Joint, Connective Tissue, and Bone

Disorders and Management

Chapter 11
ARTHRITIS
 Inflammation of a joint.
 Types of arthritis:
Both inflammatory and noninflammatory,
 Affect joints and other connective tissues in the body.
 Most common are rheumatoid arthritis and osteoarthritis.

ARTHROSIS
 limitation of a joint without inflammation.
 Trauma, recovering from a fracture, immobilization
 Due to involvement of connective tissues and muscles

 Traumatic arthritis may require aspiration if there is bloody effusion.

 CLINICAL SIGNS AND SYMPTOMS

IMPAIRED MOBILITY
patient presents with signs typical of joint involvement that are :

 Capsular pattern (characteristic pattern of limitation )

 Firm endfeel (unless acute; then the end-feel may be guarded),
 Decreased and possibly painful joint play, and joint swelling (effusion).

 Arthrosis may be present if the individual is recovering from a fracture or other

problem requiring immobilization. There is limited joint play along with other
connective tissue and muscular contractures limiting ROM.
 CLINICAL SIGNS AND SYMPTOMS (cont)

Impaired Muscle Performance:

• Any mechanical imbalances in flexibility and strength in supporting muscles.

• This is important because poor muscle support allows the joint to be more susceptible
to trauma; conversely, good muscle support helps protect an arthritic joint.

• Any asymmetry of muscle pull may be a deforming force; and if it cannot be corrected
with exercises, splinting or bracing may be necessary to prevent progressive deformity.
• Stabilizing muscles are often inhibited when there are swollen or restricted joints.
Strength returns with decreased swelling and increased joint mobility.
• So it is important to protect the joints when they are swollen and
the muscles are weak.
Impaired Balance:
 Balance deficits because of altered or decreased sensory input from joint
mechanoreceptors and muscle spindle.
 This is particularly a problem with weightbearing joints.

Functional Limitations:-
 Home, community, work-related,or social activities may be minimally to
significantly restricted.
 Adaptive and assistive devices may be used by the patient to improve function
or help prevent possible deforming forces.
 A variety of classification systems and functional instruments have been
developed for use in clinical studies as well as routine practice to measure
patient
function and outcomes in response to interventions
 Rheumatoid Arthritis
 Rheumatoid arthritis (RA) is an autoimmune,
chronic,inflammatory, systemic disease primarily affecting
the synovial lining of joints as well as other connective
tissue.
 It is characterized by a fluctuating course, with periods of
active disease and remission.
 Symptoms vary from mild stiffness requiring minor lifestyle
changes and medication OR abrupt swelling, stiffness and
progressive deformities requiring major life style
modification, surgery and medication
 Rheumatoid Arthritis: Characteristics
 Periods ofExacerbation (flare) and remission
 Inflammatory changes in
 Synovial membrane
 articular cartilage
 Subchondral marrow spaces
 Tendon sheath
 Granulation tissue (pannus) forms, covers, and erodes the articular cartilage, bone,
and ligaments in the joint capsule.
 Adhesions may form, restricting joint mobility. With progression of the disease,
cancellous bone becomes exposed.
 Fibrosis, ossific ankylosis, or subluxation may eventually cause deformity and
disability
 Inflammatory changes also occur in tendon sheaths (tenosynovitis); and if
subjected to recurring friction, the tendons may fray or rupture
 Cont.
 Extra-articular changes
• Rheumatoid nodules
• Atrophy and fibrosis of muscles
• Muscular weakness
• Fatigue
• mild cardiac changes

 Progressive deterioration and decline in the functional level of the individual

attributed to the muscular changes and progressive muscle weakness is often
seen.

