Muscular System PTA 120 Pathophysiology Week 6. Discuss anatomic structures and physiologic...

Muscular SystemPTA 120

Pathophysiology Week 6

Discuss anatomic structures and physiologic processes related to the muscular system

Discuss physical effects of aging on the body

Define muscular pathological conditions including signs and symptoms of each.

Objectives

Muscular atrophy Fibromyalgia Myofascial pain syndrome Complex regional pain syndrome Myopathy Muscular Dystrophy Torticollis Down Syndrome

Objectives

Discuss the modifications and precaution that may be required for the treatment of patients with muscular disorders.

Demonstrate understanding of the PTA’s role in the disease processes.

Objectives

Pathology for The Physical Therapist Assistant, Ch 1 pp 8 – 9, Ch. 6

Physical Therapy Clinical Handbook for PTAs

Textbooks

Produce movement Maintain posture Stabilize joints

Tendons – reinforce and stabilize joints Generate heat

By-product of muscle activity Vital in maintaining body temperature

Skeletal muscle – at least 40% of body mass

Function of Muscles

Follows inflammatory process

High level of blood and nerve supply

Heals with scar tissue formation which may reduce muscle function due to decreased extensibility

Healing of muscles and tendons

6 hours Fragmentation of injured muscle fibers begins

7 days Muscle tendon is reduced Scar tissue is seen in large muscles Muscle is able to produce near normal

tension 11 days

Regenerating myotubes are seen 6 weeks – 6 months

Contraction is 90% normal

Healing

5 days Wound gap is filled by phagocytes

7 days Collagen synthesis is initiated and placed

in a random disorganized way 4 weeks

Collagen is fully oriented with the tendon’s long axis

2 months Collagen is mature and realigned along

tendon’s axis

Healing time for tendons

Physiologic Change Functional Effect

Decreased muscle mass Correlates directly to decreases in activityDecreased strength and altered gait

Reduced glycogen stores Decreased endurance and increased fatigue

Degenerated elastic fibers in connective tissue

Correlates directly to decreases in activityReduced flexibility

Effects of aging on the muscular system

Muscular Disorders

Types of growth changes of cells

Atrophy Reduction in cell size

Hypertrophy Increase in cell size

Metaplasia Change of cell from one

type to another

Hyperplasia Increase in number of cells

Involution / hypoplasia Decrease in number of cells

Description Disuse atrophy Muscle wasting Decrease in muscle cell diameter Flaccidity – lacking normal tone (first

stage)

Muscular Atrophy

Etiology Prolonged inactivity Trauma Poor nutrition Motor nerve dysfunction

Signs and Symptoms Muscle appears smaller, looser, flattened Decreased strength, overall weakness

Muscular Atrophy

Treatment Physical activity Exercise Active and passive movements

Muscular Atrophy

Description Chronic, generalized syndrome Diffuse soft-tissue pain and physical

findings of multiple tender points Diagnosis made after 3 month history of

wide-spread pain and 11-18 bilateral tender points on palpation

Fibromyalgia Syndrome

Periods of exacerbation and remission 6 million people in US affected Women 20-50 years old Chronic fatigue syndrome – early form


Etiology Experience pain from stimuli not normally

perceived as painful Due to lowered pain thresholds Unbalanced autonomic nervous system

response to physical, chemical, and physiologic stressors


Imbalance of substance P (neuroreceptor and neuromodulator related to transmission of pain to the CNS) Develops after psychological trauma,

local or general infections, medications, excessive use of aspartame, physical trauma


Signs and Symptoms Pain

Aching, burning, gnawing Localized becoming more generalized 90% of waking hours affected



From Redrawn from Freundlich B, Leventhal L: The fibromyalgia syndrome. In Schumacher HR Jr, Klippel JH, Koopman, WJ, eds: Primer on the rheumatic diseases, ed 11, Atlanta, 1977, Arthritis Foundation. Copyright 1997. Reprinted with permission of the

Arthritis Foundation, 1330 W. Peachtree St., Atlanta, GA 30309.

Signs and Symptoms Muscle pain, tender points Visual disturbances Mental and physical fatigue Sleep disturbances Morning stiffness Mitral valve prolapse

z.


Signs and Symptoms Global anxiety Cognitive problems Irritable bowel syndrome Headaches Hypersensitivity to noise, odors, heat/cold Depression Urinary urgency or frequency TMJ dysfunction


Treatment Medications for depression and/or pain relief Stress reduction Pain management

Improve flexibility Graded exercise program Modalities for pain relief Aerobic exercise routines for endurance


Description Muscular pain disorder with the presence of

localized trigger points which produce pain Etiology

Sudden overload or overstretching of muscle Direct trauma Postural distortions Psychologic stress Chronic repetitive or sustained muscle activity

Myofascial Pain Syndrome

Signs and Symptoms Palpable taut band which is tender with

reproducible referred pain patterns Local twitch responses during palpation Reduced range of motion and muscle

weakness


Treatment Press and stretch technique Injections Acupuncture, dry needling Pain management

Physical Therapist identifies trigger points Desensitization with acupressure, modalities ,

and stretching Postural re-education Aerobic conditioning


Fibromyalgia vs. Myofascial Pain Syndrome

Variable Fibromyalgia MPS

Location Generalized Regional

Primary symptom

Tender points with pressure application

Trigger points and referred pain patterns with pressure application

Gender Female/Male ratio (10:1)

Equal

Systemic signs Many FewAdapted from McCance KL, Huether SE: Pathophysiology: the biologic basis for disease in adults and children, ed 5, St. Louis, 2006, Mosby.

