Orthopedic Conditions PST 415 2021-2022 PDF

ORTHOPEDIC CONDITIONS PST 415  PST 415: FIRST SEMESTER COURSE 2021/2022 WK 1: LESSON 1: SLIDES :1-38 Lecturer: Prof. O. WK 2: LESSON 2 : SLIDES:39-76 AYANNIYI WK 3: LESSON 3 : SLIDES:77- 115...

ORTHOPEDIC CONDITIONS PST 415  PST 415: FIRST SEMESTER COURSE 2021/2022 WK 1: LESSON 1: SLIDES :1-38 Lecturer: Prof. O. WK 2: LESSON 2 : SLIDES:39-76 AYANNIYI WK 3: LESSON 3 : SLIDES:77- 115 WK 4: Continuous Assessment 1 THE COURSE WILL BE WK 5: LESSON 4 : SLIDES: 116- DELIVERED IN BATCHES. 153 YOU MUST READ THROUGH WK 6: LESSON 5 : SLIDES: 154- 194 YOUR SLIDES FOR EACH WK 7 Continuous Assessment 2 CLASS BEFORE EACH CLASS. Learning outcomes: At the end of the course, students should be able to: (a). Describe the pathological basis, aetiology and clinical features of common orthopaedic conditions. (b). Describe assessment procedures for common orthopaedic conditions seen in physiotherapy. (c). Describe physiotherapy management of common orthopaedic conditions seen physiotherapy. COURSE CONTENT: Joint disorders – osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, gout, temporomandibular joint disorders, haemophilic arthritis. Spinal disorders – neck pain, back pain, sacroiliac joint pain, cervical and lumbar spondylosis (intervertebral disc lesions), spinal stenosis, spondylolisthesis, ankylosing spondylitis. Infectious conditions – Septic arthritis, tuberculous arthritis, osteomyelitis. Bone disorders – osteoporosis, osteomalacia, Paget’s disease etc. Musculoskeletal deformities – Scoliosis, kyphosis, kyphoscoliosis Myofascial pain syndrome. Fibromyagia. Connective tissues disorders – polymyositis, systemic lupus erythromatosus. Joint replacements (hip and knee), acute care (including precautions and safety) following surgeries (special consideration for old/elderly patients Pre-requisite courses: ANA 203 & 301 (Hours of Lectures: 30, Unit: 2, Compulsory)  JOINT DISORDERS Arthritis Multiple etiologies and presentations Three common types: Osteoarthritis (OA) Rheumatoid arthritis (RA) Gout  Osteoarthritis (OA), or degenerative joint disease (DJD), is one of the oldest and most common types of arthritis, characterized by the breakdown of the joint's cartilage, that cushions the ends of bones. Cartilage breakdown causes pain and joint swelling. With time, there will be limited joint movement. No ankyloses occurs. A degenerative process of varied aetiology which includes mechanical changes, diseases and/or joint trauma  Characterised by degeneration of articular cartilages with hypertrophy of subchondral bone and joint capsule of weight bearing joints Most commonly affects middle-aged and older people Range from very mild to very severe Affects hands and weight-bearing joints (e.g., knees, hips, feet and back). Many different medications are used to control the pain including corticosteroids and NSAIDs  OA is not an inevitable part of aging, although age is a risk factor Obesity may lead to osteoarthritis of the knees Joint injuries due to sports, work-related activity or accidents may be at increased risk of developing OA. Heberden’s atropathy affects some of the joint except MCP. Signs and symptoms of OA include: Progressive pain and stiffness “Cracking” or “crunching” of affected joints Atrophy of Quadriceps muscles occurs most commonly in the knee OA. DIAGNOSTIC TESTS: Plain film imaging demonstrate characteristic findings of OA : Diminished joint space Decreased height of articular cartilage Presence of osteophytes Other laboratory tests to rule out other disorders e.g. rheumatoid arthritis (RA) Clinical examination will assist in confirming diagnosis PHYSICAL THERAPY GOALS, OUTCOMES, AND INTERVENTIONS. Joint protection strategies Maintain/improve joint mechanics and connective tissue functions Implementation of aerobic capacity/endurance conditioning or reconditioning e.g. aquatic programmes.  Low-impact physical therapy Pain control Joint injections Arthroplasty is recommended in severe primary OA of the hip. NEW TOPIC RHEUMATOID CONDITIONS RHEUMATOID CONDITIONS NEW TOPIC: - RHEUMATOID ARTHRITICS (RA) Autoimmune disease, immune system attacks bodily tissue; Initial trigger unknown, may be linked to streptococcus bacterium, s starts off with joint tenderness and stiffness, onset is usually bilateral; periods of “flare-ups” & “remissions” – a systemic disease that affects the entire body.  Characterised by the inflammation of the membrane lining the joint, which causes pain, warmth, redness and swelling.  The inflamed joint lining, the synovium, can invade and damage bone and cartilage.  Inflammatory cells release enzymes that may digest bone and cartilage.  The involved joint can lose its shape and alignment, resulting in pain and loss of movement.  The disease usually begins in middle age, but can start at any age, and affects two to three times more women than men. Incidence  About 1% adult population affected  3 female: 1 male  Age of onset usually 20-30 (but also infancy  90's)  May be due to:-  Infection  Autoimmune disorder  Genetic predisposition   Thickening of synovium (maybe after cartilage destroyed by inflammatory process)  Thickened synovium covers adjacent joint surfaces  Over time may enlarge, fill joint space  In late stage = ankylosis = fused joint  Causes swelling; stiffness; pain   Swelling also due to increase exudate in synovial membrane  Joint deformities   Loss of joint motion   Muscular atrophy  Systemic effects variable  Generalized weakness, malaise  Rheumatoid nodules form  Focal subcutaneous swelling  Elbow, heel, dorsal surface of head; also internal  Made of macrophages, lymphocytes, collagen, cell debris  Typically painless  Rheumatoid vasculitis common   Systemic inflammation of blood vessels  May involve pericardium, pleural effusion Physiotherapy:  No cure can reverse destruction of structures.  Relieve pain, reduce swelling (anti-inflammatories)  Reduce stress  Strengthen associated muscles  Replace severely affected joints  Deformities affecting joints of the fingers are predominate – MCP, PIP.  