PTA 120 Pathophysiology Week 5. Objectives Discuss anatomic structures and physiologic processes...

PTA 120 Pathophysiology

Week 5

ObjectivesDiscuss 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.

TextbooksPathology 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 BonesSupport of the body

Protection of soft organs

Movement due to attached skeletal muscles

Storage of minerals and fats

Blood cell formation

Effects of AgingPhysiologic Change Functional Effect

Bone mass decreases Bones become more porous, brittle, and fragileIncreased instances of osteoporosis and pathologic fractures

Changes in joint structures Articular cartilage erodes, synovial fluid becomes fibroticDecreased mobility; altered gait

Intervertebral discs dehydrate and narrow

Spinal changes such as decreased height and kyphosisAltered gait

Healing timeBone

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

OsteoarthritisDescription

Also known as Degenerative Joint Disease, Degenerative Arthritis, Osteoarthrosis, OA

Progressive damage and loss of articular cartilageJoint spaces narrowOlder and elderly adultsMost common form of arthritis, most commonly seen in

hips, knees, hands, feet

OsteoarthritisProgression 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 occurAll events lead to inflammation and swelling

Osteoarthritis

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

OsteoarthritisEtiology

Aging process Can be inherited Trauma and long-term stress can accelerate the process

Pain on weight bearingStiffness after inactivityReduced range of motionMuscle atrophy, weakness, and spasmJoint deformity and enlargementJoint crepitusReduced or loss of function

OsteoarthritisJoints may enlarge and present with nodesBuochard nodes on proximal IP jointsHeberden nodes on distal IP joints

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, WB Saunders.

OsteoarthritisTreatment

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 interventionOsteoarthritis Improve functional

statusReduce painModalitiesPatient education

SpondylosisDescription

Degenerative change in the spineCommonly affects the neckResult in bone spur growths that can put pressure on

spinal nerves or the spinal cord

EtiologyAging 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 weaknessRadiologic changes

Clinical picture of spondylosis

Referred pain into the arm

Pain in sacroiliac region, buttocks, and hips

Muscle spasms Altered sensation and

paresthesiasLimited range of motion

SpondylosisTreatment

Analgesics, anti-inflammatories Decompressive surgeryCortisone injections

physical therapy interventionSpondylosis Restore function through

postural re-education and exercises

Reduce pain with use of heat, massage, relaxation exercises

ModalitiesPatient education

SpondylolysisDescription

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 gymnasticsCan cause anterior slipping of the L5 vertebra over the

sacrum called spondylolisthesis

Spondylolysis

SpondylolysisEtiology

Cause unknownRepeated microtrauma from gymnastics, weight lifting,

footballGenetic defect Spina bifida occulta

SpondylolysisSigns and Symptoms

May be clinically absentDiscovered on x-ray

TreatmentInactivityAnalgesicsSpinal fusion

physical therapy interventionSpondylolysis Abdominal and extensor

muscle strengtheningPostural re-education,

intensive functional re-education

Lifestyle adaptation

SpondylolisthesisDescription

Vertebra becomes anteriorly displacedUsually affects L4/L5 or L5/S1Age of onset usually > 40, women > men (3:1)

EtiologyDisc degeneration and bone disease (arthritis)Birth defect or trauma to vertebral column

Spondylolisthesis

SpondylolisthesisSigns and Symptoms

Low back pain, referred painMuscle spasmIncreased lumbar lordosis

TreatmentAnalgesicsExerciseSpinal fusion

physical therapy interventionSpondylolisthesis Abdominal strengthening

Postural re-educationModalities for pain reliefAbdominal binderPatient education

Infective Arthritis Description

Also called Septic ArthritisInfection of the jointChildren and elderly most commonly affectedKnee is most affected joint

Infective ArthritisEtiology

Bacteria Staphylococcus, Streptococcus pneumoniae, Neisseria gonorrhoeae, Mycobacterium tuberculosis

Viruses and fungi

Infective ArthritisSigns and Symptoms

Fever, fatigue, irritability, loss of appetite Affected joint becomes red and swollenSevere pain on movement and decreased range of

motion

Infective ArthritisTreatment

Immediate, aggressive antimicrobial treatmentRest and elevationFluid aspiration

physical therapy interventionInfective Arthritis After the infection fully

treated by physicianStrengthening and

stretching to decrease stiffness

Endurance activities

Diseases of boneWhy 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.

