Musculoskeletal disease

Spinal stenosis
Occurs when there is narrowing of the vertebral canal The most common presentation is 'pseudoclaudication' with discomfort in the legs on walking that is relieved by rest, bending forwards or walking uphill. Common causes paget s disease, spondylosis Patients may adopt a characteristic simian posture

Simian posture
forward stoop and slight flexion at the hips and knees.

Prolapsed intervertebral disc

Age-related reductions in proteoglycans within the nucleus pulposus diminish its viscoelasticity, leading to focal damage and disc herniation. Most commonly in L4/ L5 level due to increased mechanical stress Most patients have their first episode between the ages of 20 and 30 years.

Prolapsed intervertebral disc

Presentation is with radicular pain (invariably felt below the knee) in combination with evidence of root involvement (sensory deficit, motor weakness, asymmetrical reflexes) and a positive sciatic or femoral stretch test

Read Apley s

Prognosis & Treatment

About 70% of patients improve by 4 weeks. Persistent neurological deficit at 6 weeks is an indication for surgery.

Radicular pain
Radicular (nerve root) pain has a severe, sharp, lancinating quality, radiates down the back of the leg beyond the knee, and is aggravated by coughing, sneezing and straining at stool more than by back movement. On examination, there are signs of lumbar nerve root irritation

Signs of lumbar nerve root irritation

Unilateral leg pain worse than low back pain Pain radiates beyond knee Paraesthesia in same distribution Nerve irritation signs (reduced straight leg raising which reproduces leg pain) Motor, sensory or reflex signs (limited to one nerve root) Prognosis reasonable (50% recovery at 6 wks)

Signs of multiple root irritation Cauda equina syndrome

Difficulty with micturition Loss of anal sphincter tone or faecal incontinence Saddle anaesthesia Gait disturbance Pain, numbness or weakness affecting one or both legs

Arachnoiditis
Chronic inflammation of nerve root sheaths in the spinal canal can cause severe low back pain, sometimes combined with nerve root symptoms. Arachnoiditis can complicate meningitis or spinal surgery, but most frequently occurs as a late complication of myelography with oilbased contrast agents. No satisfactory treatment is available.

Management of back pain

Most episodes of mechanical low back pain settle spontaneously with explanation, reassurance and simple analgesics. After 2 days, 30% are better and at 6 weeks 90% have recovered. Recurrences of pain are common

Management Contd
Reassure patients (favourable prognosis) Advise patients to stay active Prescribe medication if necessary (preferably at fixed time intervals)
Paracetamol NSAID Consider opioids, muscle relaxants

Discourage bed rest Consider spinal manipulation for pain relief Do not advise lumbar supports, back-specific exercises, traction, acupuncture, epidural or facet injections

Neck pain

Neck pain- causes

Causes of neck pain Mechanical Postural Whiplash injury Disc prolapse Cervical spondylosis Inflammatory Infections Spondylitis Juvenile idiopathic arthritis Polymyalgia rheumatica Metabolic Osteoporosis Osteomalacia Paget's disease

Neck pain- causes

Neoplasia Metastases Myeloma Lymphoma Intrathecal tumours Other Fibromyalgia Torticollis Referred pain Pharynx Cervical lymph nodes Teeth Angina pectoris Aortic aneurysm Pancoast tumour Diaphragm

Neck pain
Pain arising from neck structures is often poorly localised. Pain from upper segments may radiate to the occiput, temple or face, and pain from lower segments to the scapula, shoulder, arm and occasionally chest wall. Mechanical neck pain is often acute in onset and associated with asymmetrical restriction of neck movements and a history of awkward posture or trauma.

Neck pain
Radicular pain may arise from compression from osteophyte or disc prolapse. Most (70%) affect the C6 disc, compressing the C7 root, but 20% affect C5 and compress the C6 root. The principles of investigation and management are identical to those for low back pain. Surgery is only required when there are neurological signs of radiculopathy or progressive cervical myelopathy

Muscle pain & weakness

Muscle weakness

Proximal weakness

Distal weakness

Inflammatory causes

Non inflammatory causes

Inflammatory causes
Polymyositis Dermatomyositis Inclusion body myositis

Non inflammatory causes

Endocrine Hypothyroidism Hyperthyroidism Osteomalacia Cushing's syndrome (usually iatrogenic) Addison's disease Metabolic Myophosphorylase deficiency Phosphofructokinase deficiency Hypokalaemia Carnitine deficiency Myoadenylate deaminase deficiency

Non inflammatory causes Contd

Drugs/toxins Alcohol Cocaine Fibrates Statins Penicillamine Zidovudine Infections Viral (HIV, cytomegalovirus, rubella, Epstein-Barr, echo) Bacterial (Clostridia, staphylococci, tuberculosis, Mycoplasma) Body_ID: P025172Parasitic (schistosomiasis, cysticercosis, toxoplasmosis)

Distal muscle weakness

Distal or generalised weakness usually indicates a neurological cause, which is even more likely if there are sensory abnormalities or if weakness is unilateral or focal.

Principles of management of MSK diseases

The aims of management of MSK disorders are to: educate the patient control pain optimize function modify the disease process where possible.

Core interventions
Education  Inform patients about the nature of their condition and its investigation, treatment and prognosis, as education can improve outcome.  Information and therapist contact can reduce pain and disability, improve self-efficacy and reduce the health-care costs of many MSK conditions, including osteoarthritis and RA.

Core interventions - Exercise

Two types of exercise should be prescribed Aerobic fitness training can produce long-term reduction in pain and disability. It improves well-being, encourages restorative sleep and benefits common comorbidity such as obesity, diabetes, chronic heart failure and hypertension. Local strengthening exercise for muscles that act over compromised joints also reduces pain and disability, with improvements in the reduced muscle strength, proprioception, coordination and balance that associate with chronic arthritis. 'Small amounts often' of strengthening exercise are better than protracted sessions performed infrequently.

Core interventions Joint protection

Excessive impact-loading and adverse repetitive use of a compromised joint or periarticular tissue can often be reduced: for example, cessation of contact sports, or altered use of machinery or tools at the workplace. Simple 'pacing' of activities-dividing physically onerous tasks into shorter segments with brief breaks in between-is helpful. Use of shock-absorbing footwear with thick soft soles can reduce impact-loading through feet, knees, hips and back, and improve symptoms at these sites. A walking stick held on the contralateral side takes weight off a painful hip, knee or foot.

Core interventions - Weight loss

Obesity aggravates pain at most sites of the body through increased mechanical strain and is a risk factor for more rapid progression of joint damage in patients with arthritis. Obese patients should receive an explanation of this and be offered strategies on how to lose and then maintain an appropriate weight

Core interventions Pharmacological

Simple analgesics paracetamol NSAIDS Topical analgesics DMARDS Corticosteroids

Core interventions non Pharmacological

Physical therapy/ heat Surgery Self help techniques/ Coping strategies