DIP – are usually spared  Other deformities: swan neck and boutonnieere  Bouchard nodes Treatment of RA: Pharmacological management varies with the stages of disease progression. Gold compounds, NSAIDs, Corticosteroid therapy, are usually prescribed. Diagnostic tests: plain film imaging demonstrating symmetrical involvement within joints. Laboratory tests: Positive tests includes increased white blood cells count and erythrocyte sedimentation rate, elevated rheumatoid factor. Clinical examination: will help to confirm diagnosis. Physiotherapy goals, outcomes, and interventions (a) Joint protection strategies. (b) Maintain/improve joint mechanics and connective tissue functions (c) Implementation of aerobic capacity/endurance conditioning or reconditioning e.g. hydrotherapy programmes.  NEW TOPIC JUVENILE RHEUMATOID ARTHRITIS (JRA)  Juvenile rheumatoid arthritis is characterized by chronic synovial inflammation of unknown cause.  may develop at any age during childhood  girls are more affected than boys  sex and age ratios differ in the various subgroups of JRA.  Diagnosis of definite JRA requires at least six consecutive weeks of objective synovitis.  Type of arthritis is determined according to the symptoms experienced during the first six months of the disease.  Adherence to these important criteria, along with a careful history and physical evaluation generally lead to a correct diagnosis.  Signs and symptoms of JRA vary from child to child.  There is no single test that makes a diagnosis of JRA. COMMON FEATURES OF JRA: Inflammation of the synovium lining of the joint causes:  heat, pain, swelling and stiffness  limitation in range of motion  joint tenderness and pain.  Joint contractures due to tighten and shorten tendons  Joint damage caused by long-lasting inflammation that erodes joint surfaces.  Altered growth, due to joint inflammation that speeds up or slows down the growth centre in bones.  affected bones may become longer, shorter or larger than usual. The disease in children is different in some respects from the adult condition.  less common in children  mono-articular presentation in one-third of patients Clinical features:  Insidious onset  May be acute  Fever, lymph gland involvement  Anaemia are usually present  Joint pain and stiffness  Joints usually affected – knees, ankles, wrists  Degree of pain varies , may be painless in some.  Deformities occurs as in adult, marked tendency to ankyloses in the cervical spine  Epiphyseal growth may be disturbed  Diagnosis as in adult.  Prognosis: usually good, full recovery in 60% - 75%  NEW TOPIC: - GOUT  Primary-Inborn error of uric acid metabolism- increases production and interferes with excretion of uric acid.  Secondary- Hyperuricemia caused by another disease.  Excess uric acid – converted to sodium urate crystals and precipitate from blood and become deposited in joints- tophi or in kidneys, renal calculi.  Very painful joint inflammation, swollen and reddened.  Typically affects one joint, usually base of the big toe.  Most frequently observed at knee and great toe of foot  Signs and symptoms of gout include:  Hot, red, swollen joint  Decreased ROM Treatment of gout:  Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid drugs,  Allopurinol, Probenecid-reduce uric acid levels Cont’d …….  Diet- excludes purine rich foods, such as organ meats, anchovies, sardines, lentils, sweet breads, red wine.  Avoid ASA and diuretics- may precipitate attacks.  Stabilization, Pain relief. NEW TOPIC: TEMPROMANDIBULAR JOINT DISORDERS (TMJ) Disease and dysfunction of the temporomandibular joints (TMJ) and the adjacent structures affect a large number of persons. Over 20 percent of the average population are affected  TMJ like the vertebral joints, function as a unit in a sliding-gliding action because of the mandible, which links the two condyles together.  Mandible, is the largest and strongest bone of the face.  It articulates with the two temporal bones and accommodates the lower teeth.  It is composed of a horizontal portion, the body, and two perpendicular portions, the rami, which unite with ends of the body nearly at right angles.  The temporomandibular joint is located between the temporal fossa (glenoid fossa) on the inferior surface of the temporal bone and the condylar process of the mandibular bone. Subluxation and Premature Translation of the Jaw:  The TMJ can subluxate itself through its own muscular dynamics.  Subluxation occurs when the condyle translates onto the articular tubercle and then back to the articular eminence. Predisposing factors for the subluxation to occur more easily in some persons than others:  A decrease in the slope of the articular eminence or a flattened articular eminence.  The stretching of the ligamentous attachments of the meniscus into the condylar pole. Signs of subluxation include:  Excessive mandibular opening (greater than 40 mm), movement of the lateral poles too far anteriorly (too much translation),  Joint noise at the beginning of closing.  In unilateral subluxation there is a quick deviation from midline to the contralateral side at the end of opening. TMJ Dislocation  Dislocation may result from actual trauma to the chin during opening of the mouth,  or it may occur without actual trauma, such as with a sudden muscular spasm during a yawn.  NB: This dislocation is always anterior and may be unilateral or bilateral, resulting in displacement of one or both condyles forward into the infratemporal fossa anterior to the articular eminences. In bilateral dislocations:  the chin is displaced forward so that the patient shows some degree of Prognathism with an open bite.  in unilateral dislocation the mandible is displaced toward the non injured side.  ** NB: What is – Prognathism? Find out. Study it and add it to your note. Reduction of TMJ dislocation:  Is accomplished unilaterally by depressing the mandible with the thumb placed on the last molar teeth and at the same time elevating the chin.  The downward pressure overcomes the spasm of the elevating muscles, and elevating the chin repositions the condyles backward behind the articular eminences. NB – VERY IMPORTANT:  Reduction is usually followed by several days of rest.  Habitual dislocation, subluxations, or self-reducing dislocations are not rare. Possible Causes of Derangement of the Disk Trauma,  overclosure of the mouth with backward displacement of the condyle,  malocclusion. NB:- Trauma to the disk can vary from an inflammatory condition to a complete or partial tearing of the disk from its capsular attachment. Cont’d  If the disk remains attached to the anterior capsule and the external pterygoid, an anterior dislocation of the disk occurs.  It may be manifested by displacement of the mandible toward the affected side and possible blockage of mandibular opening and closing.  