ALTERATIONS IN MOBILITY

Assessment of the Musculoskeletal System

And How Mobility can be Altered

Skeletal SystemBrief Overview of Anatomy

• Bone types• Bone structure• Bone function• Bone growth and metabolism affected by

calcium and phosphorus, calcitonin, vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin

Bone Structure

Joints

• Types include synarthrodial, amphiarthrodial, diarthrodial.

• Structure synovial joint.• Subtyped by anatomic structure:

– Ball-and-socket– Hinge– Condylar– Biaxial– Pivot

Structure Diarthrodial Joint

Muscular system assessmentand how it can affect mobility.

• Patient history• Nutritional history• Family history and genetic risk• General inspection:

– Posture and gait

Muscular System Assessment (Cont.)

Specific Assessments

• Face and neck• Spine• Hand• Hip• Ankles, feet • Neurovascular assessment• Psychosocial assessment

Diagnostic Assessment

• Laboratory tests—serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes

• Radiographic examinations—standard radiography, bone density, tomography and xeroradiography, myelography, arthrography, and CT

• Other diagnostic tests—bone and muscle biopsy

Question?

What is the patient at risk for developing during a CT scan with contrast material?

A. ClaustrophobiaB. Renal failureC. Allergic reaction to the contrast materialD. Panic attack

Neuromuscular affects on mobility

The electromyography

• EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies.

• Low electrical currents are passed through flat electrodes placed along the nerve.

• If needles are used, inspect needle sites for hematoma formation.

Arthroscopy

• Fiberoptic tube is inserted into a joint for direct visualization.

• Patient must be able to flex the knee; exercises are prescribed for ROM.

• Evaluate the neurovascular status of the affected limb frequently.

• Analgesics are prescribed.• Monitor for complications.

Arthroscopy (Cont’d)

Other Tests

• Bone scan• Gallium or thallium scan• Magnetic resonance imaging• Ultrasonography

Mobility can be affected by diseases

Exemplar: Osteoporosis

• Chronic metabolic disease, in which bone loss causes decreased density and possible fracture

• Osteopenia (low bone mass), which occurs when osteoclastic activity is greater than osteoblastic activity

Exemplar: Osteoporosis (Cont’d)

Exemplar: Osteoporosis (Cont’d)

• Etiology and genetic risk• Genetic considerations• Incidence/prevalence• Cultural considerations

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.

Health Promotion/Illness Prevention

• Teaching should begin with young women who begin to lose bone after 30 years of age.

• The focus of osteoporosis prevention is to decrease modifiable risk factors.

• Ensure adequate calcium intake.• Avoid sedentary lifestyle.• Continue program of weight-bearing

exercises.

Assessment

• Physical assessment• Psychosocial assessment• Laboratory assessment• Imaging assessment:

– DXA– QCT– QUS

Nursing Interventions

• Nutrition therapy• Exercise• Other lifestyle changes

Drug Therapy

• Calcium and vitamin D supplements • Estrogen or hormone therapy• Bisphosphonates• Selective estrogen receptor modulators• Calcitonin• Other agents used with varying results

Surgical Interventions

• Vertebroplasty • Kyphoplasty

Cultural Consideration Question?

Which ethnic group typically has the least amount of

bone density of any group?

A. African-American women B. Asian women C. Caucasian womenD. American-Indian women

Diseases that affect mobility continued

Exemplar: Osteomalacia

• Loss of bone related to vitamin D deficiency

• Bone softens because of inadequate deposits of calcium and phosphorus in the bone matrix

• Rickets

Collaborative Care

• Assessment• The major treatment for osteomalacia is

vitamin D

Alterations in Mobility

Exemplar: Paget’s Disease

• Chronic metabolic disorder in which bone is excessively broken down and reformed

• Genetic considerations• Collaborative care:

– Physical assessment– Diagnostic assessment

Nonsurgical Management

• Analgesics• Decrease bone resorption• Selected bisphosphonates• Calcitonin• Plicamycin• Diet therapy• Nonpharmacologic pain-relief measures

Surgical Management

• Tibial osteotomy• Partial or total joint replacement• Surgical decompression and stabilization of

the spine

• Exemplar: Osteomylitis– Infection of the bone

Osteomyelitis of the tibia of a young child. See the numerous abscesses in the bone.

