Musculoskeletal and Connective Tissue Disorders

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Musculoskeletal and Connective Tissue Disorders

• BCE 542
• November 12, 2002

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Musculoskeletal Disorders

• Arthritis and Other Rheumatoid Disorders
• Overuse Disorders
• Injuries
• Disorders of the Bones and Spine

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Arthritis

• Rheumatoid Arthritis
• Osteoarthritis
• Gout or Gouty Arthritis

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Rheumatoid Arthritis

• Common autoimmune disorder in which synovial
  joints become inflammed. Most commonly affected
  areas are the shoulder, wrist, knee, hip, ankle,
  hands, and feet affects pairs of joints
  bilateraly (i.e., both shoulders, both knees).
• Can begin at any age most common onset is in
  children aged 2-4 women over 40 men over 50.
• Joints feel hot, painful may become grotesquely
  twisted. Symptoms worsen with weight-bearing.
• Individual loses range of motion in affected
  joints.
• Complications include Sjogrens Syndrome (dryness
  and poor functioning of eyes and internal
  organs), Bakers cyst (collection of fluid behind
  the knee), anemia from poor bone marrow function,
  carpal tunnel syndrome, peripheral neuropathy.

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Rheumatoid Arthritis--Treament and Rehabilitation

• Treatment aims to alleviate symptoms rather than
  cure the disease.
• Steroids (Prednisone) and nonsteroidal
  anti-inflammatory drugs (NSAIDS, such as
  ibuprofen) to alleviate swelling, relieve pain.
• Chrysotherapy (Gold Therapy) Gold-based
  compounds are injected into the joints.
• Surgery to correct deformities.
• Physical Therapy (heat/cold, exercises,
  whirlpools/hydrotherapy)
• Spliniting of hands to improve hand function.
• Rehabilitation Considerations relate to level of
  function and site of deformity
• May lose dexterity and mobility if hands or feet
  affected.
• Heavy labor will exacerbate the disease
  sedentary/light work should be pursued.
• Climate controlled environments are advisable as
  extremes of temperature and sudden temperature
  changes worsen symptoms.

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Osteoarthritis or Degenerative Joint Disease (DJD)

• Localized wearing away of cartilage in joints by
  bone spurs (osteophytes), resulting in pain on
  movement.
• Can occur anywhere in the body most debilitating
  when hips or spine are affected.
• Part of the aging process obesity can speed
  development.
• Treatment Rest of affected area weight loss
  use of proper posture/body mechanics. Aspirin or
  similar drugs for pain relief. Firm mattresses
  for sleep. Reconstructive surgery for joints
  (esp. Hips) may be attempted.
• Rehabilitation Considerations
• Heavy work exacerbates disease persons involved
  in heavy work may need to change occupations.
• Work should not overtax the affected joints.
• Instruction in proper body mechanics to prevent
  worsening of disease.

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Gout or Gouty Arthritis

• Inability of the body to metabolize purines, a
  cellular component found most often in organ
  meats (liver, hearts, kidneys, etc.)
• Uric acid crystals develop in the body and are
  deposited in the joints, causing them to swell.
• Big toe is usually affected first.
• Complications can develop, including kidney
  disease and cardiovascular problems.
• The disease is about 20 times more common in men
  than in women.
• Treatment Avoidance of organ meats, massive
  fluid intake to flush crystals from body,
  colchicine to relieve swelling, rest of affected
  areas.
• Rehabilitation Relevant only in chronic cases
  planning should carefully consider physicians
  restrictions.

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Lupus Ertythamatosus

• Swelling and changes in structure of numerous
  body organs tell-tale butterfly rash on face.
• Most common in young women.
• Early symptoms rash on face, loss of
  weight/apetite, light sensitivity.
• Later symptoms Dysfunction of various body
  organs--heart, lungs, liver, kidneys.
• Disease progression may be rapid or slow, with
  exacerbations and remissions.
• Treatment--attempting to slow the progression of
  the disease with corticosteroids. No cure.
• Rehabilitation Considerations Relate to the
  dysfunction of internal organs and resulting
  restrictions.