If the disk remains attached to the posterior capsule, a painful blockage in closing the mandible results. Common signs and symptoms of TMJ dysfunction i. joint noise (i.e., clicking, popping, and/or crepitation), ii. joint locking, iii. limited flexibility of jaw, iv. lateral deviation of mandible during depression or elevation of mandible, v. decreased strength/ endurance of muscles of mastication, vi. tinnitus, vii. headaches, viii. forward head posture, ix. pain with movement of mandible. Clinical examination:  Cervical spine must be thoroughly examined due to close biomechanical and functional relationships between TMJ and cervical region.  Many patients with TMJ have a component of cervical dysfunction. T MJ Dysfunctions fall into three categories. 1. Degenerative joint disorder (DJD) such as OA and RA in the TMJ 2. Myofascial pain is the most common form of temporomandibular dysfunction (TMD), which is discomfort or pain in muscles that control jaw function as well as neck and shoulder muscles. 3. Internal derangement of joint, meaning a dislocated jaw, a displaced articular disc, or injury to condyle. (a) Loss of functional mobility may result from increased activity in muscles of mastication as result of stress and anxiety.  Causes.  Trauma: leading to joint oedema; capsulitis; hypermobility/ hypomobility; or abnormal function of ligaments, capsule and/or muscles.  Congenital anatomic anomalies: change in shape of palate.  Abnormal function such as repeatedly chewing ice/hard candy, paranormal breathing (mouth breather), forward head posture.  Diagnostic tests utilised: Plain film imaging and /or MRI if necessary. Clinical examination helps to identify this condition. Medications. (1) Acetaminophen for pain. (2)NSAIDS for pain and/or inflammation. (3)Muscle relaxants. (4)Trigger point injection. (5)Corticosteroid injections or by mouth.  Physical therapy interventions (1) Postural reeducation regarding regaining the normal anterior – posterior curves and left – right symmetry of the spine. (2)Modalities for reduction of pain and inflammation (3) Biofeedback to minimize effects of stress and/or anxiety. (4) Joint mobilization if restriction in TMJ is present. Primary glide is inferior, which gaps joint, stretches the capsule and allows relocation of anteriorly displaced disc. Cont’d……. (5) Flexibility and muscle strengthening exercises (e.g., Rocabado’s jaw opening while maintaining the tongue in contact with the palate, and isometric mandibular exercises). (6) Patient education (e.g., foods to avoid, and maintaining proper postural alignment). **NB: What is Rocabado exercise for TMJ? Study it and add it to your note. Cont’d ……… (7) Night splints may be prescribed by the dentist to maintain resting jaw position. (8) Educate patient regarding resting position of tongue on hard palate. (9) It is critical to normalize the cervical spine posture prior to the patient receiving any permanent dental procedures and/or appliances.  NEXT NEW TOPIC Haemophilic arthropathy Haemophilic arthropathy Epidemiology. Around 50% of patients with hemophilia will develop a severe arthropathy. Clinical presentation. Presents similarly to osteoarthritis, with chronic joint pain, reduced range of motion and function, and reduced quality of life. Pathology.... Radiographic features Treatment and prognosis.... Haemophilic arthritis  Caused by bleeding into the joint.  It is a relatively rare arthropathy.  The histopathology of haemophilic arthritis represents one extreme of changes seen in rheumatoid synovium.  Haemophilic arthritis may highlight common mechanisms in joint destruction.  An important problem in haemophiliac patients. NEXT NEW TOPIC: - SPINAL DISORDERS Patients with spinal disorders may have back or neck pain:  with or without radiation of symptoms to the extremities. Cont’d …………  Spinal disorders for which a pathoanatomical diagnosis can be made and for which physical therapy may be helpful include: (i). radiculopathy, (ii). intervertebral disc disease, (iii). spinal stenosis, (iv). spondylolisthesis, (v). whiplash-associated disorders Cont’d ………  A definitive patho-anatomical diagnosis cannot be made for majority of patients.  Therefore classification systems that are independent of pathology have been developed to direct treatment.  Three of these classification systems are:  the McKenzie approach  the treatment-based approach  the impairment-based approach Cont’d …………  Evaluation of the findings of a thorough systematic examination can guide the clinician in selection of interventions.  These include:  patient history  tests of general and specific spinal joint mobility,  muscle length and strength  neuromuscular function SPINAL PAIN ASSESSMENT/EVALUATION /TREATMENT (Back and Neck Pain)  Posture and gait  Cervical Disc Pain and stiffness  Lumbar Disc Pain and stiffness  Radiculopathy  Loss of muscle strength  Bowel and bladder control  MRI, CT scan, Neuro exam  Electromyelography and Nerve conduction studies??? CONSERVATIVE MANAGEMENT OF NECK AND BACK PAIN  Bed rest (1 -2) days (in very acute stage)  Posture / Positioning  Appropriate furniture correctly used  Appropriate size/soft pillow for head support  Firm mattress  Exercise  physical therapy  Pharmacology NEXT NEW TOPIC: Spinal Conditions Spondylolysis/Spondylolisthesis Spondylolysis is characterized by: (1). Presence of bony defect at pars interarticularis, (2). Which can result in spondylolisthesis.  Spondylolysis is a fracture of the pars interarticularis with positive “scotty dog” sign on oblique radiographic view of the spine. Cont’d …………… Etiology:  Thought to be congenitally defective pars interarticularis  Spondylolisthesis is the slippage forward of one vertebrae upon another.  It nearly always occurs between L5 and S1 (most common) or L4 and L5.  What is “scotty dog” sign? Find out and include in your note. Spondylolisthesis:  An actual anterior or posterior slippage of one vertebral on another following bilateral fracture of pars interarticularis.  Spondylolisthesis can be graded according to amount of slippage from 1 (25% slippage) to 4 (100% slippage). Cont’d ………… Diagnostic tests utilised: Plain film (oblique to see fracture and lateral views to see slippage). Clinical examination: Stork test helps to identify this condition.  