Joint, Connective Tissue, and Bone Disorders and Management PDF

CHAPTER 11: JOINT, CONNECTIVE TISSUE, AND BONE DISORDERS AND MANAGEMENT  ARTHRITIS AND ARTHROSIS Arthritis – inflammation of a joint Arthrosis – limitation of a joint w/out inflammation Impaired Mobility Pattern of limitation, usually a firm end-feel, decreas...

CHAPTER 11: JOINT, CONNECTIVE TISSUE, AND BONE DISORDERS AND MANAGEMENT  ARTHRITIS AND ARTHROSIS Arthritis – inflammation of a joint Arthrosis – limitation of a joint w/out inflammation Impaired Mobility Pattern of limitation, usually a firm end-feel, decreased and possibly painful joint play, and joint swelling Impaired Muscle Performance Disuse or reflex inhibition of stabilizing muscles occurs when there is joint swelling or pain Impaired Balance Altered or decreased sensory input from joint mechanoreceptors and muscle spindle Activity Limitations and Participation Restrictions May be minimally to significantly restricted  RHEUMATOID ARTHRITIS (RA) Autoimmune, chronic inflammatory, systemic disease primarily of unknown etiology affecting the synovial lining of joints as well as other connective tissue. Characteristics Erosive synovitis w/ periods of exacerbation and remission Inflammatory changes also occur in tendon sheaths Extra-articular pathological changes sometimes occur Progressive deterioration and decline in the functional level of the individual attributed to the muscular changes and progressive muscle weakness is often seen Degree of involvement varies Mild symptoms = mild lifestyle changes and medication Significant symptoms = major adaptations  RHEUMATOID ARTHRITIS (RA) Signs and Symptoms: Periods of Active Disease Effusion and swelling of the joints Onset is usually in the smaller joints of the hands and feet Joints become deformed and may ankylose or subluxate Pain is often felt in adjoining muscles and eventually muscle atrophy and weakness occur Low-grade fever, loss of appetite and weight, malaise, and fatigue Principles of Management: Active Inflammatory Period Patient Education Overall treatment plan, safe activity, and joint protection Joint Protection and Energy Conservation Patient learns to respect fatigue and, when tired, rests to minimize undue stress to all the body systems. Joint Mobility Exercise Depends on the symptoms that day – encouraging active exercises through as much ROM as possible Functional Training Modify ADL needed to protect the joints  Rheumatoid Arthritis (RA) Principles of Management: Subacute and Chronic Stages Treatment Approach Precautions must be taken because of the pathological changes from the disease process make the tissue more susceptible to damage Joint Protection and Activity Modification Emphasize the importance of protecting the joints by adapting the environment and modifying activities Flexibility and Strength All flexibility, strength, and endurance exercises should be done w/in the tolerance of the joints Cardiopulmonary Endurance Nonimpact or low-impact conditioning exercises performed w/in the tolerance of the individual OSTEOARTHRITIS (OA) Chronic degenerative disorder primarily affecting the articular cartilage of synovial joints, w/ eventual bony remodeling and overgrowth at the margins of the joints. Characteristics Capsular laxity as a result of bone remodeling and capsule distention, leading to hypermobility or instability in some ROM Cartilage splits and thins out, losing its ability to withstand stress Affected joints may become enlarged Most commonly involved joints: Weight-bearing (hips and knees) Cervical and lumbar spine DIP joints of the fingers CM joints of the thumbs  OSTEOARTHRITIS (OA) Principles of Management Patient Instruction How to protect the joints, while remaining active and manage symptoms Pain Management Early Stages – (stiffness) help patient find balance between activity, rest, and correct biomechanical stresses Late Stages – (pain at rest) emphasize activity modification and use of assistive devices and/or orthoses to minimize joint stress Assistive and Supportive Devices and Activity Resistance Exercise w/in tolerance of the joint – strong muscles protect the joint Stretching and Joint Mobilization Importance of movement through the