Topic 7: MSK Problems

muscular dystrophy

wasting of skeletal muscles without neurological involvement; X-linked genetic recessive disorders so usually only affects males

• symmetrical wasting with B/L weakness

• gradual loss of strength with increasing disability and deformity

• can involve diaphragm, swallowing muscles, and cardiac muscle

what are the S/S of muscular dystrophy

• no cure

• goal is to preserve mobility and independence through exercise, PT, and use of assistive devices

• corticosteroids to slow progression for up to 2 years

  • Deflazafort (Emflaza)

• disease-modifying drugs (Eterplirsen)

• mechanical vent and trach when it attacks the respiratory muscles

• keep active and avoid prolonged bed rest/sedentary periods

what is treatment for muscular dystrophy

localized pain

discomfort in a specific area

diffuse pain

pain in a larger area, deep tissue

radicular pain

irritation of the nerve root (sciatica nerve) and pain follows the nerve distribution

referred pain

the source of the pain is separate from where the pain is felt

• lack of muscle tone

• excess body weight

• pregnancy

• stress

• poor posture

• cigarette smoking

• jobs that require heavy lifting, bending, twisting, or prolonged sitting

what are RF for acute low back pain

• lasts around 4 weeks

• usually appears within 24 hours from pressure on nerve/edema

• limited flexibility/ROM

• guarded movement

• depressed/absent achilles and patellar reflex

• may be painful to use the bathroom 

• unable to or pain with standing straight upright

• muscle aches

• if shooting/stabbing pain see HCP

what are the S/S of acute low back pain

straight leg raising test; is positive for disc herniation when radicular pain (follows nerve distribution) occurs

what diagnostic test is done to test for disc herniation

• meds: NSAIDs, muscle relaxants (Flexeril, cyclobenzaprine), antidepressants

  • corticosteroids and opioids for severe pain

• check neuro function distal to pain (plantar reflex in the foot)

• cold compress for first 24 hours and then heat

• avoid prolonged bed rest, but may need it for a short time

• avoid activities that increase pain

what is treatment for acute low back pain

• wear flat or low heels with shock-absorbing shoe inserts

• stop smokin

• firm mattress

• sleep on the side or back

• work with PT to address posture and increase core strength

what does prevention for acute low back pain include

chronic low back pain

back pain that lasts for longer than 3 months or involves repeated incapacitating episodes that is usually caused by obesity, stressful posture, and pregnancy

lumbar spinal stenosis

narrowing of the spinal cord tha tis a common cause of chronic low back pain

• pain starts in the lower back and radiates to the butt and legs

• pain increases with walking and prolonged standing

• pain decreases when you bend forward or sit down

• numbness, tingling, weakness, and heaviness in legs and butt

• may worsen in cold weather

what are the S/S of lumbar spinal stenosis

• NSAIDs for daily discomfort

  • monitor for gastric ulcers and bleeding

• SSRIs and SNRIs for pain and sleep problems

• gabapentin (regulates nerve impulses)

• epidural corticosteroid injection

• implanted devices to manage analgesia like a PCA inside the patient

• weight reduction

• sufficient rest periods

• local heat application

• PT and exercise

what is treatment for chronic low back pain/lumbar spinal stenosis

intervertebral disc disease

occurs when intervertebral discs deteriorate or herniate which leads to a loss of elasticity, flexibility, and shock absorption capabilities; is progressive

• pain radiates to the arms and hands following the nerve

• decreased reflexes and hand grip

what are the S/S of cervical intervertebral disc issues 

• low back pain

• radicular pain that follows the sciatic nerve

• positive straight leg raise test

• decreased/absent reflexes

• paresthesia and muscle weakness

what are the S/S of lumbar intervertebral disc issues 

cauda equina

complication of intervertebral disc disease that occurs when the bundle of nerves at the base of the spinal cord that provides sensory and motor innervation to lower limbs becomes compressed leading to severe back pain and progressive weakness and is a medical emergency

• bowel and bladder incontinence/retention

• severe back pain

• saddle anesthesia

• progressive weakness

what are the S/S of cauda equina

immediate surgical decompression to prevent permanent paralysis

what is the treatment for cauda equina

• limit extreme spinal movement (extreme flexion and torsion)

• heat, ice, massage

• log roll to keep in proper alignment

• meds: NSAIDs, corticosteroids, opioids, muscle relaxants, anti-seizure, antidepressants, epidural corticosteroid injection

