Musculoskeletal - medical disorders Flashcards
Rheumatic disease
- systemic
- 100 different types with 10 categories
Rheumatic diseases: pathogenesis
- periods of exacerbations and remissions
Rheumatic diseases: clinical manifestations
- joint pain
- rash
- fever
- diarrhea
- scleritis
- neuritis
Rheumatic diseases: medical management
- treatment varies over time (esp with exacerbations and remission)
- requires consultation with or referral to physician
Osteoarthritis
- slowly evolving articular disease that originates in the cartilage and affects underlying bone, soft tissue, and synovial fluid
Osteoarthritis: risk factors
- Genetics
- participation in occpations and sports the have prolonged stresses on joints
- hypermbility and hypomobility
Osteoarthritis: pathogenesis
- function of condrocytes are affected with articular cartilage causing cell death
- synovial lining secretes excessive synovial fluid
- chondrocytes do no contiune to make collagen and articular cartilage wears down
Osteoarthritis: clinical manifestations
- bony enlargemetn
- limited ROM
- crepitus with motion
- tenderness with pressure
- joint effusion
- malalignment/joint deformity
- stiffess for a short duration (morning)
Osteoarthritis: diagnosis
- history
- radiological findings
- physical examination
- lab tests
Osteoarthritis: prevention/treatment
- prevent joint injuries, healthy lifestyle and exercise
- treatment: education, weight loss, exercise, orthotics, braces, meds, complentary therapy, surgery
Osteoarthritis: pharmcotherapy
- topical capsaician, glucosamine/chondroitin, NSAIDs, and Cox-2 inhibitors
RA:
- what is it
- symptoms
- chronic systemic inflammatory disease
- symetric simultaneous joint distribution
- can affect any joint but especially UE
- inflammation almost always present
- prolonged morning stiffness more than1 hr
- systemic presentation with constitutional symptoms: fatigue, malaise, weight loss, fever
RA treatment:
- reduce signs and symptoms to a state of remission
- meds: analgesics, NSAIDs, corticosteriods, disease modifying anti-RH drugs, cytokine inhibtors, lymphocyte inhibitors,
- complementary therapy: acupuncture, autogenic training, fish and plant oils
- surgery: synovectimy to reduce pain and joint damage, total joint replacements, tenosynovectomy of the hand
Juvenile idiopathic arthritis: classifications
- pauciarticular
- polyarticular
- systemic
Pauicarticular JIA
- Juvenile idiopathic arthritis
- knees, elbows, wrist and ankles
- can have a leg length discrepency
- girls>boys
- less than 5 joints are involved
classification based on how may joints are involved, girls>boys and may see leg length discrepency
Polyarticular JIA
- affects five or more joints
- including large and small joints
- joint involvement is symetrical and is similar to the adult RA
- subtypes: presence of Rheumatoid factor or absence of Rheumatoid factor
- similar to adult RA
- RF+ = affects eye, hands or feet
- RF- = affects the spine
Systemic JIA
- involvement of any number of joints
- boy=girls
- most extraarticular manifestations
- fever, chills and intermittently rash on thighs and chest
- inflammed joints and chronic destructive arthitis
Psoriasis JIA
- inclusion of joint swelling along the skin
- redness, irritation and scaling
- treatment with aggressive immunosuppressives
Stills disease clincal manifestations
- Systemic JIA
- fever
- rash
- lymphadenopathy
- polyarthritis
- pleuritis
- peptic ulcer disease
- hepatitis
- anemia
- anorxia
- weight loss
- polyarthritis,polyarthralgias
- myalgia/myositis
- tenosynovitis
- skletela growth disturbances
JIA: medical management
Dx, TX,
DX:
- history
- physical exam
- labs for inflammation and antinuclear antibodies
- rheumatoid factor and sometimes HLA-B27
TX:
- pharmacotherapy: immunosupressives, DMARDs and biologic agents such as TNF inhibitors, infiximab
- physical therapy
Spondyloarthropathies
what is it and incidence/risk factors
- chronic inflammation of axial skeleton and SI joints
- asymmetric involvement of small number of peripheral joints
- young males most commonly
- familial predisposition
Spondyloarthropathies
Signs and symptoms
- inflammation at sites of ligament, tendon, and fascial insertion into bone
- seronegativity for Rheumatoid factor but assoicated with histocompatibility antigens, including HLA-B27
- extraarticular involvement of eyes, skin, gentiourinary tract, cardiac system
Ankylosing spondlitis
Overview and incidence
- chronic inflammation that over time causes the spine to fuse
- fuses posteriorly
- 1/3 asymmetrical involvement
- 0.1-2% of US population
- higher in whites
- 15-30 years old onset
Ankylosing spondlitis: risk factors
- genetic or environmental link HLA-B27 positive
- more prevalent in males
- less severe in females
Ankylosing spondlitis
Pathogenesis
- chronic inflammation at sites of attachment
- disruption of the ligamentous-osseous junction >ossification
Clinical manifestations of
Ankylosing spondlitis
- low back, buttock, or hip pain and stiffness