 The degree of involvement varies. Some individuals experience mild symptoms that
require minor lifestyle changes and mild anti-inflammatory medications.
 Others experience significant pathological changes in the joints that require major
adaptations in lifestyle.
 Loss of joint function is irreversible, and often surgery is needed to decrease pain
and improve function.
 Early recognition is essential during the initial stages, with referral to a
rheumatologist for diagnosis and medical management to control the inflammation
and minimize joint damage
Radiographic hallmarks
Criteria for Diagnosis of Rheumatoid
Arthritis
Signs and Symptoms—Periods of Active Disease
(may last months to more than a year)
• Effusion and swelling of the joints(aching and limited motion)
• Joint stiffness in morning
• pain on motion
• Pain and stiffness worsen after strenuous activity
• smaller joints of the hands and feet ,
• PIP
• bilateral
• deformed and may ankylose or subluxate
• Pain felt in adjoining muscles; (muscle atrophy and weakness ).
• Asymmetry in muscle strength and alterations in the line of pull of muscles
and tendons add to the deforming force

• Nonspecific symptoms
 low-grade fever
 loss of appetite
 Weight, malaise, and fatigue
 Principles of Joint Protection
Do’s
• Monitor activities
Do Not’s
• frequent but short episodes • Avoid deforming
of exercise positions.
• Alternate activities to avoid • Avoid prolonged static
fatigue positioning; change
• Decrease level of activities positions during the day
• functional level of ROM,
strength and endurance
every 20 to 30 minutes
• Increase rest during flares • Muscular and total body
of the disease. fatigue
• appropriate adaptive
equipment
 Principles of Management—Active
Inflammatory Period of RA
Joint protection.
• Because periods of active disease may last several months to more than a year,
education in the overall treatment plan, safe activity, and joint protection
begins as soon as possible.
• It is imperative to involve the patient in the management so he or she learns how to
conserve energy and avoid potentialdeforming stresses during activities and when
exercising.

Energy conservation.
• It is important that the patient learns to respect fatigue and, when tired, rests to
minimize undue stress to all the body systems.
• Because inflamed joints are easily damaged and rest is encouraged to protect
the joints, the patient is taught how to rest the joints in nondeforming positions
and to intersperse rest with ROM.
 Cont…..

Joint mobility.
• Gentle grade I and II distraction and oscillation techniques are used to
inhibit pain and minimize fluid stasis.
• Stretching techniques are not performed when joints are swollen.

Exercise.
• The type and intensity of exercise varies depending on the symptoms. The
patient is encouraged to do active exercises through as much range of
motion (ROM) as possible (not stretching).
• If active exercises are not tolerated owing to pain and swelling, passive
ROM is used.
• Once symptoms of pain and signs of swelling are controlled with
medication, exercises can progress as if subacute.

Functional training.
• Activities of daily living (ADL) may need to be modified in order to protect the
joints. If necessary, splints and assistive devices should be used to provide
protection.
 Cont.
PRECAUTIONS:
• Secondary effects of steroidal medications may include osteoporosis and
ligamentous laxity, so exercises should not cause excessive stress to bones or joint.

CONTRAINDICATIONS:
• Stretching techniques should not be performed across swollen joints.
• When there is effusion, limited motion is the result of excessive fluid in
the joint space.
• Forcing motion on the distended capsule overstretches it, leading to subsequent
hypermobility (or subluxation) when the swelling abates. It may also increase
the irritability of the joint and prolong the joint reaction.
Principles of Management—Subacute
and Chronic Stages
 Joint protection (splints, avoid over use, modify environment)
 Improving flexibility
 Muscle performance
 Cardiopulmonary endurance
 Low–impact conditioning exercises
 Swimming and bicycling
 Improve aerobic capacity
 Decrease depression and anxiety.
 Group activities such as water aerobics
 Nonimpact or low-impact conditioning exercises
swimming and bicycling, performed within the tolerance of the
individual with RA, improve aerobic capacity and physical activity and
decrease depression and anxiety.
 Group activities such as
 water aerobics also provide social support in conjunction with the
activity
 Principles of Management—Subacute
and Chronic Stages

PRECAUTIONS
Dosage of stretching and joint mobilization techniques
CONTRAINDICATIONS
Vigorous stretching or manipulative techniques
 Osteoarthritis—Degenerative Joint
Disease
 Osteoarthritis (OA) is a chronic
degenerative disorder primarily
affecting the articular cartilage of
synovial joints, with eventual
boney remodeling and
overgrowth at the margins of the
joints (spurs and lipping)

