1
Q
Fibromyaligia syndrome (FMS)
A
- idiopathic cause
- etiology may be of peripheral or CNS origin
- functional limitations are a common factor
2
Q
Signs and symptoms of FMS
A
- pain
- fatigue
- lowered respiratory function
- reduced joint ROM
- impaired muscle endurance
- impaired muscle strength
- lowered CV fitness levels
- present with at least 11 out of 18 tender points
3
Q
chronic fatigue syndrome (CFS)
A
- idiopathic cause- characterized by profound fatigue
- accompanying disorders (neurasthenia, chronic Epstein-Barr virus, myalgic encephalomyelitis)
4
Q
CFS signs and symptoms
A
- 25% bedridden or unable to work
- 33% may work part time
- unexplained debilitating fatigue for at least 6 months
- sore throat, tender cervical or axillary lymph nodes, muscular pain, multijoint noninflammatory arthralgia, impairment in memory or concentration
- *up to 70% with CFS present with FMS
5
Q
multidisciplinary approach
A
therapeutic exercise intervention for prevention and wellness
- exercise
- pharmacologic
- psychological (education, depression)
6
Q
therapeutic exercise benefits
A
1: muscle performance
2: aerobic capacity
3: range of motion
4: posture
5: response to emotional stress
6: pain
7
Q
early phase exercises for FMS
A
week 1-on Goal: stress and pain management -relaxation -progressive relaxation -autogenic deep breathing -visualization -deep breathing -stretch
pt response model!!
8
Q
midphase exercises for FMS
A
week 2-on
Goal: musculoskeletal balance
-fluoromethane spray and stretch
-self mobilizations
-neuromuscular techniques: hold and relax, contract and relax
-strain-counterstrain
-muscle system balance exercises (Sahrman)
-neutral spine (+-tubing)
-closed chain eccentric exercise
-early aerobic exercise: supine bike, unloading equipment, easy exercises in water
9
Q
late phase exercises for FMS
A
Goal: maintenance
- stretch, cont
- musculoskeletal balance, cont
- general strength: resistance tubing, machines, closed chain eccentric exercise
- aerobic exercise: NWB to WB and nonjarring activities (ski machine, seated stationary bike, treadmill) and water exercises (aerobics, flotation belt)
10
Q
impaired muscle performance and FMS
A
- Initially: low resistance, low repetition when addressing strength deficits
- exercise can be isometric or dynamic (slow movements)
- calibrate progressions according to pt’s response
11
Q
impaired aerobic capacity and FMS
A
- introduce aerobic exercise ASAP
- initial intervention should be limited (2-5 min) with attention to patient response
- gradual increase according to tolerance levels
- by late phase, pts may tolerate elevation of HR to 50-60&
- *education component is so important bc of limited timeframe from payer
12
Q
impaired ROM and FMS
A
- hypermobility-stabilization training during agonist strengthening exercises
- graded flexibility exercises. remember, stretching should never be painful
- educate feelings of stretch and tissue damage
13
Q
impaired posture and FMS
A
- consider ALL postures (sitting, standing, resting, static/repetitive work postures
- static posture is starting point and end point for return to function
- eccentric control is frequently lost (sitting down, descending stairs- thrown by gravity)
- tai chi chuan, feldenkrais, and low level exercise strategies may help restore muscle balance and function
14
Q
impaired response to emotional stress- FMS
A
- exercise with relaxation, deep breathing, stretching
- progressive relaxation, autogenic deep breathing, visualization exercises
- diaphragmatic and lateral costal expansion breathing
15
Q
FMS-pain
A
- assess FMS and biomechanical aspects
- eliminate biomechanical origin as part of whole approach
- consider pt’s adherence and the relationship to symptoms
- consider adjunctive (pharmaceutical) and cognitive behavioral approaches
16
Q
precautions and contraindications for FMS
A
- adherence to an exercise program may be challenging due to perceived overexertion
- clarity of instruction should be reinforced via checklists and written guidance
- pacing is crucial for those who are chronically fatigued
- exercise applications and dosage should be closely monitored to reduce concerns related to perceived expectations of pain
17
Q
summary of FMS and CFS
A
- both have widespread effects and limit functioning
- unclear causes, CFS may have a viral component
- exercise appears to be effective for FMS and possibly for CFS
- exercise rx should be done carefully and tracked continuously
- exercise for both address stress, posture, mobility, muscle performance CV endurance
- exercise interventions should consider pacing, limiting overexertion and overcommitment
- establish mutually acceptable goals to contribute to pt adherence
- aerobic exercise should be low impact and progress slowly
- work w/ other practitioners and consider adjunctive therapies when helping the pt prioritize
- use of agents may be taught as self tx agents to make best use of clinical time
18
Q
inflammation is characterized by:
A
- rubor (redness)
- swelling
- calor (heat)
- pain
- diminished function
19
Q
inflammatory disorders can be further characterized as:
A
- infectious
- rheumatic
- metabolic
- regional inflammation related to overuse
20
Q
Infectious inflammatory disorders
A
1: hematogenous osteomyelitis
2: septic arthritis
21
Q
hematogenous osteomyelitis
A
- localized/generalized inflammation of bone due to pyogenic infection spread by the blood stream
- most common in boys
- in children, usually affects the metaphysis of the tibia or femur
- can occur in vertebrae and bones of the feet in diabetics, or at sites penetrated by trauma (open fx) or surgery
22
Q
osteomyelitis
A
- can be acute or chronic
- bacteria, once allowed to collect in the minute channels of the bone, may be isolated from both the cellular and chemical elements of host defenses and free to proliferate unimpeded
- microcirculation of bone within these channels is highly vulnerable to bacterial toxins, which may produce local thrombosis of these small vessels leading to the death of bone in the vicinity of infection, which further impedes access by host defenses
- nutrient vessels are quite convoluted in bone, which allows bacteria to be trapped in the metaphysics
23
Q
joint infection secondary to osteomyelitis..
