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Musculoskeletal and Connective Tissue Disorders


Common autoimmune disorder in which synovial joints become inflammed. Most commonly affected areas are the shoulder, wrist, knee, ... Gout or Gouty Arthritis ... – PowerPoint PPT presentation

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Title: Musculoskeletal and Connective Tissue Disorders

Musculoskeletal and Connective Tissue Disorders
  • BCE 542
  • November 12, 2002

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

  • Rheumatoid Arthritis
  • Osteoarthritis
  • Gout or Gouty Arthritis

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
  • 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.

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,
  • 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
  • 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.

Osteoarthritis or Degenerative Joint Disease (DJD)
  • Localized wearing away of cartilage in joints by
    bone spurs (osteophytes), resulting in pain on
  • Can occur anywhere in the body most debilitating
    when hips or spine are affected.
  • Part of the aging process obesity can speed
  • 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.

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
  • Rehabilitation Relevant only in chronic cases
    planning should carefully consider physicians

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

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
  • 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

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
  • 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.

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

Treatment/ Rehabilitationof Overuse Disorders
  • Rest of affected area, refraining from repetitive
  • 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
  • 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.

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
  • 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.

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.

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.

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

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
  • 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.

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
  • Usually the fourth or fifth lumbar vertebra are
    involved due to the weight distribution of the
  • Treatment can involve surgery, management of low
    back pain.
  • Rehabilitation considerations are similar to
    those for HNP.

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
  • Vertebra compact as they wear away person loses
  • 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
  • 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.

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

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.

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 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

Upper Extremity Prosthetic Devices (artificial
  • The lower the level, the greater the
  • 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.

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
  • At shoulder level, lifting/carrying is virtually
  • 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
  • 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.

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

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.

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.