• There is also progression of

synovial and capsular
thickening and joint effusion.
 Etiology

 etiology of OA is not known

 Mechanical injury to the joint due to a major
stress
 repeated minor stresses
 poor movement of synovial fluid when the joint
is immobilized
 genetically related, especially in the hands and
hips and to some degree in the knees.
 Characteristics of OA
• capsular laxity(as a result of bone remodeling & capsular
distention) ,hypermobility or instability in some part of range
• pain and decreased willingness to move lead to contractures
eventually.
• Rapid destruction of articular cartilage occurs with
immobilization
• The cartilage splits and thins out, losing its ability to
withstand stress.
• As a result, crepitation or loose bodies may occur in the joint.
• Eventually, subchondral bone becomes exposed.
• There is increased density of the bone along the joint line,
with cystic bone loss and osteoporosis in the adjacent
metaphysis.
• During the early stages, asymptomatic because the cartilage
is avascular and aneural (pain constant in later stages).
 Characteristics of OA

 Enlargement of effected joints:

 Heberden’s nodes (enlargement of the
distal interphalangeal joint of the
fingers)
 Bouchard’s nodes (enlargement of the
proximal interphalangeal joints)
Commonly involved joints
• Weight-bearing joints (hips and knees)
• Cervical and lumbar spine
• Distal interphalangeal joints of the
fingers
• Carpometacarpal joint of the thumb
• 1st MTP
More detail about pain mangement
Adaptive/assistive devices for OA and
RA
`FIBROMYALGIA AND MYOFASCIAL
PAIN SYNDROME
• Chronic pain syndromes that are often confused and
interchanged.
• Each has a distinct proposed etiology.
• Individuals with fm process nociceptive signals
differently from individuals without fm,
• Individuals with MPS have localized changes in the
muscle.
 FIBROMYALGIA

• a chronic condition characterized by widespread pain that

covers half the body (right or left half, upper or lower half)
• has lasted for more than 3 months
• Additional symptoms
 11 of 18 tender points at specific sites
 nonrestorative sleep (insufficiently refreshing sleep)
 morning stiffness
 Fatigue
 diminished exercise tolerance
Tender points
 Characteristics of FM
 The first symptoms of FM can occur at any age but usually
appear during early to middle adulthood.
For more than 30% of those diagnosed, the symptoms develop
after physical trauma such as a motor vehicle accident or a viral
infection.
Pain as muscular in origin (symptoms vary from individual to
indivudual)
 Predominantly reported to be in the scapula, head, neck, chest,
and low back
 Significant fluctuation in symptoms from diminished to so much
worsened symptoms that patients cannot carry out their
activities of daily living.
Individuals with FM have a higher incidence of
• Tendonitis,
• Headaches,
• Irritable bowel,
• Temporal mandibular joint dysfunction,
• Restless leg syndrome,
• Mitral valve prolapse,
• Anxiety, depression, and memory
problems.
 Contributing Factors to a Flare

• environmental stresses
 Weather changes, especially significant changes in
barometric pressure, cold, dampness, fog, and rain(An
additional environmental stress is fluorescent lights)
• physical stresses
 Repetitive activities, such as typing, playing piano,
vacuuming; prolonged periods of sitting and/or standing;
and working rotating shifts.
• emotional stresses.
 Any normal life stresses.
 Management—Fibromyalgia
• Research supports the use of exercise, particularly aerobic exercise.
• In addition to exercise, interventions include:
 Prescription medication
 Over-the-counter medication
 Instruction in pacing activities, in an attempt to avoid fluctuations in
symptoms
 Avoidance of stress factors
 Decreasing alcohol and caffeine consumption
 Diet modification.
 Myofascial Pain Syndrome
• A chronic, regional pain syndrome.
• The hallmark classification of MPS comprises the
myofascial trigger points (MTrPs) in a muscle which have a
specific referred pattern of pain
  The trigger point