What is Stork test? How will you carry it out? What is alternate name for stork test? What other condition can it be used for? Find out and include it in your note. Medications: (1) Acetaminophen for pain. (2) NSAIDS for pain and/or inflammation. (3) Corticosteroid injections or by mouth. (4) Muscle relaxants. (5) Trigger point injection. Physical therapy goals, outcomes, and interventions (1)Biomechanical faults caused by joint restrictions should be corrected with joint mobilization to the specific restrictions identified during the examination. (2) Exercise should focus on dynamic stabilisation of trunk with particular emphasis on abdominals and trunk extension with multifidus muscle working from a fully flexed position of trunk up to neutral, but not into trunk extension. (3) Avoid extension and/or other positions that add stress to defect (i.e., extension, ipsilateral sidebending, and contralateral rotation). (4) Patient education regarding elimination of positions of extension and postural reeducation. (5) Braces such as Boston brace and TLSO have traditionally been used, but frequency is decreasing. (6) Spinal manipulation may be contraindicated for this condition particularly at the level of defect.  Find out about: Boston brace and TLSO and include it in your note. Clinical Feature:  High incidence of spondylolysis in gymnasts and other athlete’s suggest repetitive injury may be contributing mechanism.  Patient aged over 50 years are usually women.  They always have backache or sciatica and claudication due to spinal stenosis.  Extent of slippage may not be correlated with severity of pain.  In young patient regardless of extent of slip there may be tight hamstrings and a knee bent, hips-flexed gait, the classical Phalen Dickson sign.  What is Phalen Dickson sign? Find out and include in your note Treatment principle is: Rest and Analgesics with or without brace. Once pain subsides put patient on exercise regimen Epidural steroids may benefit some Patient may require surgery in form of fusion of spine with instrumentation and bone grafting in cases of back pain or radicular symptoms that have not improved with conservative treatment. NEXT NEW TOPIC: - CERVICAL SPONDYLOSIS  Cluster of abnormalities arising from chronic intervertebral disc degeneration.  Like disc prolapse it occurs immediately above or below the 6th cervical vertebral (in lower two segments C5–C6 > C6–C7). Pathophysiology: Degeneration of disc cause decrease of disc height and converging of disc space causing: 1. Segmental instability resulting in facet joint arthropathy and hypertrophic osteophyte formation by uncovertebral joint of Luschka.  These spurs result in compression of existing nerve root (in intervertebral foramen) and later the spinal cord (in spinal canal). Cont’d ……. 2. Buckling of ligamentum flavum and narrowing of spinal canal. 3. Ligamentous instability. 4. Radiculopathy (more common), myelopathy or both may be seen secondarily. Clinical Features:  90% of men > 50 years and 90% of women > 60 years  Headache, neck pain and stiffness, worse in morning and improving throughout day, commonly located in occipital region and radiating to frontal area, back of shoulders, and down one or both arms.  Typically, patients have proximal arm pains and distal paresthesia.  Muscles of back of neck and interscapular region may be tender and neck movements limited.  X-rays reveal spur/osteophyte formation (or lipping) at the anterior and posterior margins of disc. Treatment:  Is usually conservative.  Patient education on physiotherapy,  lifestyle modifications and  Nonsteroidal anti-inflammatory drugs.  Surgery is advocated for cervical radiculopathy in patients who have intractable pain, progressive symptoms, or weakness that fails to improve with conservative therapy. NEXT NEW TOPIC: - Spinal or Intervertebral Stenosis Etiology:  Congenital narrow spinal canal or intervertebral foramen coupled with hypertrophy of the spinal lamina and ligamentum flavum or facets as the result of age-related degenerative processes or disease.  Results in vascular and/or neural compromise. Signs and symptoms (1) Bilateral pain and paresthesia in back, buttocks, thighs, calves and feet. (2) Pain is decreased in spinal flexion, increased in extension. (3) Pain increases with walking. (4) Pain relieved with prolonged rest. DIAGNOSIS:  Imaging –including: Plain films, MRI, and/or CT scan. Occasionally myelography is helpful. Clinical examination:  Bicycle (van Gelderen) helps to identify this condition and differentiate it from intermittent claudication  Bicycle Ergometer test (van Gelderen) – How is it conducted and used in differential diagnosis of “ intermittent claudication”? Find out and include your findings in your note. MEDICATIONS (1) Acetaminophen for pain. (2) NSAIDS for pain and/or inflammation. (3) Corticosteroid injections or by mouth. (4) Muscle relaxants. (5) Trigger point injection. Physical therapy goals and interventions (1) Biomechanical faults caused by joint restrictions should be corrected with joint mobilization to the specific restrictions identified during the examination (2) Perform flexion based exercise and exercise that promote dynamic stability throughout the trunk and pelvis. Cont’d (3) Avoid extension and/or other positions that narrow the spinal canal or intervertebral foramen i.e., extension, ipsilateral sidebending, and ipsilateral rotation). (4) Manual and/or mechanical traction.  Cervical spine positioning is at 15 degrees of flexion to provide the optimum intervertebral foraminal opening.  Contraindications include: - joint hypermobility, pregnancy, rheumatoid arthritis, Down syndrome, or any other systemic disease which affects ligamentous integrity. NEXT NEW TOPIC: THE INTERVERTEBRAL DISC: ITS STRUCTURE AND FUNCTIONS Mobility and Articulation:  Made up 25% of intervertebral column.  