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Ankylosing Spondylitis

• Gradual fusing of spinal joints from lower back
  to upper back.
• Pain present only at site of current fusion.
• Usually begins in men under 30 strong familial
  tendency.
• Cause unknown, believed to be autoimmune.
• May develop fusing of other joints, notably hips
  and shoulders.
• Can affect eyes, heart, bones of feet, causing
  additional medical problems.
• Reiters Syndrome may develop--inflammation of
  skin, eyes, urinary tract and peripheral joints.
• Ulcerative Colitis and Crohns Disease can
  develop.

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Ankylosing Spondylitis, cont.

• Treatment Pain relievers, anti-inflammatory
  drugs, surgery to correct spinal posture if
  necessary attention to disease complications.
• Rehabilitation Considerations
• Stooping, bending and twisting will be difficult
  or impossible, esp. during later stages of
  disease. Can affect not only vocational
  opportunities but also personal care, toileting.
• Psychosocial concerns--disfigurement, unusual
  posture.
• Sedentary and light work appropriate medium to
  heavy work probably inadvisable.
• Complications can cause additional
  concerns--mobility, vision, heart function,
  dexterity and mobility if eyes/feet involved.

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Musculoskeletal Disorders Resulting from Overuse

• Bursitis Inflammation of the bursa sack
  containing synovial fluid usually in elbow,
  shoulder, or knee.
• Tendinitis Inflammation of a tendon, the tissues
  which hold muscles to the bone.
• Tenosynovitis Inflammation of the tissue
  surrounding a tendon. (Tendonitis and
  Tenosynovitis usually occur simultaneously).
• Carpal Tunnel Syndrome Entrapment of the median
  nerve of the wrist, resulting in pain and
  numbness/tingling in the hands (can also be
  caused by arthritis and diabetes, but is most
  commonly seen in those who use the hands
  repetitively, such as assembly workers and
  typists).

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Treatment/ Rehabilitationof Overuse Disorders

• Rest of affected area, refraining from repetitive
  motion.
• Anti-inflammatory drugs/ pain killers.
• Surgery in rare instances (carpal tunnel release)
• Splinting of affected areas to improve function
• Appropriate ergonomics and body mechanics.
• Rehabilitation Except for Carpal Tunnel
  Syndrome, overuse disorders are not significant
  rehabilitation concerns unless they become
  chronic.
• In carpal tunnel and other chronic overuse
  disorders, ergonomic modifications may be able to
  keep the individual working in customary job.
• If ergonomic modifications do not alleviate
  symptoms, a change in occupation to less
  repetitive employment may be necessary.

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Injuries and Fractures

• Lacerations Scrapes, cuts, and punctures.
• Strains Overuse of muscles and tendons.
• Sprains Overuse or overextension of ligaments.
  Can become chronic, esp in the lower back. May
  require surgical repair if tissue is torn.
• Dislocation separation of a bone from a joint.
  If a dislocation is partial it is called a
  subluxation.
• Fractures (See Falvo, p. 225)
• Closed clean break in the bone, bone does not
  protrude through skin.
• Compound Break usually not clean, bone protrudes
  through the skin.

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Bone Disorders

• Osteoporosis Loss of bone mass, making bones
  brittle and prone to fracture. Two types Senile
  Osteoporosis (due to aging, improper diet/lack of
  calcium intake, inactivity with aging) Secondary
  Osteoporosis (arising from other causes, such as
  metabolic disorders, inactivity and lack of
  movement as in spinal cord injury).
• Treatment aims at stopping progress of disease
  through exercise, dietary changes.
• Rehabilitation If senile osteoporosis, probably
  not relevant due to the individuals age. If
  secondary, occupations should be considered in
  light of their potential to cause fractures of
  bone. Precipitating condition can place
  additional restrictions on the individual.

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Bone Disorders, cont.

• Osteomyelitis Infection of the bone tissue, due
  to vascular difficulties, skin ulcers, fractures.
• Treatment involves administration of antibiotics.
  The infection of bone is hard to eliminate and
  treatment may not be fully effective. Often, the
  disease will require amputation of the affected
  limb to prevent septicemia/gangrene.
• Rehabilitation considerations will relate to the
  affects of amputations or underlying causative
  factors such as vascular disease.