Collaborative Care

• Assessment• Antibiotic therapy• Hyperbaric oxygen therapy• Surgical management:

– Sequestrectomy– Microvascular bone transfers

Alterations in mobility

Exemplar: Benign bone tumors

• Often asymptomatic and may be discovered on routine x-ray or as a cause of pathologic fracture:– Chrondrogenic tumors—from cartilage– Osteogenic tumors—from bone– Fibrogenic tumors—from fibrous tissue; most

commonly found in children

Interventions

• Non-drug pain-relief measures• Drug therapy—analgesics, NSAIDs• Surgical therapy—curettage (simple

excision of the tumor tissue), joint replacement, or arthrodesis

Alterations in mobility

Exemplar: Bone Cancer

• Primary tumors• Metastatic lesions• Pathophysiology• Assessment• Nonsurgical management:

– Drug therapy– Radiation therapy

Surgical Management

• Preoperative care• Operative procedure• Postoperative care

Community-Based Care

• Home care management• Health teaching• Health care resources

Disorders of the hand can affect a patient’s mobility

Exemplar:

• Dupuytren's contracture—slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand

                                                                                     

Alterations in mobility continued

Exemplar: Ganglion

• Round, benign cyst often found on a wrist or foot joint or tendon

                            

Disorders of the foot can affect a patient’s mobility

Exemplars:

• Hallux valgus• Hammertoe • Morton’s neuroma• Tarsal tunnel syndrome• Plantar fasciitis • Other problems of the foot

Foot

Disorders of muscles and ligaments can alter mobility

Exemplar: Scoliosis

• Changes in muscles and ligaments on the concave side of the spinal column

              

What problems other then mobility can you see with this patient?

Exemplar: Scoliosis (Cont’d)

• Pathophysiology• History• Treatment of children • Treatment of adults

Diseases of the muscles can impair mobility

Exemplar: Progressive Muscular Dystrophies

• Pathophysiology• Genetic considerations• Diagnosis• Management • Nursing interventions

Pediatric Differences

• Primary ossification

• Secondary ossification

• Long bones

• Muscles, Tendons, and Ligaments

References

Centers for Disease Control and Prevention, National Institutes of Health. (2009). Arthritis, osteoporosis, and chronic back

conditions. Retrieved April 10, 2010, from http://www.healthypeople.gov/Document/HTML/ Volume1/02Arthritis#_Toc490538008

Chamley, C.A., Carson, P. Randoall, D, & Sandwell, M. (2005). Developmental anatomy and physiology of children. St. Louis, MO: Elsevier.

Harvey, C. (2005). Wound Healing. Orthopedic Nursing 24(2), 143-160.

References

Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing Critical Thinking For Collaborative Care. (6th Ed.) St. Louis: Elsevier Saunders.

References

Kallmes DF, Comstock BA, Heagerty PJ, et al. (August, 2009. “A randomized trial of vertebroplasty for osteoporotic spinal fractures.” New England Journal of Medicine 361(6): 569-579.

Medline Plus. (2010, July 22). Electromygraphy. Retrieved August 22, 2010, from: http://www.nlm.nih.gov/medlineplus/ency/article/003929.htm

MayoClinic.com (2010, July 22). Dupuytren’s Contracture. Retrieved August 23, 2010, from: http://www.mayoclinic.com/health/dupuytrens- contracture/DS00732

References:

Wikipedia. (2010, August 19). Scoliosis. Retrieved August 23, 2010, from: http://en.wikipedia.org/wiki/Scoliosis

Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis, Missouri: Mosby.

Vitale, M.G., Gross, J.M., Matsumoto, H., Roye, D.P. (2006). Epidemiology of pediatric spinal cord injury in the United States. Journal of Pediatric Orthopedics, 26(6), 745-749.

Wikipedia. (2010, July 10). Ganglion . Retrieved Auguast 23, 2010, from: http://en.wikipedia.org/wiki/Ganglion_cyst