PTA 120 Pathophysiology Week 5. Objectives Discuss anatomic structures and physiologic processes related to the skeletal system. Discuss physical effects.

PTA 120 Pathophysiology Week 5

Objectives Discuss anatomic structures and physiologic processes related to the skeletal system. Discuss physical effects of aging on the skeletal system. Define skeletal pathological conditions including signs and symptoms of each. Discuss how skeletal pathologies can adversely affect function requiring the modification of treatment intervention to protect the patient from worsening the condition and optimize treatment outcomes. Discuss the modifications and precaution that may be required for the treatment of patients with skeletal disorders. Demonstrate understanding of the PTA’s role in the disease processes.

Textbooks Pathology for the Physical Therapist Assistant, Ch. 1 pp. 23 – 25, Ch. 5, Ch. 6 pp. 213 – 250 Physical Therapy Clinical Handbook for PTAs

Functions of Bones Support of the body Protection of soft organs Movement due to attached skeletal muscles Storage of minerals and fats Blood cell formation

Effects of Aging Physiologic ChangeFunctional Effect Bone mass decreasesBones become more porous, brittle, and fragile Increased instances of osteoporosis and pathologic fractures Changes in joint structuresArticular cartilage erodes, synovial fluid becomes fibrotic Decreased mobility; altered gait Intervertebral discs dehydrate and narrow Spinal changes such as decreased height and kyphosis Altered gait

Healing time Bone 3-4days- Fractured edges become necrotic. Osteoclasts mobilize in the area. Up to 4 wks- Osteoclasts form soft callus. 3-4wks- Hard callus develops. 3-4 mos- Fracture is healed, but remodeling continues. Concorde Career College

Bone Healing

Osteoarthritis Description Also known as Degenerative Joint Disease, Degenerative Arthritis, Osteoarthrosis, OA Progressive damage and loss of articular cartilage Joint spaces narrow Older and elderly adults Most common form of arthritis, most commonly seen in hips, knees, hands, feet

Osteoarthritis Progression of OA Cartilage becomes thin and soft, begins to flake off and enter joint cavity Damaged tissues stimulates enzymes that accelerate the degenerative process Surface defects appear and expose underlying bone, which then becomes sclerotic Cysts develop, and new bone growths occur All events lead to inflammation and swelling

Osteoarthritis From McCance KL, Heuther SE: Pathophysiology: the biologic basis for disease in adults and children, ed 5, St. Louis, 2006, Mosby.

Osteoarthritis Etiology Aging process Can be inherited Trauma and long-term stress can accelerate the process Pain on weight bearing Stiffness after inactivity Reduced range of motion Muscle atrophy, weakness, and spasm Joint deformity and enlargement Joint crepitus Reduced or loss of function

Osteoarthritis Joints may enlarge and present with nodes Buochard nodes on proximal IP joints Heberden nodes on distal IP joints From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, WB Saunders.

Osteoarthritis Treatment NSAIDS and other medications Injections Surgery to remove torn cartilage or small pieces of bone, or to perform joint replacements Dietary changes for weight loss

physical therapy intervention Osteoarthritis Improve functional status Reduce pain Modalities Patient education

Spondylosis Description Degenerative change in the spine Commonly affects the neck Result in bone spur growths that can put pressure on spinal nerves or the spinal cord Etiology Aging process Laxity in spinal ligaments, herniated discs Previous spinal injury

Clinical picture of spondylosis Symptoms begin after a period of worry or stress Headaches, neck aches, as well as shoulder and arm pain Neck weakness Radiologic changes

Clinical picture of spondylosis Referred pain into the arm Pain in sacroiliac region, buttocks, and hips Muscle spasms Altered sensation and paresthesias Limited range of motion

Spondylosis Treatment Analgesics, anti-inflammatories Decompressive surgery Cortisone injections

physical therapy intervention Spondylosis Restore function through postural re-education and exercises Reduce pain with use of heat, massage, relaxation exercises Modalities Patient education

Spondylolysis Description Structural deformity in the pars interarticularis of lumbar spine vertebrae Usually occurs at L4/L5 or L5/S1 Incidence is 3-7% of the U.S. population, increases with athletes in contact sports or gymnastics Can cause anterior slipping of the L5 vertebra over the sacrum called spondylolisthesis

Spondylolysis

Etiology Cause unknown Repeated microtrauma from gymnastics, weight lifting, football Genetic defect Spina bifida occulta

