Musculoskeletal Disorders - Degenerative Disorders, LE Joint Replacements, LE fractures, and Spine

Mon/Wed

Musculoskeletal System Components

bones, joints, and muscles.

Bone Role in Musculoskeletal System

structure.

Joints Role in Musculoskeletal System

connect bones and allow movement.

Muscles Role in Musculoskeletal System

make movement happen.

Common Degenerative Musculoskeletal Diagnoses

RA (rheumatoid arthritis), OA (osteoarthritis), and OP (osteoporosis).

Rheumatoid Arthritis

chronic, systemic, autoimmune, inflammatory - mainly impacts women from 40-60; causes progressive synovitis.

Progressive Synovitis

destruction of ligament, tendon, cartilage, and bone; joint swelling from increased synovial fluid leads to weakened joint and use can lead to deformity.

Rheumatoid Arthritis - Common Joints

PIP, MCP, thumb joints, wrist, elbow, ankle, metatarsophalangeal joints, temporomandibular joints, hips, knees, shoulder, and cervical spine.

Rheumatoid Arthritis - Symptoms

are symmetrical; pain, redness, warmth, tenderness, morning stiffness, ROM limitations, muscle weakness, weight loss, malaise, fatigue, and depression.

Systemic Diseases with Rheumatoid Arthritis

GI, renal, neuro, and cardiovascular.

Common Deformities/Manifestations with RA

Boutonniere deformity, swan neck deformity, Mallet Finger, Ulnar drift, Subluxation of the wrist, MCP joint or both, Ankylosis, Extensor tendon rupture, Trigger finger, mutilans deformity, thumb deformities, nodules over bony prominences, Claw toe, Hammer toe, Cock-up toe, and Hallux valgus or bunion. *LOOK AT PICS!

RA Stages

acute, subacute, chronic-active, and chronic-inactive.

RA Acute Stage

pain at rest; inability to move joint after resting; no change on x-ray.

RA Subacute Stage

reduced pain; OP evident on x-ray; no joint deformity on X-ray.

RA Chronic-Active Stage

low grade inflammation; pain with movement; OP on X-ray; bone destruction; joint deformity.

RA Chronic-Inactive Stage

no signs of inflammation, limited ROM; fibrous or bony ankylosis present.

RA Assessments

client factors such as ROM, joint stiffness, joint mobility, pain, cognition (can be affected by medication or pain, lack of sleep, depression), psychological factors (depression/dependence/stress), exertion/fatigue, ADLs/IADLs, driving, work, mobility, and sleep.

RA Treatment

limit activities during flare-up to prevent damage, use AD, PAMS, therapeutic exercise, splinting (prevent deformity, reduce pain, etc.), and education (disease, joint protection).

Therapeutic Exercise with RA

AROM if pain free, PROM more appropriate during flare, and strengthening (isometric if pain free during flare; isotonic/progressive resistive later - still pain free).

Osteoarthritis

most common joint disorder, not inflammatory, breakdown of articular cartilage (eventually bone on bone), and classified.

Osteoarthritis - Classified

no known cause - localized to a joint, caused by trauma or other health issue.

Healthy Knee vs OA Knee

healthy knee has articular cartilage, good meniscus, and normal joint space; OA knee has bone spurs, cartilage loss, and joint space narrowing.

OA Common Joints

DIP, PIP, CMC, first MTP, cervical and lumbar spine; knee, and hip.

OA Symptoms

asymmetrical; joint pain, stiffness, limited ROM, local inflammation, crepitus, and osteophytes/bone spurs may develop; occur with activity and relieved with rest.

OA Osteophytes/Bone Spurs

bouchard’s node on PIP and heberden’s node on DIP.

OA Medication

pain meds, anti-inflammatory, injections (steroid), and topical.

OA Surgical

arthroscopic to address cartilage loss (remove pieces, stimulate growth) and joint replacement.

OA Assessments

pain, ADL, IADL, ROM/strength, balance, sleep, work, home environment, and driving.