full available ROM to counteract the developing restrictions Balance Activities Aerobic Conditioning Avoid activities that cause repetitive intensive loading of the joints FIBROMYALGIA AND MYOFASCIAL PAIN SYNDROME Table 11.2 Similarities and Differences Between Fibromyalgia and Myofascial Pain Syndrome Similarities Pain in muscles Decreased range of motion Postural stresses Differences Fibromyalgia Myofascial Pain Syndrome Tender points at specific Trigger points in muscle sites No referred patterns of pain Referred patterns of pain No tight band of muscle Tight band of muscle Fatigue and waking No related fatigue unrefreshed complaints  FIBROMYALGIA (FM) Chronic condition characterized by widespread pain that affects multiple body regions plus the axial skeleton and that has lasted for more than 3 months. Prevalence of Fibromyalgia Estimated 2% of the population – nearly 5 million adults (18 years or older) Women are affected more than men Characteristics of Fibromyalgia Can occur at any age but usually appear during early to middle adulthood Symptoms develop after physical trauma (motor vehicle accident or viral infection) Pain described muscular in origin and predominantly reported in the scapula, head, neck, chest, and low back Fluctuation in symptoms Higher incidence of tendonitis, headaches, irritable bowel, temporal mandibular joints dysfunction, restless leg syndrome mitral valve prolapse, anxiety, depression, and memory problems.  FIBROMYALGIA (FM) Factors Contributing to a Flare Environmental stresses (weather changes) Physical stresses (repetitive activities, prolonged sitting and/or standing, and working rotating shifts) Emotional stresses are any normal life stresses Principles of Management Exercise Particularly aerobic exercise, to reduce the most common symptoms associated with FM Additional Interventions Prescription/OTC medications Instruction in pacing activities Cognitive behavior therapy Avoidance of stress fractures Decreasing alcohol and caffeine consumption Diet modification Manual therapy  Fibromyalgia (FM) Video https://youtu.be/-hHNxfYaUUI  MYOFASCIAL PAIN SYNDROME (MPS) Chronic regional pain syndrome. Hallmark classification comprises the myofascial trigger points in a muscle that have a specific referred pattern of pain, along w/ sensory, motor, and autonomic symptoms. Possible Causes of Trigger Points Chronic overload of muscle w/ repetitive activities Acute overload of muscle (slipping and catching oneself) Poorly conditioned muscles Postural stresses (sitting for prolonged periods of time) Poor body mechanics w/ lifting and other activities  MYOFASCIAL PAIN SYNDROME VIDEO https://www.youtube.com/watch?v=QY9ePL690Dk  MYOFASCIAL PAIN SYNDROME (MPS) Principles of Management Correct Chronic Overload W/ education including stressing the importance of taking intermittent mini-breaks. Eliminate the Trigger Point Contract-relax-passive stretch Trigger point release Spray and stretch Dry needling or injection Strengthen Muscle Use a muscle endurance protocol  OSTEOPOROSIS Disease of bone that leads to decreased mineral content and weakening of the bone. Determined by the T score of a bone mineral density scan (BMD) Normal = -1.0 or higher; Osteopoenia = -1.0 to -2.4; Osteoporosis = - 2.5 or less Prevention Eating foods that are good for bone health (fruits and vegetables) Maintaining a balanced diet that is rich in calcium and vitamin D Performing regular weight-bearing exercise Healthy lifestyle w/ moderate alcohol consumption (2-3 drinks per day) and no smoking Physical Activity Maintenance of, or an increase in, bone density is important for preventing fractures Effects of Exercise Muscle contraction and mechanical loading deform bone, which stimulates osteoblastic activity and improves body mass density.  OSTEOPOROSIS Recommendations for Exercise Mode: Aerobic 5 or more days per week 30 minutes of moderate intensity or 20 minutes of vigorous intensity Mode: Resistance 2-3 days per week w/ a day of rest in between 8-12 repetitions that lead to muscle fatigue Precautions and Contraindications Stress into spinal flexion increases the risk of a vertebral compression fracture Avoid combining flexion and rotation of the trunk to reduce stress on the vertebrae and the intervertebral discs When performing resistance exercise, it is important to increase the intensity progressively but w/in the structural capacity of the bone.  