Act as shock absorbers,  Allow for segmental movements and entire spinal column Intervertebral Disc Structure The disc consists of :  an outer ring “annulus fibrosus”  central portion “a soft gel-like “the nucleus pulposus”  The annulus fibrosus provides an envelope, which restrains the nucleus pulposus. Innervation: The outer portion of the annulus possesses nerve endings. The annulus fibrosus:  thicker anteriorly  thinner posteriorly The vertebral endplate: The endplates are found above and below each disc: Approximately 1mm thick Have several functions. The most common sites for prolapse/herniation:  Cervical spine are C5-C6 and C6-C7  Lumbar spine are L5-S1 and L4-L5 (for 80-90% of all lumbar disc lesions). NEXT NEW TOPIC: - Sacroiliac joint (SIJ) Conditions a. Cause and specific pathology is unknown. Since this is a joint, it is assumed that it can become inflamed, develop degenerative changes, develop abnormal movement patterns, etc. b. Anatomically and functionally SIJ is closely related to lumbar spine, so a thorough examination of both regions is indicated if a patient present with pain in either. Diagnostic tests: Plain film imaging and possibly MRI. Occasionally double blind injections may be used to assist in making the diagnosis (first injection is provocative in nature and second injection is analgesic. If increased “same” pain with 1 st injection and decreased pain following 2nd injection joint is determined to be pathologic) i.e. it is the source of the pain. Clinical examination: The following special tests will be useful to make diagnosis. (1) Gillet’s test. (2) Ipsilateral anterior rotation test. (3) Gaenslen’s test. (4) Long sitting (supine to sit) test. (5) Goldthwaits test. Medications. (1) Acetaminophen for pain. (2) NSAIDS for pain and/or inflammation. (3) Muscle relaxants. (4) Trigger point injection. (5) Corticosteroid injections or by mouth. Physical therapy interventions: (1) Spinal manipulation such as SIJ gapping is generally indicated for this condition to inhibit pain, reduce muscle guarding, and restore normal joint motion. (2) Correction of muscle imbalances through-out pelvis using strengthening, endurance, coordination, and flexibility exercises to gain restoration of normal function. (3) Biomechanical fault caused by joint restrictions should be corrected with joint mobilisation to the specific restrictions identified during the examination. (4) Patient education regarding the elimination of harmful positions and postural re-education. (5) Sacroiliac belts may be useful in some patients.  NEXT TOPIC  Ankylosing Spondylitis - Marie Strumpell's Disease (AS)  a chronic systemic inflammatory rheumatic disorder  primarily affects the axial skeleton(sacroiliac joint and spine)  commonly affects sacroiliac joint (sacroiliitis).  involvement of the limb joints other than hips and shoulders is uncommon. o The disease is strongly associated with HLA-B27 o It show familial tendencies. o The inflammatory process involves the synovial and cartilaginous joints and the osseous attachments of tendons and ligaments. o It frequently result in fibrous and bony ankylosis. o May occur with reactive arthritis, (Reiter's syndrome), psoriasis, or chronic inflammatory bowel disease (secondary AS), o But most patients have no evidence of these associated diseases. o Onset  Age 15-40, male 3:1 ratio, rare in blacks, genetic bias o Etiology  unknown o Diagnostic Criteria - must meet four of the five criteria  Low back pain and stiffness over 3 months not relieved by back pain  pain and stiffness in thoracic spine.   limited motion in lumbar spine  history or evidence of iritis or sequelae  roentogenogram evidence of bilateral sacroiliitis  88% are HLA-B27 positive o Common joints involved  Pelvis  Spine  Shoulders o Clinical features  sacroiliac tenderness to compression  loss of lumbar lordosis  decreased motion of the lumbar motion  decreased chest expansion Characteristics/features: (1) Progressive inflammatory disorder of unknown aetiology that initially affects axial skeleton. (2) Initial onset (usually mid and low back pain for 3 months or greater before fourth decade of life. (3) First symptoms include mid and low back pain, morning stiffness and sacroilitis.  (4) Result in kyphosis deformity of the cervical and thoracic spine and a decrease in lumbar lordosis. (5) Degeneration of peripheral and costovertebral joints may be observed in advance stages. (6) Affects men three times more often than women. Clinical Presentation Males are affected more frequently than females (2 : 1 to 10 : 1) Age of onset is between 15–25 years (late adolescence and early adulthood). The initial symptom is usually dull pain, insidious in onset, felt deep in lower lumbar or gluteal region, accompanied by low back morning stiffness of up to few hour duration that improves with activity and returns following period of inactivity.. Question mark (?) posture is due to hyper kyphosis of thoracic spine and loss of lumbar lordosis. Cervical spine involvement is usually late and show forward stooping and loss of extension and rotation. Most serious complication of spinal disease is spinal fracture with even minor trauma. o Radiographic examination  Bambooing of the spine o Systemic features  aortic insufficiency  cardiac conduction disturbance  iritis or iridocycitis  pulmonary fibrosis  Goals  Limit deformity and disability  posture  breathing exercises  avoid positions of contractures  relieve pain and systemic symptoms  NSAIDs  COX-2 Physiotherapy goals, and interventions (a) Implementation of flexibility exercises to maintain/ improve normal joint motion and length of muscles. NB:- EXERCISES MUST BE DONE GENTLY NEXT NEW TOPIC: Infectious Conditions Septic Arthritis  Septic (Pyogenic) arthritis, also known as joint infection or infectious arthritis.  Invasion of a joint by an infectious agent result in joint inflammation.  All sepsis of joints do not cause arthritis only inadequately treated ones do. Onset:  Usually rapid. Symptoms:  Redness, heat, pain in a single joint.  Decreased ability to move the joint.  Fever,  weakness  headache.  Occasionally, more than one joint may be involved. Etiology and Pathology:  The heamatogenous route of infection is the most common route in all age groups. Epidemiology:  S. aureus – is the most common organism.  NB: Absent movements of a joint after ruling out trauma in peadiatric population is septic arthritis till proved otherwise. Diagnosis:  X-rays are usually normal or may indicate soft tissue swellings,  MRI may show effusion, synovitis or cartilage destruction.  Aspiration of joint will help to confirm the diagnosis by culture and sensitivity and can also help to differentiate from transient synovitis. Aspiration also decreases intra-articular pressure and reduces chances avascular necrosis (AVN) of femoral head. Septic arthritis with negative cultures – Diagnostic Criterion (Morrey and associates criterion) 5 out of 6 must be present: 1. > 38.3 degree C temperature 2. Swelling of suspected joint 3. Pain in joint that increases with movement. 