OA Treatments

educate (precautions, coping, energy conservation, joint protection), PAM (for pain/ROM), therapeutic exercise, and occupation-based activities (with modifications as needed - AE, built up handles, extended handles, etc).

OA Therapeutic Exercise

AROM good; PROM only if AROM not possible, isometric or isotonic to tolerance, low impact cardio, pinching contraindicated with CMC involvement (splint to protect CMC).

Osteoporosis

progressive condition; low bone mass/density; bone deterioration; leads to increased risk of fractures/pathological fractures; 10+ million affected.

Osteopenia

comes first, weakening of bone; reversible.

Osteoporosis Causes

can occur due to meds, steroid use, DM, RA, alcoholism, thyroid disease, or malnutrition.

Common Fracture Sites for Osteoporosis

vertebra, wrist, hip, and pelvis.

Osteoporosis Symptoms

with disease progression - back pain and deformities occur rarely referred just for OP, usually have fracture/pain as diagnosis.

OP Assessments

ADL/IADL, rest/sleep, swallow, pain, ROM/strength, balance, fear of falling - (FES).

OP Treatments

accommodations & modifications for occupations to compensate (pain, stiffness, decreased ROM, instability with AE), therapeutic exercise (low impact, WB activity), posture/positioning, home assessment/modification, and education (joint protection, energy conservation, body mechanics, disease).

Fractures

occurs when bone cannot absorb the tension, compression, shearing force exerted upon it; trauma is often the cause that is associated with falls and environmental hazards can contribute, athletes and older adults are especially susceptible and those with OP (decreased bone density means withstands less force).

Types of Hip Fractures

femoral neck, intertrochanteric, and subtrochanteric.

Femoral Neck Fracture

trauma (slight), often women over 60 with OP, and repair is often THR.

Intertrochanteric Fracture

blow to area between trochanters, often in women under 60, and repair is often ORIF.

Subtrochanteric Fracture

blow/injury below lesser trochanter, often car accident or fall, people under 60, and repair is often ORIF.

THR Precautions

must be adhered to at all times or dislocation possible, and length of time = MD decision; depends on posterior or anterior approach.

Posterior Approach Precautions

no hip flexion above 90 degrees, no internal rotation, and no adduction.

Anterior Approach Precautions

no ext rotation, no adduction, and no extension.

ORIF of Hip

repair to fracture site with pins, screws, and fixators; precautions = WB restrictions; NWB, TTWB, FWB, WBAT.

Assessments for Hip Fractures

pain/activity tolerance, ROM/strength/balance, ADL/IADL, rest and sleep, need for AE, and home modification (bathroom).

Hip Fracture Treatments

ROM/strength as allowed, ADL/IADL modify/adapt, patient education (precautions, compensatory strategies), and mobility.

TKR - Total Knee Replacement

done to decrease pain and increase function, generally WBAT, precaution = no rotation of knee, and asess and treat similar to THR with awareness of precautions.

Low Back Pain

generally resolves in 6 weeks for 90% of people and 12 weeks for 5% of people, rarely due to serious spinal disease, and often result of poor physical fitness, obesity, or reduction in strength/endurance.

Back Pain Assessments

use questionnaire to determine performance areas impacted, ADL/IADL, work, and sleep.

Back Pain Treatments

precautions - often BLT, educate (anatomy, pain management, stress reduction, coping), neutral spine techniques to decrease pain, body mechanics education, AE for occupations, task modification, energy conservation, and use occupation to address strength/activity tolerance.

Good Body Mechanics

1. Maintain a straight back; minimize lumbar lordosis.

2. Bend from the hip.

3. Avoid twisting.

4. Maintain good posture.

5. Carry loads close to body.

6. Lift with the legs.

7. Lift with a wide base of support.

8. Lift in the sagittal plane. (forward/backward) (splits r/l)

9. Lift slowly.

Rehab Goal for Back Pain

1. Reduction of pain

2. Use of back stabilization techniques

3. Use of adaptive equipment

4. Incorporation of body mechanics

5. Incorporation of ergonomic techniques

6. Ability to adapt learning to future applications