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Notes for #2- PTA Pathology
cause of primary Osteoarthritis - unknown cause of secondary Osteoarthritis - trauma or infection, hemarthrosis, and osteonecrosis Osteoarthritis - disease that: -originates in the cartilage and affects underlying bone, soft tissue, and synovial fluid -slow progressive degeneration of joint structures -loss of mobility, chronic pain, deformity and loss of function Osteoarthritis can be known as either - OA or DJD Incidence of Osteoarthritis - -most common joint disease -before age 50, higher in men -65+ years: 60% men, 70% women -40 million in U.S. -adults over 30: 6% OA of the knee and 3% at the hip Structures involved in Osteoarthritis - -most common are the weight bearing joints- hip and knee -shoulder -lumbar -cervical spine -1st CMC -MTP joints Risk factors of Osteoarthritis - Growing evidence of systemic factors -genetics -nutrition and weight control -obesity -joint laxity -estrogen use -bone density -muscle weakness -serious injury and inherited predisposition= 50% of hands, hips and knees Men: occupational activities Women: post-menopausal Pathophysiology of Osteoarthritis -
~disorder of the whole synovial joint Stress causes thinning and a progressive loss of cartilage, inflammation develops, resulting in: -bony overgrowth at joint origin (spurs, osteophytes) -ligament laxity -progressive muscle weakness -Atrophy -Loss of function Signs and symptoms of osteoarthritis - -slow or sudden onset -tenderness on palpation and pain with activity -bony enlargement -limited joint ROM/stiffness -Crepitus (audible creaking of joints) -Inflammation -Joint effusion -typically starts on one side of the body and is an aching pain Heberden's nodes effect which joint because of malalignment and joint deformities with osteoarthritis?
- DIP joints Bouchard's nodes effect which joint because of malalignment and joint deformities with osteoarthritis?
- PIP joints Common tests and measures for osteoarthritis - -history -tenderness, effusion, atrophy, varus or valgus deformity -osteophytes -diagnosis of knee OA pain with osteophyte formation and at least one of the following: age is 50+ years, morning stiffness that lasts longer than 30 minutes, and crepitus on motion Varus deformity - space between legs, bow-legged, "looks like you are riding a horse" Valgus deformity - knees touch and feet are apart; forms "L" Common management for Osteoarthritis - -Encourage education, weight loss, exercise or braces -Medication: NSAIDS and analgesics, antiresorptive drugs, Visco supplementation injection -Physical therapy to reduce pain, improve function, increase isometric muscle strength, gait speed, stride length, and aquatics -Surgery: osteotomy, joint arthrodesis or fusion, total joint replacement Rheumatoid Arthritis or RA - chronic systemic inflammatory disease- joint inflammation due to massive infiltration of immune cells
Signs and symptoms of RA - -begins insidiously and progresses slowly -weakness -weight loss -fatigue -general diffuse musculoskeletal pain What is key to relieve pain in RA? - movement Joint signs and symptoms in RA - -swollen, warm, painful and stiff -morning stiffness lasting greater than 1 hour -subluxation Finger deformities that are signs and symptoms of RA - -ulnar deviation -swan-neck deformity (hyperextension of PIP and flexion of DIP) -boutonniere deformity (flexion of PIP and hyperextension of DIP) Soft tissue signs and symptoms of RA - synovitis, bursitis, tendinitis, etc. Spine signs and symptoms of RA - -C-spine: deep aching pain radiating into occipital or temporal areas -occipital headache -C1-C2 subluxation -sleep apnea: brainstem compression Cutaneous signs and symptoms of RA - -Nodules: located in areas of repetitive pressure (elbow, Achilles tendon) Neurologic signs and symptoms of RA - -common -peripheral neuropathies: pain dysesthesias motor loss and muscle atrophy -rheumatoid vasculitis Extraarticular signs and symptoms of RA - -cardiopulmonary -ocular -renal RA criteria for classification - (Has to have 4 of 7 of these; and at least 1 of 4 have had to persist for more than 6 weeks) -morning stiffness that lasts for longer than 1 hour -arthritis of 3 or more joint areas -arthritis of hand joints -symmetric
-RA nodules -RA factor -Radiographic changes Common management for RA - Pharmacotherapy -analgesics -NSAIDS -Corticosteroids DMARDS and BRMs- alters course and clinical presentation immunosuppressants analgesics - medication for pain relief NSAIDS - medications that are used for pain, swelling, and inflammation Corticosteroids - inflammation, pain, and slows joint damage Surgery for RA - synovectomy of wrist, total joint replacement (shoulder, hip, knee, wrist and fingers), Teno synovectomy of hand Physical modalities for RA - -superficial heat -prolonged or deep heat: contraindicated (preferred) -Electrotherapy Ottawa panel suggests: -low-level laser therapy -TENS -Ultrasound -Thermotherapy -E-stim If joint pain lasts longer than 1 hour after the physical modality, how should you alter the intensity? - decrease Prognosis - a prediction of the course of a disease Prognosis of RA - -no known cure -irreversible joint changes -restrictions in ADLs: functional limitations and disability -C-spine involved with progression -Causes of death: infections and renal; respiratory, gastrointestinal disease and upper-spine subluxation -late onset better functional outcome