• back strengthening exercise 2x/day

• most heal in 6 months so may be concerned about addiction to pain meds

• surgical therapy if other fails

  • laminectomy, discectomy, spinal fusion

what does management for intervertebral disc disease include

• pillows between legs when supine and between legs when side lying

• log roll to change positions

• monitor for resp depression if using opioids and muscle relaxants together

• monitor for CSF leak

• monitor peripheral neuro status

  • report new weakness or paresthesia

• notify HCP immediately if there is bladder/bowel incontinence, which may indicate nerve damage 

what are post op considerations after spinal surgery

• will have a brace so ensure skin is not breaking down

  • educate on how to put on and remove the brace

• C-spine: watch for spinal cord edema and resp distress

  • Immobilize neck with hard/soft collar

• assess bone graft donor site

• avoid prolonged sitting/standing

• do not lift more than 10 lbs for 8 weeks

• sleep on a firm mattress

what are post op considerations after spinal fusion

• bandage with clear or yellow fluid

• positive for glucose

• severe HA

what are the S/S of a CSF leak

• lay them flat

• make NPO

• notify HCP

what should you do if a CSF leak is suspected

spinal fusion

surgery in which the spine is stabilized by creating a fusion/ankylosis of continuous vertebrae (leads to decreased ROM)

systemic lupus erythematosus (SLE)

a multisystem inflammatory autoimmune disease that is more common in women (hormonal) and 15-45 year olds

• vascular lesions in sun-exposed areas

• chronic cutaneous lupus erythematosus (CCLE)

  • discoid rash

• subacute cutaneous lupus erythematosus (SCLE)

  • butterfly/molar rash

• polyarthralgia with morning stiffness that is B/L and gets betwer with use

• Swan neck deformities and ulnar deviation in fingers

• dysrhythmias

• tachypnea and cough, pleurysm that causes sharp chest pain 

what are S/S of systemic lupus erythematosus (SLE)

ANA antibodies, increased ESR and CRP

what would diagnostics for systemic lupus erythematosus (SLE) be

• NSAIDs for mild joint pain

  • monitor for GI/renal effects

• antimalarial drugs: hydroxychloroquine

• corticosteroids

• immunosuppressive drugs: azathioprine

• anticoagulants

• topical immunomodulators

• monitor kidney funtion

• educate that they may be infertile due to medication so refer to a fertility specialist as needed

what does management for systemic lupus erythematosus (SLE) include

hydroxychloroquine

antimalarial drug used to treat fatigue, skin/joint problems, and reduce flares of systemic lupus erythematosus (SLE) that causes mild immunosuppression but does not decrease WBC; monitor eyes due to retinopathy with high doses

fatigue, sun, emotional stress, infection, drugs, surgery

what should someone with systemic lupus erythematosus (SLE) avoid to prevent flare ups

fibromyalgia

a chronic central pain syndrome that is characterized by widespread burning pain that fluctuates throughout the day, that occurs B/L, symmetrically above and below the waist; hard to describe where the pain is

pain in 11/18 pressure points on palpation over the past week, widespread pain for 3 months B/L, and symmetrically above and below the waist

what is the diagnostic criteria for fibromyalgia

• fibro fob

• morning stiffness

• non refreshing sleep

• IBS

• anxiety

what are S/S of fibromyalgia in addition to widespread burning pain that is hard to tell where it is

• OTC and nonopioid analgesics

• regular, gentle, and strengthening exercise like yoga, tai chi, and low impaact aerobic exercise

• limit sugar, caffeine, and alcohol (muscle irritants)

what is the treatment for fibromyalgia

absolute and relative

what are the type of hypovolemic shock

decreased tissue perfusion and impaired cellular metabolism 

what does hypovolemic shock cause

absolute hypovolemic shock

shock that occurs due to the external loss of blood (the blood is on the floor/out of the body)

relative hypovolemic shock

shock that occurs due to fluid shifts (burns, ascites), internal bleeding (hemothorax), massive vasodilation (Sepsis), or pooling of blood (bowel obstruction)

when > 30% of total blood volume is loss

when does someone need a blood transfusion 

• anxiety

• tachypnea

• tachycardia

• increased CO

• decreased SV, CVP, and urinary output

what are the S/S of hypovolemic shock

• CAB!

  • stop the bleeding!! (pressure, tourniquet)

• multiple large bore IVs (14-8G)

• isotonic crystalloids (NS or LR)

• Packed RBCs (fluid dilate clotting factors)

• colloids

• fresh frozen plasma

what is the treatment for hypovolemic shock