- insidious onset
- lasting for at least 3 months
Ankylosing spondlitis
medical management
DX/TX
- DX: history, physical exam, radiography, and lab tests
- Tx: pharmacotherapy: NSAIDs, DMARDS, TNF- alpha antagonistsor
- TX: surgery: remove osteophytes or spinal fusion
Implications for PT with Ankylosing spondlitis
- watch for signs and symptoms of systemic diseases
- exercise: consistency for remodeling and alignment and proper prescription
- outcome measures
- positioning - fuses in the best position
Diffuse Idiopathic Hyperostosis
- idiopathic variant of OA
- ossification of ligaments anteriorly
- thoracic spine
- women>men
Diffuse Idiopathic Hyperostosis: risk factors/pathogenesis
- disease that produce endothelial cell damage (HTN, CAD, DM< AS, metabolic)
- ossification at insertions anteriorly (typically thoracic spine but can affect hip/knee)
Clinical manifestations: Diffuse Idiopathic Hyperostosis
- dull pain and stiffness
- hoarseness
- stridor/snoring
- dysphagia (voice)
medical management: Diffuse Idiopathic Hyperostosis
- DX: radiographic findings (4 vertebrae fusions), rhematoid workup
TX:
- pharmacotherapy: NSAIDs
- surgical: removal of osteophytes
- PT exercise: gentle ROM, STM, dont over stretch at the insertions
Typical MSK infections
- necrotizing fasciitis
- streptococcal myositis
- soft tissue infeciton leading to gangrene
- cellulitis
Osteomyelitis
- inflammation of the bone caused by an infectious organsm such as strep
- common areas: spine, pelvis, extremities
Osteomyelitis: incidence
- children> adults, boys>girls
- acute: children, older adults, IV drug users
- Chronic: adults, immunocompromised
- exogenous Osteomyelitis: direct bone exposure
- hematogenous Osteomyelitis: preexisting infecitons
Congential states associated with MSK infections
- chronic granulomatous disease: hemophilia, hypogammaglobulinemia, sick cell disease
Acquired states associated with MSK infections
- DM
- hematologic malignancy
- HIV infection
- pharmocologic immunosuppression (organ transplant, collagen-vascular diseases)
- uremia
- myelopathy
- alcoholism
- malnutrition
Pathogenesis: Osteomyelitis
- acute infection may develop in the metaphysis of long bones
- infecting organism, personal immune status plays a role
- intial infection
- the bacteria reaches the metaphysis through nutrient artery
- bacterial growth results in bone desctruction and abcess formation
- abcess cavity and pus spreads between trabeculae into medulla through the cartilage into the joint
Clinical manifestations
MSK infections
osteomyellitis
Adults:
- back pain –described as deep and constant, increases with WB in spine in LE
- systemic infection
- fever
- spine pain is intermittent or constant, throbbing, radiculopathy, myopathy, paralysis, antalgic gait
Children:
- intense pain
- high fever
- edema, erythema, tenderness
- joint pain
- diminished function
Medical managemetn of osteomyellitis
Prevention, screening, diagnosis, treatmnet, prognosis
- prevention: education/nutrition
- screening: hx/review of systems
- diagnosis: X-ray, MRI, CT, bone scan, blood tests, cultures (drainage)
- treatment: IV antibiotics, surgical debridement
- prognosis: good if caught early
- chronic osteomyelitis has poort prognosis and higher risk of amputation
Implications for PT
when treating patients with osteomyelitis
- history and screening
- wound care
- precautions with WB
- prevent complications in other joints and tissue
- external fixation devicies often get infected
- if there is an infection do not move that much as this can cause infection to spread
Infections of prostheses and implants
incidence
- 2/3 of prosthetic joint infections occur within 1st year
- staph typicall causes
- acute infections: perioperative, hematogenous, contiuous (around structures)
Infections of protheses and implants: pathogenesis
- local
- prosthetic implants
Infections of protheses and implants: clinical manifestations
- persistent joint pain –pain should calm down with healing
- edema, hematoma, tenderness, fever
- prosthetic lossening – may complain of slipping, rubbing, or hearing a cluck
Infections of protheses and implants prevention/screening
- prevention: sterilization and infection control cover in the shower
- screening: history and review of systems
Infections of protheses and implants: diagnosis
- differentiate mechanical from aseptic
- aspiration of joint fluid and culture
- blood tests, cultures
- US< radiographs, bone scane, CT
Infections of protheses and implants
Treatment
- use of microbial prophylaxia for anyone undergoing joint replacements
- surgical removal/replacement, debridement
- antimicrobials, antibiotics, perioperative, cephalosporins
Infections of protheses and implants: implications for the PT
- history/screening: recent and previous surgeries or infecitons
- inspection of scars or incisions and surrounding tissues
- if they say they had a recent surgery or infection you want to look and palpate
PT treatment
- precautions or restricitions in movement or WB