4. Systemic symptoms 5. No other pathologic process 6. Satisfactory response to antibiotics therapy Clinical features: Knee (most commonly affected joint) – Position is Flexion Hip—Position is Flexion, Abduction and External Rotation as this is the position of maximum capacity of joint to accommodate pus. Treatment: Arthrotomy (opening of the joint capsule) Surgical drainage (decompression) synovectomy and antibiotics. (2 weeks I/V and 4 weeks oral). Duration of antibiotics is same as osteomyelitis as usually focus is from the bone. NOTE: Non-operative treatment is not considered in joint infections as cartilage destruction occurs very rapidly and can cause permanent joint destruction. Septic arthritis results in bony ankylosis and it is the most common cause of bony ankylosis.  Ankylosis is the pathological fusion of bones in a joint leading to stiffness of the joint. NEW TOPIC: TUBERCULOSIS OF BONES AND JOINTS Two strains of tubercle bacillus are responsible, human and bovine. The initial infection is usually via respiratory tract or intestine to the bone/joint by blood spread. INCIDENCE Usually occurred in children. PATHOLOGY 1. Destruction of bone and articular cartilage by tuberculous granulation tissue with areas of healing by fibrosis. 2. Thickening of synovial membrane. 3. Abscess formation: in spinal tuberculosis; within psoas sheath; CLINICAL FEATURES Usually the infection involves both bone and joints Tuberculosis is the most common cause of cold abscess. Psoas abscess can give rise to pseudo - hip flexion deformity.  The flexion deformity of hip joint due to spasm of iliopsoas muscle does not show any limitation of rotation of hip joint when tested in the position of flexion deformity.  Ipsilateral flexion of hip joint (more than the deformity) relieves pain and extension increases pain (by stretching muscle).  Kyphosis most commonly involves thoracic.  Gibbus in the thoracic spine. INVESTIGATION: 1.The E. S. R. IS usually raised 2. Moderate lymphocytosis is usual. 3. Tuberculin (Mantoux or Heaf) Test is positive in all except early case. 4. Biopsy of lymph glands. 5. Bacilli may be cultured from sputum or urine. TUBERCULOSIS OF SPINE- POTT’S SPINE The spine is the most common site of skeletal tuberculosis, accounting for 50% of cases followed by hip (15%) and knee (10%). Spina Ventosa is Tuberculosis of short bones of hand. Tuberculosis of shoulder is dry (no effusion) - caries sicca (dry). Tuberculosis with polyarthritis is called as Poncets disease. Route of infection/spread:  The Tubercular spread to spine usually takes place from Lungs>lymph nodes is usually secondary.  The route of spread is mostly heamatogenous (through artery and Bateson’s plexus).  The initial focus of infection usually begins in the cancellous bone of vertebral body near the disc (paradiscal type). General features: Acute pyogenic infections of spine are uncommon. Mostly caused by staphylococcus aureus. Any level of the spine may be involved. Lower thoracic region is the most common; Next in decreasing order of frequency are the lumbar, upper dorsal, cervical and sacral region.  In the thoracic region kyphosis is most marked because of normal kyphotic curvature. Tuberculosis is the most common cause of kyphosis in males. TUBERCULOUS PARAPLEGIA – POTTS’ PARAPLEGIA - May occur at any level, usually thoracic. - Occurs at two stages of the disease process. 1. Early paraplegia, due to abscesses and necrotic debris. 2. Late paraplegia, partly mechanical due to bone destruction. 3. First sign in a patient with TB of spine is: increased deep tendon reflexes. TREATMENT:  Conservative treatment through drug therapy.  Immobilisation on plaster bed and antibiotics.  Spinal decompression to drain abscess.  Spinal segmental fusion may be warranted.  Physical rehabilitation. NEXT NEW TOPIC: METABOLIC BONE DISORDERS OSTEOPOROSIS OSTEOMALACIA PAGET’S DISEASE : Osteoporosis A metabolic disease which depletes bone mineral density/mass, predisposing individual to fracture. Incidence Common disorder of bone metabolism Heredity evidence in women Fracture due to bone weakness Common -- vertebrae, distal radius, proximal femur Fractures after trauma Compression fractures (esp vertebral)  Non-symptomatic until indicated by  Affects women ten times more than men.  Primary or postmenopausal osteoporosis is directly related to a decrease in the production of estrogen.  Senile osteoporosis occurs due to a decrease in bone cell activity secondary to genetics or acquired abnormalities.  Diagnostic tests: CT scan to assess bone density. Single and dual photon absorptiometry are also used, but very expensive.  Clinical examination will assist in confirming diagnosis – Pathophysiology Age  – Bone resorption exceeding bone growth –  Net bone mass loss – More rapid in women » Exaggerated at menopause » Type I (Postmenopausal) – Type II common both sexes over age 70 » Neck, hip, humerus, tibia Pathophysiology May involve postaglandins, interleukins, various growth factors that affect osteoclasts Estrogen decrease with menopause  increased risk Estrogen inhibits bone resorption Also in young, female athletes Training  decreased estrogen Decreased bone mass lead to increase Classification of Osteoporosis Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility. Regional osteoporosis occurs when a limb is immobilized. – Clinical S/S: Pain Bone deformity Fractures Vertebral collapse  hunchback, decreased height – Treatment: Control slow rate of Ca, bone loss Increase dietary Ca Vit D  increase intestinal absorption Ca Regular, moderate exercise Hormone treatment (estrogen, progesterone) Reduce risk of falls Physical therapy interventions 1. Joint/bone protection strategies. 2. Maintain/improve joint mechanics and connective tissue functions. 3. Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programmes. Avoid sedentary life style (lifestyle with a lack of physical exercise). Continue programme of weight-bearing exercises. Drug Therapy Osteoporosis Hormone replacement therapy Parathyroid hormone Calcium and vitamin D Bisphosphonates ** Slow down loss of bone Selective estrogen receptor modulators Calcitonin Other agents used with varying results Drug Therapy Osteoporosis (cont’d) Drugs that improve bone formation: Teriparatide Fosamax Actonel Boniva Reclast Diet Therapy - Osteoporosis Protein Magnesium Vitamin K Trace minerals Calcium and vitamin D Avoid alcohol and caffeine Fall Prevention - Osteoporosis Hazard-free environment High-risk assessment through programs such as Falling Star protocol Hip protectors that prevent hip fracture in case of a fall Others – Osteoporosis Prevention &Management Exercise Pain management Orthotic devices NEXT NEW TOPIC: Osteomalacia Softening of the bone tissue characterized by inadequate mineralization of osteoid Vitamin D deficiency, lack of sunlight exposure Similar, but not the same as osteoporosis Major treatment: vitamin D from Physical therapy interventions 1. Joint/bone protection strategies. 