The evolution of the patient’s clinical course usually indicates when the time has arrived to discontinue life-sustaining treatment and to allow a patient to die. However, time is not always on the physician’s or the patient’s side. The conscious, alert, and ventilator-dependent patient certainly presents one of the greatest and most difficult challenges to clinicians […]

Although several guidelines have stated that patients are not obliged to undergo, and physicians are not obliged to offer, begin, or continue treatments that are futile, there is continuing confusion and controversy about the meaning and usefulness of futility as an indicator for the withholding or withdrawal of treatments.
In this section, the futility of an […]

The principle of proportionality, succinctly stated, affirms that life-prolonging treatments are contraindicated when they cause more suffering than benefit. This principle also comes to expression in the Canadian Law Reform Commission’s recommendation that the Criminal Code should not bind physicians to administer therapeutically useless treatments or treatments that conflict with a patient’s best interests. Other […]

The method of clinical ethics in palliative medicine, outlined in the section on clinical ethics, will now be exemplified in a series of considerations of when and why it is ethically justified to withhold or to discontinue life-extending therapy. These considerations refer to the principles most frequently invoked when decisions about treatment have to be […]

A contemporary consensus
Although saving lives always has been, and will ever remain, a primary goal of clinical practice, the initiation and continuation of intensive life-prolonging procedures may result in little more than a stretching out of the dying curve, or in the extension of an unbearable and unrelentingly miserable life. Over the last 20 years […]

People in Western societies today clash profoundly on two levels: on the level of their cultural beliefs, within which people define the goals of life and the meaning of death; and on their hierarchies of value against which people decide which values may be sacrificed and which values must be maintained at all costs. In […]

Ethical issues in palliative medicine and palliative care arise with particular intensity, although not exclusively, at the bedsides of gravely ill and dying people. There would be no issues to resolve if there were no uncertainties and conflicts about what clinically should and should not be done in the care of patients afflicted with advanced […]

Causes
Impairments from conditions such as thoracic outlet syndrome (TOS) or carpal tunnel syndrome (CTS) may be caused by one or more of the following in pregnancy: postural changes in the neck and upper quarter, fluid retention, hormonal changes, or circulatory compromise. Overall, women are three times as likely as men to experience carpal tunnel syndrome. […]

Significance
All joint structures are at increased risk of injury during pregnancy and during the immediate postpartum period. The tensile quality of the ligamentous support is decreased, and therefore injury can occur if women are not educated regarding joint protection. There is much controversy regarding the impact of postpartum hormone levels; however, elevated levels have been […]

The following are adaptations of interventions that have already been described that should be considered for the bed-bound patient with a high-risk pregnancy.
Positioning
• Left side-lying to prevent vena cava compression, enhance cardiac output, and decrease lower extremity edema
• Pillows between the knees and under the abdomen
• Supine positioning for short periods, with a wedge placed […]

Varicosities are aggravated in pregnancy by the increased uterine weight, venous stasis in the legs, and increased venous distensibility.
Characteristics
Varicosities can present in the first trimester, and are more prevalent with repeated pregnancies. They can occur in the lower extremities, the rectum (hemorrhoids), or vulva. Symptoms usually include heaviness or aching discomfort, especially with dependent leg […]

All exercise programs for high-risk populations should be individually established based on diagnosis, limitations, physical therapy examination and evaluation, and consultation with the physician. Activities must address patient needs but should not further complicate the condition.
Develop good rapport with the patient and instill trust. Closely monitor the patient during all activities; re-evaluate her after each […]

Characteristics
Sacroiliac pain is localized to the posterior pelvis and is described as stabbing deep into the buttocks distal and lateral to L5/S1. Pain may radiate into the posterior thigh or knee but not into the foot. Symptoms include pain with prolonged sitting, standing or walking, climbing stairs, turning in bed, unilateral standing, or torsion activities. […]

Back pain commonly occurs because of the postural changes of pregnancy, increased ligamentous laxity, and decreased abdominal muscle function.
Incidence
Back pain is reported by 50% to 70% of pregnant women at some point during pregnancy; this condition contributes to lost work days and decreased functional ability. In addition, symptoms may continue in the postpartum period, with […]

Teach the patient to perform the corrective exercise for diastasis recti exclusive of other abdominal exercise until the separation is decreased to 2 cm or less. The rationale for this is that, due to the angle of attachment of the obliques into the linea alba, there is a possibility that trunk rotation exercises will perpetuate […]