OsteoporosisDescription

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

EtiologyBone reabsorption exceeds bone formation

OsteoporosisNormal Bone Osteoporotic Bone

OsteoporosisRisk factors

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

OsteoporosisModifiable:

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

OsteoporosisSigns 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 hipLow back and neck pain

Osteoporosis

OsteoporosisCompression fracture of the vertebra

OsteoporosisTreatment

Prevention is bestEstrogen replacement therapyCalcium and vitamin D supplementsRegular weight-bearing exerciseLifestyle changes to decrease risk factors

physical therapy interventionOsteoporosis Contraindications include

spinal flexion exercises, mobilization techniques, traction

Patient education regarding exercises and postural advice

Spinal extension exercisesHeat, massage, spinal

support to reduce painBalance training if needed


Day 3

Abnormal curvatures

KyphosisDescription

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.

KyphosisEtiology

Can be from posture or diseaseChronic spasticity of pectoralis major and minor,

serratus anterior, weak rhomboid major and minorOsteoporosis in older personsTuberculosis of vertebral bodies, ankylosing spondylitis,

cancer, benign tumors, spina bifida, cerebral palsy, poliomyelitis

KyphosisSigns and Symptoms

Asymptomatic until hump becomes obviousMild back pain and fatigueDecreased mobility of the spineRounded back and shouldersChest may cave in, head moves forward

KyphosisTreatment

ExercisesBracingSpinal fusion

physical therapy interventionKyphosis Strengthening of the

back musclesStretching of the chest

musclesPostural education

LordosisDescription

Also known as hyperlordosis, saddleback, or swaybackExaggeration of the normal anterior curvature of the

lumbar spine Can lead to degenerative disc disease or herniated discs

in the lumbar spine

Lordosis

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 asymptomaticLow back pain due to strain on muscles and

ligamentsProtruding abdomen and buttocks, arched lower

back

LordosisTreatment

If caused by pregnancy, delivery of the baby resolves the condition

Weight lossSpinal fusion

physical therapy interventionLordosis Exercises for weight loss

Strengthening of abdominal muscles

Pelvic tilt exercises, stretching of back extensors

Postural education

ScoliosisDescription

Lateral curvature in the normally straight vertical line of the spine

Affects approximately 2% of the populationGirls > boys (5:1)

ScoliosisEtiology

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

ScoliosisEtiology

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

ScoliosisSigns and Symptoms

Best observed from posterior viewUnilateral 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

ScoliosisWaistline unevenHip and shoulder malalignmentOne scapula is more prominentLeaning to one sideRestricted and painful breathing in severe cases

Scoliosis

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

ScoliosisTreatment

MonitoringBody / back brace if curve is > 20 degreesSurgery if curve is > 40 -45 degreesSpinal fusion

physical therapy interventionScoliosis 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 EpiphysisDescription

SCFEFemoral head slides on the femur at the epiphysis

during bone growthFemur becomes laterally rotated

EtiologyTraumatic twisting injuryBoys > girls, between 11 and 16 years oldObesity or growing rapidly

Slipped Capital Femoral EpiphysisSigns and Symptoms

Pain, restriction of movement at hipKnee pain, referred from the hipImpaired ambulation

TreatmentSurgery

physical therapy interventionSlipped Capital Femoral Epiphysis

Strengthening exercisesGait training with

crutches or a walker for change in weight-bearing status after surgery

Patient education in weight-bearing precautions

Paget’s DiseaseDescription

Also called osteitis deformansBone 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

Paget’s DiseaseEtiology

UnknownSlowly developing virus of osteoclastsMay be genetic link

Paget’s DiseaseSigns and Symptoms

Can be asymptomaticMinor skeletal pain,

worse at nightKyphosis, bowlegs,

larger/misshapen skull

Thickened cranial bones may compress nerves and cause headaches, hearing loss or dizzinessFrom Damjanov I: Pathology for the health-related professions, ed 2, Philadelphia, 2000, WB Saunders.

