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Impaired Joint Mobility
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At the end of this unit the student will be able to:
Explain the current evidence of age-associated changes
in joint mobility
Analyze the implications of impaired joint mobility forclinical management of older adult patients/ clients.
Learning outcomes:
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perationally defined! joint mobility is the capacity of
a joint to move passively! ta"ing into account the joint
surfaces and surrounding tissue.
#nteractions between muscle! tendon! ligament!synovium! capsule! cartilage! and bone at a joint create
the uni$ue aspects of joint mobility.
%he result of the structural changes can include joint
impairment! activity limitation! and participationrestriction.
JOINT MOBILITY WITH AGING
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&oint structures can be categorized as chondroid!
fibrous! and bony. 'hondroid structures are of cartilaginous ma"e-up and
include articular cartilage! menisci! labra! and
fibrocartilaginous discs.
(ibrous structures include the ligaments and tendons
that surround the joint )i.e.! extraarticular* as well as
ligaments within the joint boundaries )i.e.!
intraarticular*. %he other primary fibrous structure is
the joint capsule of diarthroses.
+one creates the structural segments that move relative
to one another at the articulations.
Change in Joint Structures
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As with all joint structures! there is no clear distinction
between typical aging and pathology of chondroid
structures.
ne factor complicating this delineation is theinfluence of loading history.
%he incidence of osteoarthritis )A* in individuals
involved in sports and occupations with high levels of
traumatic and static joint loading. nce articular cartilage becomes damaged! the capacity
to heal is limited and initial injury may progress to the
development of cartilage lesions )i.e.! cartilage
fibrillation*
Chondroid Structures
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A histologic change specific to articular cartilage is
increased calcification over time.
,ecreased hydration compromises the viscoelastic
properties and load-absorbing capacity of the cartilage. ,istinct changes specific to the intervertebral disc also
occur over time.
%he nucleus becomes more fibrous and less gel-li"e
and the annulus becomes less organized. 'rac"s may also develop in the annulus and nucleus.
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,ecreased water content is also noted in the
intervertebral discs and is associated with shorter disc
heights.
%he loss of disc height can lead to the chronicpathological condition referred to as spinal stenosis! a
major cause of pain and disability for older adults.
'hange of the intervertebral disc also alters
surrounding structures. (or example! the diarthrodialfacet joints may experience greater loads! and elasticity
of the ligamentum flavum may decrease because of
decreasing tensile forces over time.
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#n typical function! fibrous structures absorb and
transfer some level of tensile load! based on collagen
content.
Although orientation and composition of tissuecomponents vary between fibrous structures and
between joints! the overarching similarities in response
to aging are increased stiffness and reduced elasticity.
#n addition! there is evidence in animal models thatcross-sectional area and tensile strength of fibrous
structures decrease with age.
i!rous Structures
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+ony change is both directly and indirectly related to
joint mobility.
,irectly! changes in bone can influence the joint
surfaces to alter joint mechanics. #ndirectly! fractures and other bony structural change
can alter joint alignment and function with possible
secondary influences on joint mobility.
%he thic"ness and density of subchondral bone tends todecrease with advancing age! although this is not
uniform at all joint surfaces.
Bone
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#t is well established that osteopenia is prevalent with
aging! because of increased osteoclast and decreased
osteoblast activity! leading to increased ris" of
osteoporosis.
%he combination of lowered threshold for loading and
increased load demand results in an increased ris" of
bone fracture with aging. (ractures can alter joint mobility in a variety of ways!
such as disrupting circulation to joint structures!
altering loading patterns! and decreasing available
range of motion. #n addition! pain associated with fractures can be a
major problem! interfering significantly with an
individuals activity and participation.
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At the level of the whole joint! changes include
decreased joint space! increased laxity! altered
dispersion of loads! and altered joint moments of force.
ver time! the unloading of surrounding tissues and
joint structures that provide tensile support! because of
decreased joint space! may predispose the joint to
decreased range of motion.
(unctionally! joint changes are reflected by ageassociated changes seen in "inematics at both the
segmental level )i.e.! osteo"inematics* and between
joint surfaces )i.e.! arthro"inematics*.
Who"e Joint Changes
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&oint range of motion )* decreases with increasing
age! although nonuniformly among joints! and is often
direction-specific within a given joint.
0enerally! active and passive motion both decrease!
with active tending to decline more than passive.
(or the cervical spine! gradual decline in is seen
beyond the age of with extension and lateral flexion
demonstrating the greatest decline. Examinations of thoracic and lumbar motion reveal
extension to be most limited in older adults! with
minimal or no age-dependent decline in rotation.
#ange o$ Motion
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,eclines in joint motion occur at the hip and foot/an"le
joint complexes! whereas "nee motion! in the absence
of pathology! remains relatively consistent across the
life span. #t has been postulated that reduced hip extension seen
with aging may directly relate to decreased wal"ing
speed in older adults! especially those with sedentary
lifestyles. ,ecreased an"le sagittal plane motion is also seen with
aging! particularly in the direction of dorsiflexion.