2. Maintain/improve joint mechanics and connective tissue functions. 3. Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programmes. NEXT NEW TOPIC: Paget’s Disease of the Bone Metabolic disorder of bone remodeling, or turnover; increased resorption (the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) of loss results in bone deposits that are weak, enlarged, and disorganized Excessive and haphazard bone formation and breakdown, usually in spine, pelvis, femur, or skull  Pagetic bone has very high ratio of spongy to compact bone and reduced mineralization Unknown cause (possibly viral) An imbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy. Bone pain most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone. Paget’s Disease TREATMENT: Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold treatment. Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin Surgical management: tibial osteotomy or partial or total joint replacement Physical therapy interventions 1. Joint/bone protection strategies. 2. Maintain/improve joint mechanics and connective tissue functions. 3. Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programmes. NEXT NEW TOPIC: Osteomyelitis A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue Exogenous, endogenous, hematogenous, contiguous Osteomyelitis Infection of bone; causative agent – Staph/Strept Typical signs and symptoms : Acute osteomyelitis include: Fever that may be abrupt Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection Chronic osteomyelitis include: Warmth, swelling and redness over the area of the infection Pain or tenderness in the affected area Chronic fatigue Drainage from an open wound near the area of the infection Fever, sometimes Treatment – IV antibiotic; long term for 4- 6 months Surgical Management of Osteomyelitis Sequestrectomy (Surgical removal of a sequestrum), a detached piece of necrotic bone that often migrates to a wound, abscess, etc. Bone grafts Bone segment transfers Muscle flaps Amputation Physical therapy interventions 1. Joint/bone protection strategies as well as cast care. 2. Maintain/improve joint mechanics and connective tissue functions. NEXT NEW TOPIC: MUSCULOSKELETAL DEFORMITIES Scoliosis Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments. A lateral curve or tilt of a part of the spine. Types of scoliosis: 3 major types (i). Functional scoliosis; (ii). Structural scoliosis; (iii). Congenital Scoliosis. The major types of scoliosis: Functional scoliosis—This may be caused by muscle spasm (secondary to lumbar or thoracic injuries) or leg length discrepancy (which causes a lateral shift in the spine). Functional scoliosis resolves with healing of the lumbar or thoracic injuries or correction of the leg length discrepancy.  Structural scoliosis—This type of scoliosis is usually idiopathic. Congenital scoliosis—This type is caused by vertebral anomalies and is much less common than the other two types of scoliosis. Idiopathic scoliosis usually occurs in adolescents between 11 and 14 years of age. Possible causes of idiopathic scoliosis: The role of genetics has been debated. Idiopathic scoliosis Two types: Structural and nonstructural both of unknown etiology. (i). Structural scoliosis is an irreversible lateral curvature of spine with a rotational component. (ii). Nonstructural scoliosis is a reversible lateral curvature of spine without a rotational component and straightening as individual flexes spine. Intervention: Intervention for structural scoliosis includes bracing and possible surgery with placement of Harrington rod instrumentation. Rule of thumb is: (i). If lateral curvature is less than 25 degree do conservative physical therapy, (ii). between 25 – 45 degree use spinal orthoses, (iii). surgery for curvatures greater than 45degree. Diagnostic tests: Plain full imaging using full length Cobb method. CT scan and/or MRI may be used. Clinical examination: To assist in confirming diagnosis. Physical therapy interventions 1.Implementation of flexibility exercises to maintain/improve normal joint motion and length of muscles through out trunk and pelvis. 2. Implementation of strength, power, and endurance exercises. 3. Electrical stimulation to improve muscle performance. 4. Application and patient education regarding spinal orthoses.  NEXT NEW TOPIC: Kyphosis  Name given to a curvature of spine in the sagittal plane, the convexity being posterior.  Is most prevalent in the thoracic spine.  A mild kyphosis is normal in the dorsal spine.  But is abnormal in other areas of the spine.  It may exist in two forms, localized and generalised. Localised kyphosis:  Can occur in any portion of the spine.  Segment involved is usually short but the angular deformation is considerable.  It result in a prominent knuckle of spine, called “gibbus or kyphus”.  It is common in tuberculous or other infection. Generalised kyphosis: Arises from generalised vertebral disease, e.g. ankylosing spondylitis in the young and osteoporosis in the elderly. Kyphotic deformities There are four types of kyphotic deformities:  localized,  sharp,  posterior angulation (a gibbous);  dowager's hump, which results from postmenopausal osteoporosis. Signs /symptoms:  Senile kyphosis and upper thoracic kyphosis are usually asymptomatic  Some patients may present with severe, aching pain  Pain may have been present for many years,  Pain is worse after activity, disturbs sleep, and tends to be episodic  Pain difficult to control effectively with analgesics. Management  Use of brace, analgesics, exercise  postural control, stretching to the intercostal area  mobilization techniques may provide temporary relieve NEXT NEW TOPIC: Myofascial Pain Syndrome/Trigger Points Develop due to mechanical stress Either acute strain or static postural positions producing constant tension in muscle Typically occur in neck, upper and lower back Signs and Symptoms Pain with palpation, with predictable pattern of referred pain which may also limit motion Pain may increase with active and passive motion of