A
may occur in shoulder and hip as a result of synovial membrane inserting distally to epiphysis, allowing bacteria to spread directly from metaphysis to the joint space
24
Q
signs and symptoms of osteomyelitis
A
- severe/constant pain near the end of the affected long bone with exquisite tenderness to palpation
- may be febrile, report malaise, weight loss
25
treatment of osteomyelitis
- life threatening condition
- treated with aggressive antibiotic regimen, surgical debridement
- radiographic changes can be evident within 10-14 days in acute cases; initial x-rays are usually normal
- draining sinuses develop if untreated due to increased pressure from accumulation of pus
- lab work reveals elevated leukocyte counts due to infection
26
septic arthritis
- often secondary to osteomyelitis; often affects children or adults >60
- synovial fluid becomes contaminated with bacteria- nice environment for bacteria to thrive
- the body's immune response can destroy both bacteria and joint surfaces
27
infection of septic arthritis can be introduced by:
- direct penetration (open fx; surgery)
- extension into the joint from adjacent infection (osteomyelitis, infected wound)
- bloodstream (skin, respiratory, UTI)
28
symptoms of septic arthritis
- moderate to severe joint pain
- calor
- tenderness
- decreased ROM
- muscle spasm
- most often affects the hip or knee, but can also affect hands, feet, shoulders, wrists
- x-rays and joint aspiration/culture confirm diagnosis
29
treatment options for infectious inflammatory disorders
During infection
-joint protection/splinting
After infection is controlled:
- progressive ROM
- strengthening
- functional activities
**all based on pt response model
30
Inflammatory rheumatic diseases
1: rheumatoid arthritis (RA)
2: Juvenile rheumatoid arthritis (JRA)
3: ankylosing spondylitis
4: reiter's syndrome
5: psoriatic arthritis
31
rheumatoid arthritis
- chronic, autoimmune, inflammatory disease
- etiology unknown
- rheumatoid factor present in 60-80% of adults and 20% of children with RA
- most autoimmune conditions (RA, lupus, celiac disease, etc) have some genetic linkage
- more common in women; prime of life disease
- can occur in any joint; seen often in small joints of the hands, wrists, elbows, ankles, MTPs
32
how does RA differ from OA?
- RA attacks joints in a balanced way (Bilateral involvement)
- OA stiffness usually gets better within 30 minutes
33
diagnosis of RA
- lab work usually shows elevated RA factor, but not necessarily in all cases. Elevated RA factor can be seen in people without the disease as well as other diseases
- early x-rays won't show much changes
34
RA characterized by:
- a.m. stiffness lasting >30 minutes
- weight loss
- fatigue
- muscle atrophy
- subcutaneous nodules in chronic phase
- synovitis
35
treatment of RA
- disease-modifying antirheumatic drugs (DMARDs) that can slow or sometimes prevent joint destruction are recommended early in the course of the disease
- joint replacement
- splinting/joint fusion
- joint protection
- strengthening
- modalities
36
ankylosing spondylitis
- autoimmune disease affecting the spine
- more common/severe in men
- genetic predisposition
- involves ligamentous insertions, fibrocartilage, and discs
- in the paravertebral soft tissues, the lesion manifests as a formation of new bone within the outer layers of the annulus fibrosis of the intervertebral disk. the margins of the disk are invaded by hyperemic (excess of blood) granulation tissue arising from the subchondral bone. this tissue replaces the disk fibers with new bone
37
signs and symptoms of ankylosing spondylitis
- usually presents as morning back stiffness
- can see diminished chest expansion due to costal joint involvement
- weight loss
- fever
- increased kyphosis
38
treatment of ankylosing spondylitis
- postural training
- extensor muscle strengthening
- ROM
- pharmaceuticals including steroidal and non steroidal anti inflammatory meds (NSAIDS)
39
Reiter's syndrome
- triad of conjunctivitis, arthritis, nonspecific urethritis
- infection passed through sexual contact or enteric bacterial infection due to improperly handled foods
- non contagious per-se, but affects ppl who are predisposed to develop the disease
- commonly results in inflammation of tendinous insertions (achilles' tendonitis, plantar fascitis)
"the patient can't see, can't pee and can't climb a tree"
40
treatment of reiter's syndrome
- many cases resolve after 4-5 months; 50% incur recurrences
- antibiotics
- exercise, relaxation, joint protection, modalities
41
psoriatic arthritis