-MRI- identify sacroiliitis pain earlier -bamboo spins on x-ray -ROM tests common management for ankylosing spondylitis - •Medical- NSAIDS & DMARDS •Physical therapy- exercise consistently, aerobic, stretching, pulmonary exercises balance training, strengthening of trunk extensors, avoid high-impact and flexion exercise & contact sports •Client education- postural training and body mechanics prognosis for ankylosing spondylitis - -80% who are ill for longer than 20 years usually have daily pain
- <1% have a complete remission
- periods of exacerbation and remission
- onset of hip disease: long-term severe and more common in people with onset at a young age
- increased mortality rate Gout - -metabolic disorder (seen as a type of arthritis) -elevated level of serum uric acid and deposition of urate crystals in joints, soft tissues and kidneys -joint disorder: acute or chronic arthritis -middle aged men; peak in 50s -symptomatic after a period of hyperuricemia lasting 10-20 years Gout - most common inflammatory disease in men older than 30 risk factors of gout - -family history -increased serum urate concentration -age -heavy alcohol consumption -obesity -fasting -medication -medication (thiazide diuretics & levodopa) -renal insufficiency -hypertension -hyperthyroidism -hyperparathyroidism -diet rich in purines structures involved in gout - crystals frequently collect on: -articular cartilage -epiphyseal bone -periarticular structure •triggers an inflammatory response resulting in local tissue necrosis and production of fibrous tissue •1st MTP (big toe)- very common site! could be ankle, instep, knee, wrist, elbow &/or fingers
are the signs and symptoms of gout have a quick or slow onset? - quick signs and symptoms of gout - •most common site: acute no monoarticular, inflammatory arthritis: -joint pain -erythema -warmth -extreme tenderness -hypersensitivity -chills, fever tachycardia how long does the asymptomatic phase last in gout - months or years attacks from having what can return suddenly with increasing frequency and severity? may result from: -trauma -surgery -alcohol -overindulgence in foods with high purine - gout common management of gout - -NSAIDS for pain and inflammation -Intraarticular injection of corticosteroids -Medication to prevent or lessen future attacks -rest -elevation -protection -dietary changes -weight loss -moderate alcohol intake How many bones are in the spine? - 33 How many regions are in the spine? - 5 How many intervertebral disks and ligaments are in the spine? - 23 muscle strain - -sudden, violent contraction -rapid stretching -combined lumbar extension and rotation -eccentric loading -repetitive overuse
HNP is rare in _____ - elderly HNP is most common at __ and __ space - 4th and 5th Clinical features of HNP - -protrudes in a posterolateral direction -pain in buttock, down posterior or posterolateral thigh, calf, and onto foot. -numbness and tingling, especially in distal extremity -decrease lumbar motion
Directional preference- peripheralization -want centralization What is centralization? - pulling of pain back up to the originating site of pain Spondylosis - bony defect Spondylolisthesis - forward slippage of one vertebrate over another Type 1 Spondylolisthesis - congenital Type 2 Spondylolisthesis - isthmic (most common) -common victims: weightlifters, gymnasts and football players Type 3 Spondylolisthesis - degenerative Type 4 Spondylolisthesis - traumatic Type 5 Spondylolisthesis - pathologic Clinical features of - Spinal stenosis - narrowing of spinal canal, which causes: -radicular ache into the thigh -complaints of pain with extension -parethesias, that affects the lower extremities -disturbances of motor function
-more common in males -result in degenerative arthritic changes -patient education Lumbar spine fractures - -vertebral fractures -most common osteoporosis related fracture -acute local pain with bending or lifting -relief of pain through activity modification, analgesics/NDSAIDS, physical agents, avoid thoracic or lumbar activities -patient education to prevent fracture TBC for lumbar fracture - Rehab focused on overall symptoms subgroupings: -manual therapy/exercise for directional preference -traction -neuromuscular reeducation and stabilization -exercise -aerobic exercise Invasive management for lumbar fracture - -epidural steroid injection -surgery (laminotomy with decompression) -bed mobility and transfer training -limited sitting -avoid forward bending and trunk rotation Thoracic spine muscle injuries - -direct contact -indirect overstretching/contraction -young active patients management for thoracic spine muscle injuries - -control pain and swelling -modalities -exercise Thoracic disk injuries - -rare -40-50 years old -between 9th and 12th segment -large central disk prolapse (spastic paraparesis, increased deep tendon reflexes, positive Babinski signs of nerve root compressions in thoracic disk injuries - lateral protrusions Management for less severe lateral protrusions - -active rest -analgesics