FRACTURES Structural break in the continuity of a bone, an epiphyseal plate, or a cartilaginous joint surface. Identification of Fractures by Site – location fracture occurred Extent – complete or incomplete Configuration – direction of fracture line Relationship of the fragments – undisplaced or displaced Relationship to the environment – closed (skin intact) or open (penetrated the skin) Complications – local or systemic; related to the injury or to the treatment TYPES OF FRACTURES  FRACTURES Risk Factors Sudden Impact – trauma, accidents, abuse, or assault Osteoporosis – women more than men History of Falls Repetitive stress/microtrauma Pathology – abnormal fragile bone from neoplastic, poor health, or disease conditions Bone Healing Following a Fracture Cancellous Bone Healing Healing occurs primarily through formation of an internal callus (endosteal callus). There is a rich blood supply and a large area of bony contact, so union is more rapid than in dense cortical bone. Epiphyseal Plate Healing There may be growth disturbances and bony deformity as the skeleton continues to mature. Disturbances depends on the type of injury, age of the child, blood supply to the epiphysis, method of reduction, and whether it is a closed or open injury. BONE HEALING  FRACTURES Bone Healing Following a Fracture Cortical Bone Healing Inflammatory Phase – amount of bleeding depends on the degree of fracture displacement and amount of soft tissue injury in the region Reparative Phase – there is callous formation uniting the breach and ossification Remodeling Phase – there is consolidation and remodeling of the bone Rigid Internal Fixation Sometimes it is necessary to surgically apply an internal fixation device, such as a rod or a plate w/ screws, to protect a healing bone Healing Time Varies w/ age of the patient, the location and type of fracture, whether it was displaced, whether surgical repair was needed, amount of soft tissue injury, and the blood supply to the fragments. Children (4-6 weeks) Adolescents (6-8 weeks) Adults (10-18 weeks)  POSTTRAUMATIC IMMOBILIZATION Principles of Management Local Tissue Response Connective tissue weakening, articular cartilage degeneration, muscle atrophy, and contracture development as well as sluggish circulation It is important to keep structures in the related area in a state as near normal as possible by using appropriate exercises w/out jeopardizing alignment of the fracture site while it is healing. Immobilization in Bed General exercises for the uninvolved portions of the body are initiated to minimize secondary physiological changes that occur in the body. Functional Adaptations The choice of device and gait pattern depends on the fracture site, the type of immobilization, and the functional capabilities of the patient.  POSTTRAUMATIC IMMOBILIZATION Postimmobilization Impairments Decreased ROM, joint play, and muscle flexibility Muscle atrophy w/ weakness and poor muscle endurance Pain is experienced as movement begins but should decrease as joint movement, muscle strength, and ROM improve If there was soft tissue damage at the time of the fracture, an inelastic scar restricts tissue mobility in the region of the scar. Postimmobilization Management Joint Mobilization Effective for regaining lost joint play w/out traumatizing the articular cartilage or stressing the fracture site PNF Stretching Monitor intensity of contraction and to not apply resistive or stretch force beyond the fracture site Posttraumatic Immobilization Postimmobilization Management Functional Activities Can resume normal activities w/ caution It is important to not traumatize the weakened muscle, cartilage, bone, and connective tissue Muscle Performance Resistive force should be applied proximal to the fracture site until the bone is radiologically healed Once healed, PRE and other more intense dynamic exercises can be initiated Scar Tissue Mobilization Manual techniques to mobilize the scare are used The choice of technique depends on the tissue involved