Preterm rupture of membranes. The amniotic sac breaks, and amniotic fluid is lost before onset of labor. This can be dangerous to the fetus if it occurs before fetal development is complete. Labor may begin spontaneously after the membranes rupture. The chance for fetal infection also increases when the protection of the amniotic sac is […]

Test all pregnant patients for the presence of diastasis recti before performing any abdominal exercises. This test should be repeated throughout the pregnancy and appropriate modifications made to existing exercises.
Instruct patients to perform a self-test on or after the third postpartum day for optimal accuracy. Until 3 days after delivery, the abdominal musculature has inadequate […]

• Abdominal massage or kneading. Have the patient lie supine or on the left side. This is very effective and typically done with either long or circular strokes. Begin on the right side at the ascending colon, stroking upward, then stroke across the transverse colon from right to left and down the descending colon, then […]

The combined influence of hormones, weight gain, and postural changes of pregnancy contributes to a variety of impairments (in addition to pelvic floor dysfunction that was described in the previous section) that can be addressed with physical therapy.
Diastasis Recti
Diastasis recti is separation of the rectus abdominis muscles in the midline at the linea alba. The […]

Potential Impairments and Functional Limitations:
Risk of pulmonary or vascular complications
Postsurgical pain and discomfort
Development of adhesions at incisional site
Faulty posture
Pelvic floor dysfunction
  • urinary or fecal incontinence
  • organ prolapse
  • hypertonus
  • poor proprioceptive awareness and disuse atrophy
Abdominal weakness, diastasis recti
Coughing or Huffing
Coughing is difficult because of incisional pain. An alternative is huffing. A huff […]

Visual Aids
Visual aids are critical in teaching patients about pelvic floor function. Emphasis should be placed on both the sling/hammock fibers and the figure-eight orientation of the musculature patient to visualize the fibers that run anterior-posterior (to create a “lifting” motion toward the heart) as well as the circumferential fibers (which produce a drawstring or […]

Exercises
• Instruct the woman during her pregnancy in all appropriate exercises, if she is able.
• Instruct the woman to begin preventive exercises as soon as possible during the recovery period.
  • Initiate ankle pumping, active lower extremity ROM, and walking to promote circulation and prevent venous stasis.
  • Initiate pelvic floor exercises to regain tone […]

A cesarean section is the delivery of a baby through an incision in the abdominal wall and uterus rather than through the pelvis and vagina.. General, spinal, or epidural anesthesia may be used.
Significance to Physical Therapists
Cesarean section (C-section) delivery is now at an all-time high in the United States. In 2004, the rate was 29.1% […]

Childbirth
Childbirth is obviously the most significant risk factor for pelvic floor impairments. The process of labor, particularly with vaginal delivery and current medical management, can produce significant trauma to the structures of the pelvic floor.
• A longitudinal cohort study with follow-up 15 years after delivery (N = 55) showed that stress incontinence during the first […]

Management
Early Intervention
It is a progressive disorder unless vigorous intervention is used during the acute stage. The best intervention is prevention when it is recognized that development of CRPS type I (RSD) is a possibility, such as when there has been trauma to the extremity or when the extremity is immobilized. It requires that the therapist […]

After an uncomplicated vaginal delivery, exercise can be started as soon as the woman feels able to exercise, and has been cleared by her physician or midwife.
Pelvic floor strengthening. Exercises should be resumed as soon after the birth as possible. These exercises may increase circulation and aid healing of lacerations or episiotomy. Combining pelvic floor […]

• Pain or hyperesthesia at the shoulder, wrist, or hand out of proportion to the injury.
• Limitation of motion develops. Typically, the shoulder develops limitation in a capsular pattern with most restriction in lateral rotation and abduction. In the wrist and hand, the most common restrictions are limited wrist extension and metacarpophalangeal and proximal interphalangeal […]

Prolapse
A prolapse is a supportive impairment. It refers to the descent of any of the pelvic viscera out of their normal alignment because of muscular, fascial, and/or ligamentous deficits, and increased abdominal pressure. A prolapse often worsens over time and with subsequent pregnancies and can be aggravated by constipation and straining with elimination.
• A recent […]

Knee-chest position with buttocks elevated above heart level. An air embolism, although rare, can occur when the buttocks are elevated and the uterus moves superiorly. The pressure change causes air to be introduced into the vagina and uterus, where it can enter the circulatory system through the open placental site. A pregnant woman is at […]

Developing the ability to relax requires awareness of stress and muscle tension. Techniques of conscious relaxation allow the individual to control and cope with a variety of imposed stresses by being mentally alert to the task at hand while relaxing tense muscles that are superfluous to the activity. This is particularly important during labor and […]