-decreased motion -referred pain in upper extremities -analgesics, NSAIDS and muscle relaxants -rest -modalities for pain/swelling -AROM -isometric strengthening exercise -education cervical rediculopathy - mechanical compression/inflammation of a nerve root -cervical disk herniation -spondylolysis -osteoporosis -peripheral pain -radicular signs -cervical pain -scapular pain Cervical Spondylotic Myelopathy - -symptoms in lower extremity -combo of cervical root and cord symptom -gait difficulties, weakness and spasticity -UMN lesion with hyperreflexia, clonus and pathologic reflexes Cervical spondylosis - chronic degenerative disk (DDD or DJD) Symptoms characteristic of: -spinal cord compression -nerve root compression 40-50yr olds Men C5-C6 and C6-C clinical features and treatments of cervical spondylosis - sustained impact loading and repetitive microtrauma -cervical cord impingement -nerve root impingement -osteophytes -bone sclerosis -loss of cervical lordosis -central or posterolateral disk herniations treatment for cervical spondylosis - -thermal and electrical agents -analgesics -rest -exercise -traction
-surgery Cervical Facet Syndrome - -posterior neck stiffness -pain with extension or rotation -headache -shoulder/scapula pain -pain control -ROM -exercise Thoracic Inlet Syndrome - commonly known as outlet syndrome (TOS) -neurovascular compression (most common) -proximal compression of subclavian artery/vein and brachial plexus causes of thoracic inlet syndrome - -cervical rib (extra rib from 7th cervical vertebrate) -shortened or hypertrophied anterior scalene muscle -malunion of clavicle and subluxed 1st rib clinical features/treatment of thoracic inlet syndrome - Radicular signs of: -pain and paresthesia along ulnar nerve distribution -weakness, numbness, tingling in head -skin and temperature changes treatment for thoracic inlet syndrome - -stretching -strengthening -cervical posture correction -education TBC of cervical spine - -mobility -centralization -exercise and conditioning -pain control -headache shoulder - most mobile of all joints, contains SITS muscles subacromial rotator cuff impingement - -tendons are crowded/compressed/buttressed -mechanical wear, stress and friction -osteophytes -supraspinatus tendon
-men -anterior more frequent than posterior -rotator cuff tears Bankart Lesion (glenohumeral joint) - an avulsion of the capsule and glenoid labrum off of the anterior rim of the glenoid Hill-Sachs lesion (glenohumeral joint) - compression or impaction fraction of the posterolateral aspect of the humeral head multidirectional instability - Subluxation/dislocation in all directions nonoperative management of glenohumeral joint injury - -protection for 4-6 weeks -NSAIDS/analgesics -ice packs -E-stim -AROM and strengthening to hand, wrist and elbow -ROM, active assistive stretching and strengthening operative management and rehab for glenohumeral joint injury - -open or arthroscopic -immobilization -degree and direction of shoulder motion depends on procedure and physician Anterior capsulolabral reconstruction (glenohumeral) - reattaches capsule to the glenoid SLAP (glenohumeral) - superior labrum anterior to posterior repair arthroscopy (glenohumeral) - less postop pain and soft tissue damage Disorders of the biceps tendon - -tenosynovitis -long head of the biceps -inflammation of the tendon and sheath in bicipital groove -restricted active/passive motions -increased pain with forceful extension or abduction against resistance with elbow extended and forearm supinated Adhesive capsulitis - known as "frozen shoulder" -decreased ROM -pain and inflammation -fibrous synovial adhesions -reduction of synovial cavity
-females -40-60yr olds Primary adhesive capsulitis - idiopathic Secondary adhesive capsulitis - trauma or immobilization features/treatment of adhesive capsulitis - -pain at rest and with activity -as the condition progresses, the pain subsides -severely restricted motion (externally rotates) -loss of function -analgesics -ice -heat/US/phonophoresis -infrared laser -exercise acromioclavicular sprains and strains are also known as - separated shoulder reasoning for acromioclavicular sprains and strains - -fall on acromion -FOOSH acromioclavicular joint 1st degree - Partial tearing or confusion of AC ligaments -joint tenderness -no joint instability or laxity -minimal loss of function acromioclavicular joint 2nd degree - Complete rupture of the AC with partial tearing of the coracoacromial -moderate pain -decreased shoulder abduction + adduction -palpable gap between acromion + clavicle acromioclavicular joint 3rd degree - AC and CC ligaments ruptured -acromion and clavicle dislocated -pain -severe limitation of shoulder motion rehab and management of AC sprains and strains (grade 1) - -pain control: ice packs, NSAIDs, analgesics, rest rehab and management of AC sprains and strains (grade 2) -
-FOOSH
-may be combined with feature of radial head, 10% -Men -median, radial and ulnar nerves and brachial artery treatment for dislocation of the elbow - -closed reduction and immobilization -hand/shoulder motion -PROM then AROM -loss of extension could be a complication fracture/dislocations: -excision of radial head -early protected active motion -passive stretching is AVOIDED -immobilization -loss of 25-30 degrees of pronation/supination -loss of full elbow extension