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SpinalAlignment Disorders

• Alignment disorders
• Scoliosis lateral (side to side) misalignment of
  spine.
• Kyphosis front to back misalignment of the upper
  spine
• Lordosis front to back misalignment of the
  lower spine (swayed back).
• Treated during adolscence with braces to prevent
  development of unusual posture.

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Disorders of the Intervertebral Discs

• Herniated Nucleus Pulposis (HNP) A rupture of
  the soft tissue inside a vertebra (nucleus
  pulposes), causing it to protrude through the
  spinal column and impinge spinal nerves, causing
  pain, weakness and loss of sensation in lower
  extremities. Can affect bowel/bladder function
  if it occurs in sacral spine.
• Treatment involves surgery or injection of an
  enzyme to dissolve the herniated tissue.
  Treatment may be ineffective, as resulting scar
  tissue can be as much or more irritating to
  nerves.
• Rehabilitation Rehabilitation considerations may
  be significant, as this disorder is most commonly
  caused by heavy lifting and is more common in
  those persons working in heavy labor occupations.
  Lifting capacity can be greatly reduced,
  necessitating an occupational change.

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Disorders of the Intervertebral Discs, Cont.

• Spondylosis Wearing away of the locking
  mechanisms between the vertebra.When the disease
  progresses far enough to cause the vertebra to
  slide on each other, this is called
  Spondolysthesis. This can entrap spinal nerves
  and cause pain, weakness, and loss of
  sensitivity.
• Usually the fourth or fifth lumbar vertebra are
  involved due to the weight distribution of the
  body.
• Treatment can involve surgery, management of low
  back pain.
• Rehabilitation considerations are similar to
  those for HNP.

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Disorders of the Intervertebral Discs, Cont.

• Degenerative Disc Disease (DDD) A naturally
  occuring part of the aging process in which the
  intervertebral disc material wears away.
• Most people show no symptoms others develop
  painful complications.
• Sprains/strains/overuse of the back can speed
  degeneration.
• Vertebra compact as they wear away person loses
  heigth.
• Development of bone spurs can press on spinal
  nerves, causing pain.
• Movement is limited, posture may change to
  relieve pain.
• Treatment Nothing can halt the progress of the
  disease. Pain management is attempted in severe
  cases. Surgery can help to relieve spinal nerve
  impingement.
• Rehabilitation Although the disorder is more
  common in individuals who are older and have
  retired, it can also affect persons in their
  working years. Reemployment in a less physically
  demanding occupation is often necessary.

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Amputation

• Loss of a limb
• Congenitally
• Due to a disease process (i.e., diabetes)
• Due to Trauma (cuts, tears, burns, etc.)

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Medical Management of Amputation

• If the amputation is planned, the individual is
  counseled on outcomes and attempts are made to
  have the patient meet an individual who has
  undergone a similar amputation.
• If the amputation is unplanned, attempts are made
  during surgery or medical management to provide
  the person with an artificial limb before they
  regain consciousness.
• Complications
• Contractures
• Infections in neglected stumps.
• Neuromas--scar tissue full of nerves that can
  become sensitive to touch, change of temperature.
• Phantom limb or phantom pain--sensation of
  presence of old limb in remaining nerve endings
  tends to decrease over time.
• Bone spurs.
• Low back pain with use of prosthetic.

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Upper Extremity Amputations Definitions

• Interscapular-Thoracic (Forequarter) Removal of
  arm, scapula, clavicle.
• Shoulder Disarticulation (S/D) Removal of arm
  at shoulder joint.
• Above Elbow (A/E) Between the shoulder and the
  elbow.
• Elbow Disarticulation (E/D) Removal of arm at
  the elbow.
• Below Elbow (B/E) Between elbow and wrist.
• Wrist Disarticulation (W/D) Removal of hand at
  the wrist.
• Partial Hand Loss of any part of the fingers or
  palm of the hand. (Surgery may be done to restore
  pinch/grasp capacity especially if thumb is
  involved)