Paget’s DiseaseTreatment

Medications to inhibit bone resorption and decrease pain

physical therapy interventionPaget’s Disease Fall prevention

Ambulation re-trainingExercises for

strengthening and endurance

Bone CancerDescription

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 CancerMetastatic 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 CancerRisk factors

Cancer in other parts of the bodyPaget’s diseaseHistory of radiation therapy

Bone CancerSigns and Symptoms

Pain increases at nightLocalized swelling, limited movementPalpable massMay develop fever, fatigue, anemia, pathologic fracture

in the later stagesPossible leg length discrepancyMay mimic arthritis, requiring referral back to the

physician

Bone CancerTreatment

Surgical excisionChemotherapy and radiation Joint replacementLimb amputation Other medications, such as ones used mostly for

arthritis

physical therapy interventionBone 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 EquinovarusDescription

Also called clubfootFoot and ankle held in plantarflexion and inversionAffects 1 in 1000 live birthsMales > females

EtiologyGenetic trait, family history of clubfootCerebral palsy or spina bifida

Talipes EquinovarusSigns and symptoms

Ankle is plantarflexed, subtaloid and mid-tarsal joints are adducted and inverted

Can be bilateral or unilateralCan be postural or positional

TreatmentSplintingSurgery

Talipes Equinovarus

physical therapy interventionTalipes Equinovarus Positioning and

stretchingWeight-bearing activities

after cast removal

Developmental Dysplasia of the HipDescription

Congenital hip disorder affecting infants and childrenUnilateral or bilateral Three stages or types

Unstable hip dysplasia Subluxation or incomplete dislocation Complete dislocation

Developmental Dysplasia of the HipEtiology

HereditaryHip ligament laxity, shallow acetabular shapeBreech deliveriesFirst born infants

Developmental Dysplasia of the HipSigns and Symptoms

Shortening of the affected leg Trendelenburg gait patternDecreased active movement and external rotation in

affected legAsymmetry in buttock or gluteal folds, extra thigh skin

foldsSpinal scoliosis and lumbar lordosis associated

Developmental Dysplasia of the HipTreatment

Early detection is important Positioning in spica cast or Pavlik harnessSurgery

Developmental Dysplasia of the Hip

physical therapy interventionDevelopmental Dysplasia of the Hip

Positioning and stretching

Weight-bearing activities after cast removal

Osteogenesis ImperfectaDescription

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

EtiologyDefect in genes that are responsible for collagen

synthesis, which results in brittle bones

Osteogenesis ImperfectaSigns and Symptoms

Bones are easily fractured, often while still in the uterusTriangular-shaped head, thin skin, reduced enamel on

the teethScoliosis and bone deformities where fractures have

healed, osteoporosisDecreased height due to lack of bone growthWeakened heart valves

Osteogenesis Imperfecta

From J Med Genet 2002;39:23-29

Osteogenesis ImperfectaTreatment

Casting, bracing, and splintingTry to avoid surgeryMedications to increase bone strength

physical therapy interventionOsteogenesis 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 bracingPool therapy

Spina BifidaDescription

Neural tube defectPosterior spinous processes of vertebral column do not

close properly during development in uteroBony gap can permit meninges, spinal fluids and spinal

cord to hernitate, resulting in neurological impairmentCaucasian and Hispanic descent > risk than African-

American descent

Spina BifidaIncidence 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

Spina BifidaEtiology

UnknownMaternal folic-acid deficiency and genetic alterations

are associatedMaternal diabetes, use of anti-seizure medications or

exposure to high temperatures during pregnancyCaucasian and Hispanic descent > risk than African-

Americans

Spina BifidaSigns 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 BifidaHydrocephalus, often requiring surgeryHypotoniaBowel and bladder dysfunctionScoliosis, dislocated hip joint contractures, talipes

equinovarusPressure ulcers

Spina BifidaTreatment

Dependent on the degree of severitySpina bifida occulta

No treatment

Meningocele and myelomeningocele Surgically closed after birth Defects can be seen in ambulation, bowel or bladder function

physical therapy interventionSpina 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 disordersHemophilic ArthritisLyme DiseaseGoutRicketsOsteomalaciaLegg-Calve-Perthes DiseaseOsteomyelitisMarfan’s Syndrome

Other diseases which can affect the skeletal systemHIV / AIDSSyphilisTuberculosis in the BoneLyme Disease