- wound care
- prevent complications in surrounding strucutures by limiting movement
movement may mobilize the infection
Spondylodiscitis
Defintion
- infection that affects the vertebra spine components
- intervertebral discs
Spondylodiscitis : incidence
- S. anureus and M. Tuberculosis
- hematogenous spread
Spondylodiscitis
Clincal manifestations
- fever
- spinal pain not relieved by rest
- cant get comforable = are you running a fever/malaise etc
- if back is hurt you cna typically find a position that is comfortable
Spondylodiscitis: diagnosis
- blood test- inflammatory markers
- cultures
- radiographs, bone scans, MRI
Spondylodiscitis
treatment
- bed rest: may be to protect area but will be modified
- body jacket around spine clamshell that must be when OOB
- IV antibiotics: banomyocen
- Surgery: debridement
Spondylodiscitis
Prognosis
- good
- potential for vertebral collapse, kyhposis, bony ankylosis and abscess formation
Infectious athritis
Most common locations
- adults: hip/knee
- children: ankle and elbow
Infectious athritis
most common causes
- S. aureus
- streptococcus pneumoniae
- kingella kingae
- neisseria gonorrheae
Infectious athritis
Predisposing factors for adults
- immunosupressants or immunodeficiency
- preexisting arthritis
- arthrocentesis
- DM (poorly controlled)
- Sickle cell disease
- Alcohol or drug abuse
- trauma
- infectious disease
- chronic renal failure
- abnormal synovium from rheumatoid or degenerative conditions
Bacterial arthritis
- hematogenous spread
- direct inoculation and penetrating injury
- direct extension
- periarticular osteomyelitis
- contigous soft tissue infection, abscess, cellulitis
most of the time related to an invasive procedure
Infectious athritis
Pathogenesis
- bacterial growth, phagocytosis, synovial reaction, fibrin production, abscess formation, pannus formation, necrosis
Infectious athritis
Clinical manifestations
- acute onset joint pain
- swelling
- tenderness
- loss of motion
- warm joint
- pus
- systemic symptoms: fever, chills etc
- can destroy a joint quickly
- pericarditis, septic shock
- pyelonephritis, multi-organ involvement
Infectious athritis
Diagnosis
- joint fluid aspiration
- X-rays, contrast MRI, US
Infectious athritis
Treatment
- IV antibiotics in hopsital and then 2-3 weeks with oral
- corticosteriods
- aspiration and surgical drainage
Infectious athritis
prognosis
- Good if treatment within 5-7 days of onset
- mortality 10-25%
- permanent joint disability
- possible complications - osteomyelitis abscess formation, septicemia
Infectious athritis
Implications for the PT
- history and screening: immediate referal
- post medical managemetn:
- *joint ROM and WB precautions or restrictions
- education for signs of infection
- joint protection adn strengthenign supporting structures*
Myositis
- inflammation of muscules
- dermatomyositis
- polymyositis
- inclusion body myositis
- myositis ossifcans
- idiopathic inflammatory myopathies
- rhabdomyolysis
- pyomyositis
Myositis
Most often causes
- S. aureus and parasites
Myositis
incidence
- IBM is most common in ages 50+
Myositis
Pathogenesis
- intramuscule fiber degeneration
- severe weakness
Myositis
clinical manifestations
- muscule swelling
- tenderness
- fever
- lethargy
- atrophy
- weakness
- necrosis
- dysphagia
- cardiomyopathy
Myositis
Dx
TX
- DX: history muscle biopsy, EMG< blood tests
- TX: immunosuppressive therapy and corticosteriods, submaximal exercise
Myositis
implications for PT
- history and screening,
- lipid lower medications
- may be the first sign of malignancy
- exercise: submax, limit eccentric activity, avoid overworking
Infections of bursae and tendons
Incidence
- hand
- knee
- elbow
- cellulitis>tenosynovitis
Infections of bursae and tendons
Clinical manifestations
- localized swelling
- pain
- erythema
- warmth
- loss of fucntion
Infections of bursae and tendons
DX
TX
prognosis
- Dx: aspiration, culture, surgery
- Tx: antibiotics
- Prognosis: good if treatmetn started early; potential for complications, necrosis, osteomyeitis
Infections of bursae and tendons: implications for PT
- hand specialization
- wound care
- splinting - wrist in 30º to 50ºof extension
- metacarpophalangeal joints 85ºto 90º of flexion and the interphalangeal joints in full extension AROM
Skeletal tuberculosis
Incidence/pathogenesis
- 10 million new cases annuall 1.6 million die
- extrapulmonary TB 2-3 years after primary infection
Skeletal tuberculosis
clinical manifestations
- pain and stiffness
- localized or referred
- lower thoracic and lumbar
- elbows or WB joints
- systemic signs: chills, fever, weight loss
Skeletal tuberculosis
Dx:
Tx:
- DX: delayed due to lack of symptoms initially; MRI, CT, X-ray, bone scans, smear culture
- TX: chemotherapy, surgical decompression
Skeletal tuberculosis
implications of PT
- HIstory an screening
- precautions and PPE - droplet exposure
- postural drainage and percussion
- referral for other psychosocial issues
- long term disability concerns