%he shoulder complex is most influenced! with flexion
and external rotation being the primary motions
affected.
At the elbow and wrist! no age-associated declines in
motion have been noted in absence of disease.BPHTI: PTH5201 Jul 2015 15
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%he connective tissue changes previously described can
potentially alter arthro"inematics through such
mechanisms as increased fibrous structure stiffness!
decreased chondroid structure volume and
viscoelasticity! and altered bone structure.
Although isolated arthro"inematic motions cannot be
performed volitionally! limitations can have a direct
influence on joint mobility.
Arthro%inematics
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#t has already been noted that connective tissue
structures demonstrate altered capacity to transmit
tensile and compressive loads in older adults.
%hese alterations can result in increased demands on
specific regions within joints! possibly leading to
disease.
%he changes in posture relate to alterations in joint
alignment and mobility. As a conse$uence of alignmentchange! static and dynamic demands on joints are
altered.
orce Transmission
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1ostural control during activities such as wal"ing!
position transfers! and reaching are "nown to decline
with age.
Age-associated activity limitation often culminates in
decreased participation in life events.
%he relationship also wor"s in the opposite direction!
with changes in activity and participation leading to
more sedentary lifestyles and secondary changes tojoint structure and function.
In$"uence on Acti&it' and (artici)ation
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2istory Activity and participation
3ymptoms
ccupation/Activity 2ealth condition/3urgery
(amily history
4iving Environment
3ystems eview
Joint *+amination
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5 bservational tas" analysis 5 3elf-report measures of activity and participation
5 1erformance-based measures of activity
5 &oint-specific mobility testing
our Ma,or T')es o$ Tests and Measure Categories
to Consider When Assessing Joint Mo!i"it'
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(or example! consider an older adult presenting with
impaired hip mobility that limits wal"ing.
#f this individual see"s intervention after a proximal
femur fracture! 6#mpaired joint mobility! muscle
performance! and range of motion associated with
fracture7 is an appropriate diagnostic classification. #n contrast! consider the patient who presents with hip
mobility impairment in addition to several other
ipsilateral symptom manifestations from a cerebral
vascular accident. #n this case! the musculos"eletal diagnostic
classification of the hip is secondary to a primary
neuromuscular diagnosis.
0oals
*&a"uation and -iagnosis
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emediation- Education! therapeutic exercise! and
manual therapy techni$ues
'ompensation- use of assistive devices
1revention-prevent onset or progression of problems.
Inter&ention
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Education on activity modification 8se of assistive devices
(atient education
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3tretching-the longer the hold of stretch! up to 9
seconds! the greater the benefit.
3trengthening- joint mobility improvement can be
achieved partly as a result of improved muscle
function. 3trengthening also influences joint mobility
by loading the joint structures.
Endurance training! and
+alance training-stabilization exercises! %ai 'hi! yoga
Thera)eutic e+ercise
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Age is not a contraindication to joint mobilization andmanipulation.
#n relation to older adults with osteoporosis! the use of
manual intervention techni$ues is controversial.
(or individuals with spinal osteoporosis! grade ;
mobilization )i.e.! manipulation* has been
contraindicated based on concerns for fracture ris".
Manua" Inter&ention Techni.ues
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Assistive and adaptive devices can be used ascompensatory or preventive approaches to protect joint
structure and assist with load transfer across joints.
,evices such as canes and wal"ers are useful
components to physical therapy intervention for
individuals with joint mobility impairment.
+races designed to alter joint alignment have also been
used with older adults. (indings indicate that alignmentcan be altered and joint loading decreased across
painful areas of osteoarthritic joints during gait
function.
Assisti&e/Ada)ti&e -e&ices and *.ui)ment
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3election of appropriate footwear! designed tostrategically cushion and support! may be a simple way
to provide immediate relief of symptoms by decreasing
loads across lower extremity joints.
Additionally! shoe orthotics may improve lower
extremity alignment and bring about changes in joint
loading
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3elf-eport utcome #nstruments-3*!
%he >estern ntario otator 'uff #ndex )>'* %he otator 'uff =uality of 4ife =uestionnaire )'-
=4*!
Outcomes
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Australian/'anadian steoarthritis 2and #ndex
)A83'A
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%he functional reach test %imed up and go test
(ive times sit-to-stand test
3ix-minute wal" test 3tair climb test
0ait speed
(er$ormance0Based Outcome Instruments
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Andrew A. 0uccione! ira A. >ong! ,ale Avers! @@0eriatric 1hysical %herapy! Brded! Elsevie
%imothy 4. ?auffman! &ohn . +arr! ichael 4. oran
@C 0eriatric ehabilitation anual! @nded! 'hurchill
4ivingstone
A'3s guidelines for exercise testing and
prescription.Dthedition.
#e$erences:
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Than% 'ou