• A hyper irritable area in a tight band of muscle. The

pain from these points is described as dull, aching,
and deep.
• Active (producing a classic pain pattern)
• Latent (asymptomatic unless palpated).
• Additional impairments from the trigger points
include
decreased ROM when the muscle is being stretched,
decreased strength in the muscle, and increased pain
with muscle stretching.
 Possible Causes of Trigger Points
• Chronic overload of the muscle that occurs with repetitive activities
or that maintain the muscle in a shortened position.
• Acute overload of muscle, such as slipping and catching oneself,
picking up an object that has an unexpected weight, or following
trauma such as in a motor vehicle accident.
• Poorly conditioned muscles compared to muscles that are exercised
on a regular basis.
• Postural stresses such as sitting for prolonged periods of time,
especially if the workstation is not ergonomically correct, and leg
length differences.
• Poor body mechanics with lifting and other activities
 Management—Myofascial Pain
Syndrome
• Three main components
1. Eliminating the trigger point
2. Correcting the contributing factors
3. Strengthening the muscle
• When ROM is restored and the trigger point has been addressed,
muscle strengthening is initiated. Several techniques are used to
eliminate trigger points.
• Contract–relax–passive stretch done repeatedly until the muscle
lengthens
• Contract–relax–active stretch also done in repetition
• Trigger point release
• Spray and stretch
• Dry needling or injection
 OSTEOPOROSIS

• Osteoporosis is a disease of bone that leads to

decreased mineral content and weakening of the
bone. This weakening may lead to fractures,
especially of the spine, hip, and wrist.
 Diagnosis …(Tscore)

• The diagnosis of osteoporosis is determined by

the T-score of a bone mineral density (BMD)
scan.
• T score is the number of standard deviations (SD)
above or below a reference value (young, healthy
Caucasian women).
• Normal: –1.0 or higher
• Osteopenia: –1.1 to –2.4
• Osteoporosis: –2.5 or less
 Risk Factors
• Primary osteoporosis. ( post-meupausal, low calcium or vit-D,
Caucasian or Asian descent, family history, low body weight,
little or nophysical activity, and smoking. prolonged bed rest
and advanced age )
• Secondary osteoporosis. (due to some medical condition-
gastrointestinal disease, hyperthyroidism, chronic renal
failure, alcohol use, use of steroids-{glucocorticoids})

osteoporosis is detected radiographically by cortical thinning,

osteopenia (increased bone radiolucency), trabecular changes,
and fractures.
 Prevention of Osteoporosis
The National Osteoporosis Foundation (NOF) recommends
four ways to prevent osteoporosis

 Diet rich in calcium and vitamin D

 Weight-bearing exercise
 Healthy lifestyle with moderate alcohol
consumption and no smoking
 Testing bone for its density and medication if
needed.
• Bone is living tissue, continually replacing itself in response to the daily
demands placed on it.
• Normally this continual replacement keeps our bone at its optimum
strength.
• Cells in bone called osteoclasts resorb bone, especially if calcium is needed
for particular body functions and not enough is obtained in the diet.
• Another type of cell, the osteoblast, builds bone. This cycle is usually kept in
balance with bone resorption equaling bone replacement until the third
decade of life.
• At this point,peak bone mass should be reached. With increasing age there
is shift to greater resorption. For women, resorptionis accelerated during
menopause owing to the decrease in estrogen.
Physical Activity
Physical activity has been shown to have a positive affect on bone
remodeling.
• In children and adolescents, this activity may increase the peak bone
mass.
• In adults, it has been shown to maintain or increase bone density; and in
the elderly, it has been shown to reduce the effects of agerelated or
disuse-related bone loss.
• Maintenance of, or an increase in, bone density is important for
preventing fractures associated with osteoporosis.
• Weak bones due to osteoporosis have been attributed to causing more
than
1.5 million fractures per year at a cost of $17 billion dollars. Many of these
individuals never return to their previous functional level.
Effects of Exercise
• Muscle contraction (e.g., strengthening exercises, resistance training) and
mechanical loading (weight bearing) deform bone.
• This deformation stimulates osteoblastic activity and improves BMD
 Recommendations for Exercise

 Weight-bearing exercise, such as walking, jogging,

climbing stairs
 Non-weight-bearing exercise, such as with a bicycle
ergometer
 Resistance (strength) training
Recommendations for Exercise

