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Principles of Management of Selected Pathologies

• Arthritis• Arthrosis• Fibromyalgia• Myofacial Pain Syndrome• Osteoarthritis• Fractures

Arthritis:

• PT’s/PTA’s job is to manage the physical impairments and functional restrictions

• Clinical signs and symptoms (impaired mobility):

--Capsular pattern of restriction--Firm end-feel (where the last ROM is hard)--Decrease and possible painful joint pain--joint swelling-effussion

Rheumatoid Arthritis: (RA)

• Signs and symptoms: --With synovial fluid there is effusion and

swelling of the involved joints, with associated pain and limited ROM. Typically joint stiffness is reported in the morning, with minimal to no pain, but as the day progresses…pain and swelling increase with a slight increase in skin temperature

--Onset is usually in the smaller joints of the hand and feet and usually bilateral

Rheumatoid Arthritis-Continued:

--Progression can lead to deformity

--Pain is felt in adjoining muscles, muscle atrophy and weakness occurs, deformity worsens as there is asymmetry of muscle pull

--Other symptoms may include: low-grade fever, loss of appetite and weight, malaise, and fatigue

Rheumatoid Arthritis-Continued:

• Exercise regarding the intensity and type will vary pending the patients status, patients are encouraged to do active exercises through their available ROM….NOT STRETCHING, if active is not tolerated well—then PROM can be used, as long as symptoms are reduced then the amount and intensity of exercises can be progressed

• Contraindications: To stretch/manipulate a joint that is already distended can lead to hypermobility or subluxation when the swelling abates; stretching will also further irritate the joint and cause a greater healing time

Osteoarthritis-Degenerative Joint Disease (OA):

• Signs and symptoms--Hypermobility/instabilty, pain, less movement, contractures…causing additional limitations--Affected joint may become enlarged--Most common joints affected are: weight bearing joints ie: knees/hips, cervical and lumbar spine, and distal interphalangeal joints of the fingers and carpometacarpal joints of the thumb

Principles of Management Osteoarthritis:

• Patient instruction-to teach about OA, but to also protect joints while active and management of symptoms; HEP should be designed to improve muscle performance, ROM and endurance in a safe manner

• Pain and stiffness are common with loss of motion• Aquatic exercises can offer less pain and

improve patients function as it is a decrease weight bearing activity; or the use of open chain activities

• Gentle stretching can assist to increase mobility• All activities should be performed in the correct

position to avoid undo stresses

Fibromyalgia:

• Signs and Symptoms:--Usually occurs in middle adulthood--Greater than 30% develop symptoms after a physical trauma--Significant fluctuation in symptoms--Patients have greater incident of tendonitis, headaches, irritable bowel syndroms, mitral valve prolapse, TMJ dysfunction, restless leg syndrome, anxiety, depression, and memory problems

Principles of Management Fibromyalgia:

• Exercise: aerobic• Medicine• Education to pace activities to avoid

fluctuations in symptoms• Avoid stress factors• Decrease alcohol/caffeine

consumption• Diet modification

Myofascial Pain Syndrome:

• Signs and symptoms--Chronic regional pain syndrome, which comprises trigger points with specific referred pattern of pain--Trigger Point-is a hyper-irritable area in a tight band of muscle, described as dull, aching and deep and can be active (symptomatic) or latent (asymptomatic-unless palpated)

Causes of Trigger Points:

• Chronic overload to a muscle ie: repetitive activities or muscles being in a shortened position too long

• Acute overload of muscle ie: slipping or picking up an object without knowing hoe much it weighs

• Poor conditioning of muscles• Postural stresses ie: poor work

station• Poor body mechanics with ADL’s

Principles of ManagementMyofascial Pain Syndrome:

• Eliminate trigger point• Correcting the contributing factors• Strengthening the muscles

Osteoporosis:

• Signs and symptoms--Having a T-score of -2.5 or less (please refer to pp. 340-341 in you text)--A patient can have either primary or secondary osteoporosis--Is detected radiographically (bone mineral density scan-BMD)