Spondylolysis Signs and Symptoms May be clinically absent Discovered on x-ray Treatment Inactivity Analgesics Spinal fusion

physical therapy intervention Spondylolysis Abdominal and extensor muscle strengthening Postural re-education, intensive functional re- education Lifestyle adaptation

Spondylolisthesis Description Vertebra becomes anteriorly displaced Usually affects L4/L5 or L5/S1 Age of onset usually > 40, women > men (3:1) Etiology Disc degeneration and bone disease (arthritis) Birth defect or trauma to vertebral column

Spondylolisthesis

Signs and Symptoms Low back pain, referred pain Muscle spasm Increased lumbar lordosis Treatment Analgesics Exercise Spinal fusion

physical therapy intervention Spondylolisthesis Abdominal strengthening Postural re-education Modalities for pain relief Abdominal binder Patient education

Infective Arthritis Description Also called Septic Arthritis Infection of the joint Children and elderly most commonly affected Knee is most affected joint

Infective Arthritis Etiology Bacteria Staphylococcus, Streptococcus pneumoniae, Neisseria gonorrhoeae, Mycobacterium tuberculosis Viruses and fungi

Infective Arthritis Signs and Symptoms Fever, fatigue, irritability, loss of appetite Affected joint becomes red and swollen Severe pain on movement and decreased range of motion

Infective Arthritis Treatment Immediate, aggressive antimicrobial treatment Rest and elevation Fluid aspiration

physical therapy intervention Infective Arthritis After the infection fully treated by physician Strengthening and stretching to decrease stiffness Endurance activities

Diseases of bone Why does the PTA need to know about diseases of the bone?

Diseases of Bone … to enable appropriate development of exercise programs and interventions, taking into account comorbid diagnoses for patients, as well as understanding the precautions and contraindications for these patients.

Osteoporosis Description Systemic condition and metabolic disease involving a wasting or deterioration of bone in mass and density Combination of decreased bone mass and microdamage to the bone structure that results in a susceptibility to fracture Etiology Bone reabsorption exceeds bone formation

Osteoporosis Normal Bone Osteoporotic Bone

Osteoporosis Risk factors Non-modifiable Female Age > 50 Caucasian / Asian Thin, small-frame Early menopause ( < age 45) Family history

Osteoporosis Modifiable: Sedentary lifestyle Diet and nutrition Low calcium intake Smoking Excessive alcohol intake (> 2 drinks / day) Excessive caffeine intake (equivalent to > 3 cups of caffeinated coffee) Excessive tobacco use Certain medications Low body weight and BMI

Osteoporosis Signs and Symptoms Loss of height, leading to breathing problems and eating difficulties Marked thoracic spine kyphosis and “Dowager’s Hump” Fractures, commonly in the wrist or hip Low back and neck pain

Osteoporosis

Compression fracture of the vertebra

Osteoporosis Treatment Prevention is best Estrogen replacement therapy Calcium and vitamin D supplements Regular weight-bearing exercise Lifestyle changes to decrease risk factors

physical therapy intervention Osteoporosis Contraindications include spinal flexion exercises, mobilization techniques, traction Patient education regarding exercises and postural advice Spinal extension exercises Heat, massage, spinal support to reduce pain Balance training if needed

PTA 120 Pathophysiology Day 3

Abnormal curvatures

Kyphosis Description Exaggeration of the normal posterior thoracic curvature Excessive rounding > 45-50 degrees (20-40 degrees is normal) Can have rounded shoulders and dowager’s hump

Kyphosis Kamal A, Brockelhurst JC: Color atlas of geriatric medicine, ed 2, St. Louis, 1992, Mosby.

Kyphosis Etiology Can be from posture or disease Chronic spasticity of pectoralis major and minor, serratus anterior, weak rhomboid major and minor Osteoporosis in older persons Tuberculosis of vertebral bodies, ankylosing spondylitis, cancer, benign tumors, spina bifida, cerebral palsy, poliomyelitis

Kyphosis Signs and Symptoms Asymptomatic until hump becomes obvious Mild back pain and fatigue Decreased mobility of the spine Rounded back and shoulders Chest may cave in, head moves forward

Kyphosis Treatment Exercises Bracing Spinal fusion

physical therapy intervention Kyphosis Strengthening of the back muscles Stretching of the chest muscles Postural education

Lordosis Description Also known as hyperlordosis, saddleback, or swayback Exaggeration of the normal anterior curvature of the lumbar spine Can lead to degenerative disc disease or herniated discs in the lumbar spine