Description Also known as Causalgia, Reflex

Sympathetic Dystrophy Chronic pain condition Continuous, intense pain out of proportion

to the severity of the injury Most often affects one arm, leg, hand, or

foot

Complex Regional Pain Syndrome

Etiology Unknown Sympathetic nervous system can play a

role Immune response triggering inflammatory

response


Signs and Symptoms Pain that begins in a portion of a limb and

can spread to the entire limb Changes in color and temperature of the

skin Intense burning pain, skin sensitivity,

sweating, swelling


Treatment Focused on pain relief Corticosteroids, opiates, antidepressants Sympathetic nerve block, spinal cord stimulation,

intrathecal drug pumps No drug or combination of drugs have produced

consistent long-term improvement in symptoms Early mobilization of the limb post-surgery Modalities to decrease pain and hypersensitivity Tactile desensitization activities Exercise, reduce guarding of affected limb Physical Therapy is sometimes controversial , can be

unsuccessful


Description Non-specific muscle weakness secondary

to identifiable disease or condition Can be classified as inherited (Muscular

Dystrophy), or acquired (inflammatory, Rheumatoid Arthritis)

Myopathies

Signs and Symptoms Progressive proximal muscle weakness Varying degrees of pain and tenderness Acute inflammation, painful movement Symptoms of systemic illness

Fever, fatigue, morning stiffness, anorexia

Inflammatory Myopathies

Treatment Corticosteroids or immunosuppressive

medications EMG to detect changes in the muscle

Positioning and prevention of contractures Avoid overexertion to prevent damage to muscle

fibers Exercise programs, aquatic therapy Patient education with home programs, energy

conservation, any affected ADLs (activities of daily living)

Inflammatory Myopathies

Description Genetic muscle diseases characterized by

progressive weakness and atrophy of skeletal muscles

Symptoms and disease progression range from mild to severe

Many types, with Duchenne MD and Becker’s MD the most common

Muscular Dystrophy

Etiology Duchenne and Becker’s MD are x-linked,

recessive, inherited, genetic diseases Genetic defect causes lack of dystrophin in DMD,

and altered dysfunctional dystrophin in BMD Limb-girdle MD is from an autosomal dominant

or autosomal recessive genetic defect Facioscapulohumeral MD is from an autosomal

dominant genetic trait

Muscular Dystrophy

Signs and Symptoms Loss of muscular strength, lack of

coordination, progressive deformity, eventual disability

Muscles become hypertrophied with connective tissue

“Gower’s sign” Weakness spreads distally and to lungs

Muscular Dystrophy

From Jorde LB et al: Medical genetics, ed 3, St. Louis, 2006, Mosby.

Treatment No known successful cure has been

developed yet; possibility of stem-cell therapy

Orthopedic devices and surgery to address deformities

Medications if necessary to address seizures and infections as needed

Muscular Dystrophy

Duchenne muscular dystrophy Occurs only in males Age of onset: 2-6 years Muscles initially affected: hip and shoulder

girdle Symptoms/course: severe, death around

25 years of age Associated findings: mental retardation

Types of Muscular Dystrophies

Becker’s Age of onset: 5-25 years Muscles initially affected: hip and shoulder

girdle Symptoms/course: mild but progressive,

more normal life span


Limb/girdle Age of onset: teens to adulthood Muscles initially affected: hip and shoulder

girdle Symptoms/course: moderate weakness,

slow progression Associated findings: cardiomyopathies Life span usually normal


Myotonic Age of onset: usually adulthood Associated findings: cataracts, cardiac, and

endocrine disorders Life span usually normal

Maintain strength and function as long as possible, while avoiding overexertion

Equipment and adaptive device consultations, changing as disease progresses

Team approach with Occupational and Speech Therapists


Description Also called wryneck Spasms of the sternocleidomastoid muscle Scalenes, trapezius, splenius muscles may

be involved Unilateral causing tilt and/or rotation of

head Although a condition in children, can also

refer to acquired cases in adulthood

Torticollis

Etiology Possible injury to the sternocleidomastoid

muscle Intrauterine position, continues with

positioning after birth Result of ear or throat infection Heredity Rarely from spinal cord or brain tumor Sometimes cause unknown

Torticollis

Signs and Symptoms Contraction of the SCM muscle

Head rotates toward one side and tilts toward the other

Other postural compensations Decreased range of motion, localized

tenderness

Torticollis

Torticollis

Treatment Physical therapy Extensive stretching May explore botulin toxin injections or surgery in

severe cases Parents performing home program is paramount Extensive stretching of the SCM, side tilting away from

the affected side, while rotating toward the affected side Massage Strengthening of opposing muscle groups

Torticollis

Description Also called Trisomy 21 Genetic disorder (not hereditary) Extra chromosome number 21 in each cell Arises during the formation of the a sex

cell Etiology

Inherited chromosome disorder

Down Syndrome

Down Syndrome

Signs and Symptoms Distinctive facial features Poor muscle tone,

leading to developmental delay

Cognitive delay Lowered immunity Prone to heart disease,

leukemia, Alzheimer’s disease, impaired mental function

Treatment No known cure Treat specific medical problems Folic acid supplements before and during

pregnancy Stimulate more normal muscle tone Strengthening Be aware of developmental dysplasia of the hip Family education in neurological and motor

development

Down Syndrome

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