MODE : Aerobic
 Frequency
 5 or more days per week
 Intensity
 Thirty minutes of moderate intensity (fast
walking) or 20 minutes of vigorous intensity
(running). Doing three short bouts per day of
10 minutes of activity is acceptable
Recommendations for Exercise
MODE : resistance
 Frequency
 Two to three days/week with one day
of rest between each session
 Intensity
 Eight to 12 repetitions that lead to
muscle fatigue
 Exercise Precautions and
Contraindications
 Because osteoporosis changes the shape of the vertebral
bodies (they become more wedge-shaped), leading to
kyphosis, flexion activities and exercise such as supine curl-
ups and sit-ups as well as the use of sitting abdominal
machines should be avoided. Stress into spinal flexion
increases the risk of a vertebral compression fracture.
 Avoid combining flexion and rotation of the trunk to reduce
stress on the vertebrae and the vertebral discs.
 When performing resistance exercise, it is important to
increase the intensity progressively but within the structural
capacity of the bone.
 FRACTURES—POST-TRAUMATIC
IMMOBILIZATION
 A fracture is a structural break in the continuity of a
bone, an epiphyseal plate, or a cartilaginous joint
surface.
. When there is a fracture, some degree of injury also
occurs to the soft tissues surrounding the bone.
Depending on the site of the fracture, the related soft
tissue injury could be serious if a major artery or
peripheral nerve is also involved. If the fracture is more
central, the brain, spinal cord, or viscera could be
involved
Types of fractures
Types of fractures
 Identification of A fracture
 Site: diaphyseal, metaphyseal, epiphyseal, intra-
articular
 Extent: complete, incomplete
 Configuration: transverse, oblique or spiral,
comminuted (two or more fragments)
 Relationship of the fragments: undisplaced,
displaced
 Relationship to the environment: closed (skin in
tact), open (fracture or object penetrated the skin)
 Complications: local or systemic; related to the injury
or to the treatment
 Risk Factors

 Risk factors for fracture include :

 Sudden impact (e.g., accidents, abuse,
assult)
 Osteoporosis (women men)
 History of falls (especially with
increased age, low body mass index,
and low levels of physical activity
 Bone Healing
 Following a Fracture Fracture healing has
 (1) an inflammatory phase where there is hematoma
formation and cellular proliferation;
 (2) a reparative phase where there is callous formation
uniting the breach and ossification
 (3) a remodeling phase where there is consolidation and
remodeling of the bone.
 Time for healing

Healing time varies with age of the patient, the location and
type of fracture, whether it was displaced, and the blood
supply to the fragments. Healing is assessed by the physician
using radiological and clinical examinations. Generally, children
heal within 4 to 6 weeks, adolescents within 6 to 8 weeks, and
adults within 10 to 18 weeks
Principles of Management— Period of
Immobilization
• Local Tissue Response
With immobilization, there is connective tissue
weakening, articular cartilage degeneration, muscle
atrophy, and contracture development as well as sluggish
circulation.In addition, there is soft tissue injury with
bleeding and scar formation.
It is important to keep structures in the related area in a
state as near normal as possible by using appropriate
exercises without jeopardizing alignment of the fracture
site while it is healing.
 Immobilization in Bed

If bed rest or immobilization in bed is required, as with

skeletal traction, secondary physiological changes occur
systematically throughout the body. General exercises for
the uninvolved portions of the body are initiated to
minimize these problems
 Functional Adaptations

If there is a lower extremity fracture, alternate modes of

ambulation, such as use of crutches or a walker, are taught
to the patient who is allowed out of bed. The choice of
device and gait pattern depends on the fracture site, the
type of immobilization, and the functional capabilities of
the patient. The patient’s physician should be consulted to
determine the amount of weight bearing allowed
 Postimmobilization Period
• Signs and Symptoms
• There is decreased ROM, joint play, and muscle flexibility.
• Muscle atrophy with weakness and poor muscle endurance occur,
as well as pain in the structures that have been immobilized.
• Initially, the patient experiences pain as movement begins, but it
should progressively decrease as joint movement, muscle
strength, and ROM improve.
• If there was soft tissue damage at the time of the fracture, an
inelastic scar restricts tissue mobility in the region of the scar.