiness, sweating, confusion, pallor, tachycardia; treat with 15g fast-acting carbohydrate (Rule of 15)
- Oncology rehab: exercise is safe and beneficial during/after cancer treatment; monitor for fatigue, bone metastases (fracture risk), neutropenia (infection risk), and thrombocytopenia (bleeding risk)
- Osteoporosis: T-score of -1.0 to -2.5 is osteopenia; T-score below -2.5 is osteoporosis; weight-bearing and resistance exercises are recommended; avoid excessive spinal flexion
- GI/GU considerations: pelvic floor dysfunction is treated with Kegel exercises, biofeedback, and behavioral training; urinary incontinence types include stress, urge, and mixed
- Obstetric PT: diastasis recti screening, pelvic floor strengthening, exercise modifications by trimester, and postpartum rehabilitation
- Metabolic syndrome: cluster of conditions including central obesity, hypertension, hyperglycemia, high triglycerides, and low HDL cholesterol
Other Body Systems
This section covers body systems beyond the primary musculoskeletal, neuromuscular, and cardiopulmonary domains. While individually representing smaller portions of the NPTE, these topics collectively account for 4-7% of the exam and often involve complex clinical scenarios.
Lymphedema Management
Lymphedema is chronic swelling caused by impaired lymphatic drainage. It is most commonly secondary to lymph node removal or radiation for cancer treatment.
Complete Decongestive Therapy (CDT) — Gold Standard
CDT has two phases:
Phase I: Intensive/Reductive Phase (2-4 weeks)
| Component | Description |
|---|---|
| Manual Lymphatic Drainage (MLD) | Gentle, rhythmic massage that redirects lymph fluid from congested to functional lymphatic pathways |
| Compression Bandaging | Short-stretch bandages applied in layers to maintain fluid reduction after MLD |
| Therapeutic Exercise | Gentle, rhythmic exercises performed WITH compression to enhance lymph flow |
| Skin Care | Meticulous skin hygiene to prevent infection (cellulitis is a major complication) |
Phase II: Maintenance Phase (lifelong)
- Custom-fitted compression garments (20-60 mmHg depending on severity)
- Continued exercise and skin care
- Self-MLD as needed
- Garment replacement every 4-6 months
Contraindications to MLD:
- Acute infection (cellulitis) in the affected limb
- Active cancer in the lymphatic drainage area
- Congestive heart failure (risk of fluid overload)
- Deep vein thrombosis (DVT) in the affected limb
Diabetes and Exercise
Type 1 vs. Type 2 Diabetes
| Feature | Type 1 | Type 2 |
|---|---|---|
| Cause | Autoimmune destruction of pancreatic beta cells | Insulin resistance + relative insulin deficiency |
| Onset | Usually childhood/adolescence | Usually adulthood (but increasing in youth) |
| Treatment | Insulin required | Lifestyle modification, oral medications, may need insulin |
| % of Cases | ~5-10% | ~90-95% |
Exercise Considerations for Diabetes
Benefits of exercise:
- Lowers blood glucose (muscles uptake glucose without insulin during exercise)
- Improves insulin sensitivity for 24-72 hours post-exercise
- Reduces cardiovascular risk factors
Pre-exercise blood glucose guidelines:
- <100 mg/dL: Consume 15-30g carbohydrate before exercising
- 100-250 mg/dL: Safe range for exercise
- >250 mg/dL with ketones: Do NOT exercise (risk of ketoacidosis)
- >300 mg/dL without ketones: Use caution; may need to wait
Hypoglycemia Management (Rule of 15)
If blood glucose falls below 70 mg/dL:
- Consume 15 grams of fast-acting carbohydrate (4 oz juice, glucose tablets)
- Wait 15 minutes
- Recheck blood glucose
- Repeat if still below 70 mg/dL
Signs of Hypoglycemia: Shakiness, sweating, confusion, pallor, tachycardia, dizziness, irritability, hunger
Oncology Rehabilitation
Exercise During Cancer Treatment
Current evidence strongly supports exercise during and after cancer treatment:
- Reduces cancer-related fatigue (most common side effect)
- Improves physical function, quality of life, and psychological well-being
- May reduce recurrence risk for certain cancers
Precautions by Lab Values
| Lab Value | Threshold | Precaution |
|---|---|---|
| Hemoglobin | <8 g/dL | No resistive exercise; limit to light activity |
| Platelets | <50,000/mm3 (thrombocytopenia) | Avoid activities with bleeding/bruising risk |
| Platelets | <20,000/mm3 | Active ROM only; no resistance |
| WBC (ANC) | <500/mm3 (severe neutropenia) | Avoid group settings; strict infection control |
| Bone metastases | Identified on imaging | Avoid high-impact activities; fracture risk |
Osteoporosis
DEXA Scan T-Score Interpretation
| T-Score | Classification |
|---|---|
| -1.0 and above | Normal bone density |
| -1.0 to -2.5 | Osteopenia (low bone mass) |
| Below -2.5 | Osteoporosis |
| Below -2.5 with fracture | Severe (established) osteoporosis |
Exercise Recommendations
- Weight-bearing exercise: Walking, jogging, stair climbing, dancing
- Resistance training: Progressive strengthening with emphasis on back extensors
- Balance training: Fall prevention is critical
- Avoid: Excessive spinal flexion, high-impact activities in severe osteoporosis, trunk rotation with load
Pelvic Floor Dysfunction
Types of Urinary Incontinence
| Type | Mechanism | Presentation | PT Treatment |
|---|---|---|---|
| Stress | Weak pelvic floor muscles or urethral sphincter | Leakage with cough, sneeze, laugh, exercise | Kegel exercises, biofeedback, electrical stimulation |
| Urge | Detrusor overactivity | Sudden strong urge, unable to delay; frequency | Bladder training, urgency suppression, timed voiding |
| Mixed | Combination of stress and urge | Features of both | Combined approach |
| Overflow | Incomplete bladder emptying | Dribbling, weak stream, frequent small volumes | Address underlying cause; may need catheterization |
A patient with Type 2 diabetes has a pre-exercise blood glucose of 280 mg/dL with no ketones present. The PT should:
Which of the following is a component of Complete Decongestive Therapy (CDT) for lymphedema?
A patient with cancer has a platelet count of 35,000/mm3. The PT should:
A DEXA scan T-score of -2.8 indicates:
The Rule of 15 for managing hypoglycemia involves:
Which type of urinary incontinence is characterized by leakage with coughing, sneezing, or laughing?
A contraindication to manual lymphatic drainage (MLD) is:
For a patient with osteoporosis, which of the following exercises should be AVOIDED?