Lordosis

Etiology Postural compensation for added abdominal mass, girth, as in pregnancy and obesity May accompany spinal disease such as osteoporosis or spondylolisthesis

Lordosis Signs and Symptoms Can be asymptomatic Low back pain due to strain on muscles and ligaments Protruding abdomen and buttocks, arched lower back

Lordosis Treatment If caused by pregnancy, delivery of the baby resolves the condition Weight loss Spinal fusion

physical therapy intervention Lordosis Exercises for weight loss Strengthening of abdominal muscles Pelvic tilt exercises, stretching of back extensors Postural education

Scoliosis Description Lateral curvature in the normally straight vertical line of the spine Affects approximately 2% of the population Girls > boys (5:1)

Scoliosis Etiology Structural Unknown (80% of cases), or a congenital malformation of the spine and diseases Causes a permanent change in the spine Functional Caused by pain or poor posture Appears to change configuration when the patient moves

Scoliosis Etiology Can result from other disorders such as muscular dystrophy or spinal cord injuries

Scoliosis Signs and Symptoms Best observed from posterior view Unilateral fullness in a segment of the paraspinal region Caused by protrusion of transverse process of the rotated vertebrae On the side of curve’s convexity

Scoliosis Waistline uneven Hip and shoulder malalignment One scapula is more prominent Leaning to one side Restricted and painful breathing in severe cases

Scoliosis From Gould BE: Pathophysiology for the health professions, ed 3, 2006, St. Louis, Saunders.

Scoliosis Treatment Monitoring Body / back brace if curve is > 20 degrees Surgery if curve is > 40 -45 degrees Spinal fusion

physical therapy intervention Scoliosis Functional scoliosis can be improved by exercises and postural education to restore alignment of the spine PT goal for structural scoliosis is to ensure good functioning of cardiac and respiratory system

Slipped Capital Femoral Epiphysis Description SCFE Femoral head slides on the femur at the epiphysis during bone growth Femur becomes laterally rotated Etiology Traumatic twisting injury Boys > girls, between 11 and 16 years old Obesity or growing rapidly

Slipped Capital Femoral Epiphysis Signs and Symptoms Pain, restriction of movement at hip Knee pain, referred from the hip Impaired ambulation Treatment Surgery

physical therapy intervention Slipped Capital Femoral Epiphysis Strengthening exercises Gait training with crutches or a walker for change in weight- bearing status after surgery Patient education in weight- bearing precautions

Paget’s Disease Description Also called osteitis deformans Bone resorption followed by excessive bone formation, resulting in weakened, deformed bones of increased mass Seldom seen before 40 years of age, usually affects those older than 70 Affects men > women

Paget’s Disease

Etiology Unknown Slowly developing virus of osteoclasts May be genetic link

Paget’s Disease Signs and Symptoms Can be asymptomatic Minor skeletal pain, worse at night Kyphosis, bowlegs, larger/misshapen skull Thickened cranial bones may compress nerves and cause headaches, hearing loss or dizziness From Damjanov I: Pathology for the health-related professions, ed 2, Philadelphia, 2000, WB Saunders.

Paget’s Disease Treatment Medications to inhibit bone resorption and decrease pain

physical therapy intervention Paget’s Disease Fall prevention Ambulation re-training Exercises for strengthening and endurance

Bone Cancer Description Malignant tumors that originate in bone, marrow, and cartilage Common bone cancers – characterized by primary tissue type, peak age, bones involved Ostoesarcoma – growing bone Chondrosarcoma – cartilage Ewing sarcoma – marrow of growing bone

Bone Cancer Metastatic or secondary bone tumors are common Cancers that metastasize include breast, lung, prostate, thyroid, kidney The bones most affected with metastatic tumors are the pelvis, spine, ribs, hips, femur, humerus

Bone Cancer Risk factors Cancer in other parts of the body Paget’s disease History of radiation therapy

Bone Cancer Signs and Symptoms Pain increases at night Localized swelling, limited movement Palpable mass May develop fever, fatigue, anemia, pathologic fracture in the later stages Possible leg length discrepancy May mimic arthritis, requiring referral back to the physician

Bone Cancer Treatment Surgical excision Chemotherapy and radiation Joint replacement Limb amputation Other medications, such as ones used mostly for arthritis

physical therapy intervention Bone Tumors Assist patients to return to functional activity after surgery or chemotherapy Ambulation re-training for non-weight-bearing status Exercises for strengthening and endurance Transfer and Hoyer lift training if appropriate