- chronic, erosive form of polyarthritis associated with psoriasis
- occurs in 5-7% of ppl with psoriasis
- usually asymmetric when compared to RA
- DIPs and small joints affected
- suspect if psoriasis and arthritic complaints present together
- may see pitting of nails
- treat like you would RA
42
metabolic inflammatory diseases
1: gout
2:
43
Gout
=recurrent acute or chronic arthritis of peripheral joints that result from deposition in and about the joints and tendons of monosodium urate (MSU) crystals from supersaturated hyperuricemic body fluids
-this produces an inflammatory response at the joint/tissues
- occurs more in men, >40
- very painful
- MSU crystal aggregates form and can be seen or felt as subcutaneal nodules
44
cause of gout
attacks can be precipitated by conditions that produce metabolic acidosis:
- trauma
- dietary/alcohol ingestion
- fatigue
- stress
- infection
- medication
45
treatment of gout
- colchisine
- NAIDS
- joint aspiration
- steroid injection
- joint mobility after episode
- special footwear
46
hemophilia
- constant bleeding into the joint causes an inflammatory response from the synovium leading to arthritis
- joint bleeding can occur as a result of trauma, or with spontaneous hemophilia
- most often involves the knee, elbow, ankle, hip and shoulder
- can range in severity from minor pain and swelling to severe swelling that lasts for several weeks
47
chronic joint changes from hemophilia
decreased ROM
atrophy
flexion contractures
*all putting the joint at further risk
48
x-ray changes of hemophilia
- changes due to synovial proliferation and hyperemia
- widening of the intercondylar notch of the femur
- chronic hyperemia produces enlargement of epiphyses
- especially medial condyle
49
PT treatment of hemophilia
PT focuses on:
- protecting joints
- protective strengthening of surrounding muscles
- avoiding stress to the affected joints
50
specific soft tissue inflammations
bursitis
tendonitis
result of trauma and overuse
51
osteoarthritis
- wear and tear, with possibility of genetic predisposition to developing OA
- evidence of OA on x-ray (especially early on) does not necessarily mean that there will be frank functional deficits
- affects both axial and peripheral joints
52
primary OA
no specific trauma
| wear and tear
53
secondary OA
major trauma that precedes the progression of OA
54
OA sequence
```
overgrowth of bone called "arthritis"
more strain on ligaments
ligament weakness
excessive joint movement
joint bones start colliding
crunching noise heard with jt movement
```
55
benign bone tumors
1: osteochondromas
2: benign chondroma
3: chondroblastoma
4: osteoid osteoma
5: giant cell tumors
56
Osteochondromas
most common benign bone tumor
| occur most between ages 10-20
57
benign chondroma
benign bone tumor
located centrally within a bone (marrow cavity)
ages 10-30
58
chondroblastoma
rare benign neoplasm that arises from the epiphysis
| ages 10-20
59
osteoid osteoma
benign lesion most often found in long bones
| pain relieved by small doses of aspirin is classic
60
giant cell tumors
benign lesions that occur in the epiphysis of long bones that may erode the parent bone and produce soft extensions.
tend to recur, and linked to later sarcoma development
61
primary malignant tumors of bone
1: osteosarcomas
2: fibrosarcomas
3: malignant fibrous hisiocytoma
4: chondrosarcoma
5: mesenchymal chondrosarcoma
6: Ewing's sarcoma
62
osteosarcoma
highly malignant tumor with tendency to metastasize to the lungs
-about 1/2 the lesions are found in the knee, but can occur anywhere
- dx rests with biopsy, since x-ray findings vary greatly
- tx: chemo and surgery >50% of pts survive more than 5 years
63
presentation of osteosarcoma
- history
- 5-30 y/o
- dull, aching pain
- night pain
- hx of minor trauma, injury, sprain or ms strain
- fever, night sweats, weight loss
- physical exam
- local tenderness
- swelling, mass, deformity
- limp, muscle atrophy, decreased joint motion
- pathologic fx
- lymphadenopathy
64
chondrosarcoma
malignant tumor of cartilage
dx: only by biopsy
tx: total surgical resection; radiation and chemo are ineffective
65
mesenchymal chondrosarcoma
rare but distinct type of chondrosarcoma; cure rate is low
66
Ewing's sarcoma
peak incidence between 10-20
-pain and swelling are most common symptoms
-requires biopsy to differentiate
~50% cure rate with combined therapies
67
malignant metastatic lesions of bone
- primarily from carcinomas arising from the prostate, breast, (Pb) kidney, thyroid, and lung (ktl)
- anyone known to have or have had CA should be evaluated with skeletal x-rays to rule out metastatic bone disease