Principles of ManagementOsteoporosis:

• Physical activity/AROM has been shown to have a positive affect on bone remodeling, it helps to maintain or increase bone density, and reduce the effects of age-related or disuse-related bone loss

• Non-impacting weight bearing activities ie: walking, climbing stairs

• Non-weight bearing exercises ie: biking• Resisted training, but with knowledge of

precautions and contraindications with exercises

Precautions and ContraindicationsOsteoporosis:

• Secondary to the re-shaping of the vertebral bodies ie: edge-shaped, leading to kyphosis….exercise that promotes flexion should be avoided ie: sit-ups

• Avoid combining flexion and rotation of the trunk to decrease stress to vertebrae and the vertebral disc

• When performing resisted exercises, increase progressively-within the structure capacity of the bone

Fractures-Post-Traumatic Immobilization

• Types of Fractures:--Transverse or oblique--Greenstick--Spiral--Avusion--Compression--Torus (buckle)--Fatigue/Stress--Pathological

Please reference Table 11.3 pg 322 in your Kisner & Colby Text

Types of Fractures

Example X-Rays of Fractures:

Transverse FractureGreenstick Fracture

Compression Fracture

Cortical Bone:

• Stage of Clinical Union• Stage of Radiological Union• Rigid Internal Fixation• Time for Healing• Abnormal Healing

Cancellous Bone:

• Healing occurs faster than that of a Cortical bones-as it is less dense and more blood supply

• However-it is more susceptible to compression forces, resulting in crush or compression fractures

Epiphyseal Plate:

• Growth disturbance and bony deformation can occur with a fracture

• Prognosis will vary pending: age, type of injury, available blood supply, method of reduction, and if open/closed

Principles of Management:Period of Immobilization

• Connective tissue weakness, articular cartilage degeneration, muscle atrophy, contracture development, scar formation, sluggish circulation

• It is important to exercise the uninvolved portions of the body to minimize secondary physiological changes

• Functional adaptations may be necessary ie: assisted device

Post-Immobilization Period:

• Signs and symptoms--Decrease ROM--Decrease joint play--Decrease muscle flexibility--Muscle atrophy with weakness--poor muscle endurance--With initial movements the patient will experience pain, but as ROM, joint play and muscle strengthens the pain will decrease--Scar formation will decrease with mobility

Typical Interventions Include:

• Joint Mobilization (To be done by the PT)• Stretching and muscle inhibition• Functional activities to the tolerance of the

patient and to the healing site-per MD orders for weight bearing status

• Muscle performance with proper progression-isometrics to light resistance; remember: resistive force should be applied proximal to the fracture site until radiologically healed

• Soft tissue mobilization• HEP

EMG Biofeedback:

• Is a technique used to record muscle activity generated in a muscle for diagnostic purposes

• Typically uses in clinical settings with surface electrodes, but can be used with intramuscular needle electrodes

• Used for: muscle re-education, muscle relaxation, regain neuromuscular control (balance/posture), increase muscle strength, decrease muscle guarding/spasms, and psychological relaxation

EMG BiofeedbackContinued:

• It can promote normal movement or reveal abnormal movement

• Can be visual, auditory, or both• High sensitivity levels should be used for

relaxation; Low sensitivity levels should be used for muscle re-education

• It does NOT measure a muscle contraction, but it does measure the electrical activity associated with muscle contraction

• Should be practiced in the most functional position/activity

Things to Remember:

• Always ask questions when you are unsure of certain types of techniques or equipment being used

• Your role as a PTA is to assist the PT to give the patient information and knowledge of their condition throughout their treatments and should be geared towards the POC’s goals/function including HEP and preparations for discharge

Break for Lab with Lecture on UE Manual Resistance Exercises, Mechanical Resisted Exercises,Selected Resistance Training

Regimens, Equipment for Resisted Training

Resistance Techniques in Anatomical Planes of Motion/Diagonals of the UE’s

(If time permits may review LE’s)