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Upper Extremity Prosthetic Devices (artificial
limbs)

• The lower the level, the greater the
  functionality.
• Issues
• Suspension How the prosthetic is held in
  place--by suction on the stump, by straps, by
  clamping to bone.
• Sockets Where the remaining limb and the
  prosthetic meet. Fit must be as perfect as
  possible sockets are custom made with plaster
  casts of limbs. Socks are worn over the stump to
  prevent ulceration.
• Movement In higher levels of amputation, the
  prosthetic can be moved only by the other limb
  can be locked in place and terminal device used
  as a clamp to hold objects. At lower levels,
  prosthetics are either voluntary opening (V/O) or
  voluntary closing (V/C), and may be powered by
  muscle movement through attached cables, by
  compressed air, or microelectronics.
• Terminal Devices Terminal devices can be
  cosmetic for social use (although no prosthetic
  is completely unnoticeable) or specifically
  tailored for occupational or other use (for
  instance, in the shape of certain tools), and can
  be interchangeable. Most terminal devices allow
  for simple pinch or grasp capability. There is
  no capacity for sensation or fine dexterity in
  the affected limb, so the use of the prosthetic
  must be guided by sight.

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Upper Extremity Amputation Rehabilitation

• In higher levels of amputation, grip/pinch is
  weak stronger at lower levels.
• Dexterity is a major concern visual cues must
  guide the prosthetic.
• Lifting/Carrying capacity is affected by
  prosthetics
• At shoulder level, lifting/carrying is virtually
  nil.
• At above elbow, individuals may carry objects but
  cannot lift.
• At the below elbow and wrist disarticulation,
  lifting is possible and capacities increase as
  the stump lengthens.
• At partial hand, lifting and carrying are usually
  at normal capacity (although dexterity is still
  affected).
• Bilateral amputees will have far greater
  limitations. Often, the individual may develop
  dexterity in the feet to perform various
  activities (including driving), esp if the
  amputation is congenital or occurs at a young age.

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Lower Extremity Amputations

• Hemipelvectomy Removal of leg and half of
  pelvis.
• Hip Disarticulation (H/D) Removal of leg at
  pelvic joint.
• Above-Knee (A/K) Removal of leg between hip and
  knee.
• Knee Disarticulation (K/D) Removal of leg at
  knee.
• Below-Knee (B/K) Between knee and ankle.
• Syme Amputation Removal of foot at ankle
  (usually performed for injury, not for vascular
  problems).
• Transmetatarsal/Partial Foot Removal of part of
  the foot.

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Lower Extremity Prosthetics

• As with upper extremity prosthetics, the more
  natural limb is left, the greater the function of
  the prosthetic.
• Issues
• Suspension Same as for upper extremity lower
  extremity prosthetics are more prone to loosening
  and falling off.
• Sockets Same as upper extremity prosthetics.
• Movement If above knee, only the hip joint will
  be movable, causing a stiff-legged gate.
• Power From residual parts of leg in lower
  levels thrusting of body at higher levels.
• Alignment Keeping legs at same level is critical
  in proper functioning of prosthetics even shoes
  are critical.

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Rehabilitation Issues Lower Extremity Amputations

• Lower extremity amputations usually are a result
  of vascular problems. Rehabilitation potential
  is often poor.
• Walking, standing, pushing, pulling, balancing,
  climbing, bending and stooping can all be
  affected effect is greater at higher levels.
• In higher level amputations, cardiovascular
  capacity must be strong to provide for extensive
  use of prosthetic for ambulation. Sedentary work
  is an ideal option. At lower levels (i.e., below
  the knee, Syme, transmetacarpal) prosthetics are
  quite functional for walking, although running is
  usually not possible stair climbing and even
  work in a standing position for extended periods
  may be possible.
• Some persons may choose to use crutches instead
  of prosthetics, for speed. Bilateral amputees
  will almost always use a wheelchair at least part
  of the time.
• Dirty, hot and humid environments are not
  advisable (damage to prosthetics).
• Wet/slippery surfaces and uneven surfaces should
  be avoided.