involved muscle. NEXT NEW TOPIC: Fibromyalgia Chronic musculoskeletal syndrome Get diffuse chronic pain, tenderness w/ no inflamm=n, fatigue Tenderness @ 9 common points in body (neck, shoulders, hips, knees) Profound fatigue May  depression Also migraine, irritable bowel disease common Incidence Mostly women Peak age = 30-50 yrs Increases w/ age Probably several causes virus, Phys/emotional trauma, emotional trauma, medication Found metabolic alterations in muscle May lead to pain, fatigue Also found diff blood flow to thalamus May C> chronic stress response Treatment Anti-inflammatories (not very effective) CNS active agents somewhat helpful NEXT NEW TOPIC: CONNECTIVE TISSUES DISORDERS Polymyositis:  Polymyositis is an autoimmune disease  Present symmetric weakness in the proximal muscles of the upper and lower extremities. Clinical features /Signs/Symptoms:  Difficulty in rising from a sitting position,  Difficulty in going upstairs,  Difficulty in getting in and out of a bath  Eventually difficulty in getting out of bed. Cont’d ……….. Clinical features /Signs/Symptoms:  Axial muscle involvement, especially of neck muscles may become prominent and the patient has difficulty in raising his head from the pillow.  Upper limb girdle weakness is Characterised by difficulty in elevation of shoulders, e.g. doing hair and reaching for things on shelves.  Muscle pain and tenderness are usually absent.  Wasting of muscle groups may be prominent. Cont’d ……………. Clinical features /Signs/Symptoms:  In some patients there is asymmetrical wasting of muscles.  Pharyngeal muscle involvement is sometimes seen, leading to dysphagia and choking when swallowing.  Dysarthria may be prominent.  In some patients’ respiratory muscle involvement may lead to respiratory failure. Differential diagnosis: Dermatomyositis also causes proximal weakness and inflammation of the skin. NEXT NEW TOPIC: Systemic lupus erythematosus (SLE)  SLE is a multisystem inflammatory (autoimmune rheumatic) disease.  May cause fever, fatigue, rash  blood count abnormalities  renal disease, serositis  lung disease, nervous system changes  joint pain, and other problems. SLE – Cont’d …….. Diagnosis  Lupus is diagnosed by the presence of antinuclear antibodies (ANA).  Lupus is a clinical diagnosis. SLE – Cont’d …….. The spectrum of disease Is broad:  from a mild syndrome of rash  joint pain and fatigue,  a life threatening syndrome of renal failure  uncontrolled neurological disease. SLE – Cont’d …….. Differential diagnosis The differential in autoimmune rheumatic disease is very broad It is important to exclude infections, in particular bacterial endocarditis, human immunodeficiency virus (HIV) and tuberculosis (TB) all of which can cause multisystem disease. SLE – Cont’d …….. Differential diagnosis NB: Some drugs can cause lupus-like syndromes, including procainamide and hydralazine, but disease is usually relatively mild, with renal involvement seen very rarely. Musculoskeletal problems that patients with SLE can develop. Arthralgia and arthritis Osteonecrosis Tendinitis and tendon rupture Fibromyalgia Steroid myopathy Polymyositis NEXT NEW TOPIC: JOINT REPLACEMENT INDICATIONS Rheumatoid arthritis Trauma Congenital deformity Avascular necrosis TOTAL HIP REPLACEMENT (THR) Indications for surgery: Arthritis Femoral neck fractures Congenital hip disease Failed prosthesis TOTAL HIP REPLACEMENT-COMPLICATIONS Dislocation of hip prosthesis Thromboembolism Infection Avascular necrosis Loosening of the prosthesis THR …. CONT’D DISLOCATION OF PROSTHESIS Increased pain, swelling Acute groin pain Shortening of the leg Abnormal internal or external rotation Restricted ability or inability to move leg Reported popping sensation in hip.  IMPAIRED PHYSICAL MOBILITY: JOINT REPLACEMENT AND PAIN Maintain bed rest with affected joint abducted with wedge pillow. Perform passive and teach active ROM to unaffected joints, quad, isometric, gluteal exercises. Ambulate with assistance, Weight Bearing restrictions. Physical therapy (THR) POST SURGERY  Physiotherapist must be familiar with post-operative protocol for each patient relative to procedure and/or the orthopedic surgeon.  Bed positioning with a wedge to prevent adduction.  Patient should avoid the position of hip flexion greater than 90 degrees with adduction and internal rotation.  Partial weight bearing to tolerance is initiated on the second post-surgery day using crutches or a walker with typical surgical procedures.  Physical therapy goals, outcomes, and interventions.  Physical therapy intervention focus on bed mobility  transitional movements  ambulation  return to premorbid activities of daily living. NEXT NEW TOPIC: TOTAL KNEE REPLACEMENT(TKR) Indications: Osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, bleeding into joint. Post-op compression bandage and ice. Assess N/V status of leg, active flexion q1h. While awake, CPM machine. Wound suction drain OOB within24 hrs., knee immobilizer and elevated while sitting. Physical therapy TKR surgery is typically performed as a result of a severe DJD of the knee joint which has led to pain and impaired function. Physical therapy goals, outcomes, and interventions. (a). Goals of early rehabilitation (1 – 3 weeks) include:  muscle reeducation,  soft tissue mobilisation,  lymphedema reduction,  initiation of PROM (e.g. a continuous passive motion [ CPM] is used in the hospital following surgery),  AROM and reduction of post-surgical swelling. BIBIOGRAPHY Guyton: Physiology of the human body, fifth edition Stuart B. P.: Tidy's Physiotherapy. 13th Edition Duckworth T: Lecture Notes on Orthopaedics and fractures. Blackwell Scientific Publications; Oxford London Edinburgh Boston Melbourne. Peter H. Seidenberg, Jimmy D. Bowen, The Hip and Pelvis in Sports Medicine and Primary Care; Springer New York, Dordrecht Heidelberg, London Darlene H, Randolph M. K. Management of Common Musculoskeletal Disorders; Physical Therapy Principles and Methods. 3rd Edition; Lippincott) Philadelphia New York Robert A. D., Michael J. W., Orthopaedic Physical Therapy; 4th Edition. Churchill Livingstone Elsevier, St. Louis, Missouri. Jessica J. M, Sharon A. C, David A. I, Joan T. M, Michael E. S. Rapid review of rheumatology and musculoskeletal disorders. CRC Press, Taylor & Francis Group 6000 Broken Sound Parkway NW, Boca Raton. Kisner C, Colby L. A, Therapeutic Exercise Foundations and Techniques, 5th Edition. F. A. Davis Company, Philadelphia.