Talipes Equinovarus Description Also called clubfoot Foot and ankle held in plantarflexion and inversion Affects 1 in 1000 live births Males > females Etiology Genetic trait, family history of clubfoot Cerebral palsy or spina bifida

Talipes Equinovarus Signs and symptoms Ankle is plantarflexed, subtaloid and mid-tarsal joints are adducted and inverted Can be bilateral or unilateral Can be postural or positional Treatment Splinting Surgery

Talipes Equinovarus

physical therapy intervention Talipes Equinovarus Positioning and stretching Weight-bearing activities after cast removal

Developmental Dysplasia of the Hip Description Congenital hip disorder affecting infants and children Unilateral or bilateral Three stages or types Unstable hip dysplasia Subluxation or incomplete dislocation Complete dislocation

Developmental Dysplasia of the Hip Etiology Hereditary Hip ligament laxity, shallow acetabular shape Breech deliveries First born infants

Developmental Dysplasia of the Hip Signs and Symptoms Shortening of the affected leg Trendelenburg gait pattern Decreased active movement and external rotation in affected leg Asymmetry in buttock or gluteal folds, extra thigh skin folds Spinal scoliosis and lumbar lordosis associated

Developmental Dysplasia of the Hip Treatment Early detection is important Positioning in spica cast or Pavlik harness Surgery

Developmental Dysplasia of the Hip

physical therapy intervention Developmental Dysplasia of the Hip Positioning and stretching Weight-bearing activities after cast removal

Osteogenesis Imperfecta Description Also known as OI or “Brittle Bone Disease” Disorder of bones and connective tissue resulting in extremely fragile bones Staged I through VIII by characteristics, not by severity Etiology Defect in genes that are responsible for collagen synthesis, which results in brittle bones

Osteogenesis Imperfecta Signs and Symptoms Bones are easily fractured, often while still in the uterus Triangular-shaped head, thin skin, reduced enamel on the teeth Scoliosis and bone deformities where fractures have healed, osteoporosis Decreased height due to lack of bone growth Weakened heart valves

Osteogenesis Imperfecta From J Med Genet 2002;39:23-29

Osteogenesis Imperfecta Treatment Casting, bracing, and splinting Try to avoid surgery Medications to increase bone strength

physical therapy intervention Osteogenesis Imperfecta Encourage gross motor skills Resistive exercises are contraindicated Positioning and seating systems Gait training with assistive devices Patient, family, and school education for handling and fall prevention Splinting and bracing Pool therapy

Spina Bifida Description Neural tube defect Posterior spinous processes of vertebral column do not close properly during development in utero Bony gap can permit meninges, spinal fluids and spinal cord to hernitate, resulting in neurological impairment Caucasian and Hispanic descent > risk than African-American descent

Spina Bifida Incidence is 17.96 per 100,000 live births affecting 200,000 people in the US Three types Spina bifida occulta – condition is hidden Meningocele – meninges and spinal fluid protrude through bony defect Myelomeningocele – herniation of spinal cord, nerves, meninges, spinal fluid Most serious form Neurologic impairment

Spina Bifida

Etiology Unknown Maternal folic-acid deficiency and genetic alterations are associated Maternal diabetes, use of anti-seizure medications or exposure to high temperatures during pregnancy Caucasian and Hispanic descent > risk than African-Americans

Spina Bifida Signs and Symptoms Spina bifida occulta Skin depression, dark tuft of hair, hemangioma, subcutaneous mass Meningocele or myelomeningocele Sac on the back Weakness and paralysis possible if nerves involved

Spina Bifida Hydrocephalus, often requiring surgery Hypotonia Bowel and bladder dysfunction Scoliosis, dislocated hip joint contractures, talipes equinovarus Pressure ulcers

Spina Bifida Treatment Dependent on the degree of severity Spina bifida occulta No treatment Meningocele and myelomeningocele Surgically closed after birth Defects can be seen in ambulation, bowel or bladder function

physical therapy intervention Spina Bifida Assessment of and training in adaptive equipment and wheelchairs Precautions surrounding shunt for hydrocephalus Family education including ROM and signs of shunt malfunction

Other skeletal disorders Hemophilic Arthritis Lyme Disease Gout Rickets Osteomalacia Legg-Calve-Perthes Disease Osteomyelitis Marfan’s Syndrome

Other diseases which can affect the skeletal system HIV / AIDS Syphilis Tuberculosis in the Bone Lyme Disease