Musculoskeletal Disorders (Adult Care Nursing) Part 3

Degenerative Disorders

Muscular Dystrophies

Muscular dystrophies are chronic, degenerative diseases of skeletal muscles that are often inherited. These disorders are characterized by various degrees of progressive weakening and wasting of the muscles.

Although causes of muscular dystrophies are unknown, some researchers believe that they are related to a disruption in enzyme production. Treatment focuses on support. Encourage clients to continue all activities as normally as possible. Exercise programs and splints may help prevent deformities. Often, clients can use special braces to permit ambulation. Inform clients of the need to prevent upper respiratory infections, to maintain ideal weight, and to strive for general good health.

Special Considerations :LIFESPAN

Muscles of the Older Adult

With advanced age, a person experiences a decrease in muscle strength. Joints become stiff and slightly more flexed with age.

Repetitive Strain Injuries

Repetitive strain injuries commonly occur in the workplace because of the necessity of performing certain motions, such as keyboarding, repeatedly in some occupations. These injuries may also be identified as overuse disorders.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a compression neuropathy of the median nerve in the wrist. Often, its cause is repetitive movements, such as knitting or keyboarding. Other causes include arthritis, trauma, myxedema, gout, or tumors.


Signs and symptoms include forearm and wrist pain, numbness, and tingling. Symptoms often increase at night. The client’s grip is weak. When the provider taps the median nerve, the client experiences paresthesia and pain of the thumb and first three fingers (Tinel’s sign).

Treatment includes wrist splinting, rest, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroid injections. If these therapies are unsuccessful, surgery may be done to decompress the carpal tunnel.

Special Considerations: LIFESPAN

Pregnancy

Pregnant women may experience carpal tunnel syndrome related to fluid retention in that area.

Lateral Epicondylitis

Repeated forceful wrist and finger movements that stress the origins of muscles cause lateral epicondylitis. Lateral epicondylitis is often related to activities such as tennis, bowling, pitching, and golf, and thus may be called “tennis elbow.” Clients with lateral epicondylitis often complain of pain along the outer aspect of the elbow, radiating to the forearm. Pain increases on stretching and on resisted wrist and hand flexion. Common treatments include splinting, analgesics, rest, and corticosteroid injections. Surgery is generally not needed, but is usually successful if performed.

Rotator Cuff Injury

Injury to the rotator muscles in the shoulders may be caused by repetitive injury or sudden trauma. The injury can vary in severity. Pain, weakness, and loss of shoulder movement generally result. Less-severe injuries may be treated with extended physical therapy to increase ROM and muscle strength. With more severe injuries, surgical intervention often is necessary because these injuries tend not to heal by medical intervention alone.

Inflammatory Disorders

Bursitis

The bursa is a sac filled with synovial fluid that pads bony prominences in the joints. Bursitis is inflammation of a bursa related to mechanical irritation, bacterial infection, trauma, or gout. In response to inflammation, fluid increases, causing distention. With chronic inflammation, calcification may result. Pain and tenderness in the joint limit movement.

Usual treatment includes heating and resting the affected part. Anti-inflammatory medications may be indicated. The healthcare provider may inject the bursal sac with corticosteroids or aspirate fluid from it to provide relief. A surgical drainage is performed for infectious bursitis. If these treatments are ineffective, the bursa is excised surgically.

Tenosynovitis

Tenosynovitis, an inflammation of the tendon sheath that may result from irritation or an infection, typically affects the wrist or ankle. The infected tendon swells and is painful and disabling. Non-infectious tenosynovitis is caused by strains, blows, or prolonged use of a particular set of tendons (e.g., playing the piano over a long period). Symptoms include pain and tenderness, especially on movement. Treatment involves:

•    Resting the affected body part; application of a splint

•    Application of ice for 1 to 2 days to decrease swelling

•    Physical therapy

•    Use of NSAIDs, when indicated

•    Surgery, if needed

•    Antibiotics

•    Elimination of activities that exacerbate symptoms during the inflammatory phase

Arthritis

Arthritis means joint inflammation. More than 100 arthritic disorders are known. The most common types include:

•    Rheumatoid arthritis (RA)

•    Osteoarthritis (OA), degenerative joint disease (DJD), hypertrophic arthritis

•    Ankylosing spondylitis, rheumatoid spondylitis, RA of the spine

•    Gouty arthritis

•    Systemic lupus erythematosus (SLE), lupus

•    Scleroderma, progressive systemic sclerosis

Arthritis affects many people in the United States. Monoarticular arthritis affects one joint; polyarticular arthritis affects many joints. Most types of arthritis, except for ankylosing spondylitis and gouty arthritis, are more common in women than in men. Several factors may be associated with the cause of arthritis:

•    Infection of a joint by a virus or microorganism (infectious arthritis)

•    Direct injury to a joint (traumatic arthritis)

•    Degeneration or deterioration of a joint (degenerative arthritis)

•    Metabolic disorder, such as gout (metabolic arthritis)

Many researchers believe that some types of arthritis have an autoimmune component andlor familial tendencies. In most cases, the cause of the arthritis and its cure are unknown. However, control of the disorder or correction of its crippling effects may be possible. Arthritis occurs in both acute and chronic forms. Acute exacerbations may also occur with chronic forms of the disease.

Key Concept Arthritis can interfere with an individual’s ability to perform both basic (hygienic) and instrumental (functioning) activities of daily living. For example, because of pain and physical joint deformations, arthritis interferes with using one’s hands (buttons, laces, handling coins) or lifting objects (shopping, gardening, cleaning). The individual can have difficulty maintaining social activities owing to the interrelationship of pain, fatigue, and frustration.

Monocyclic arthritis, which accounts for approximately 35% of cases, has a sudden onset, usually responds well to medications, and may never return. Polycyclic arthritis, accounting for approximately 50% of cases, is marked by exacerbations and remissions. Progressive arthritis, accounting for approximately 15% of cases, continues to worsen, not stopping without treatment.

The clinical features of arthritis include the following:

•    Persistent pain and stiffness on arising lasting for 6 weeks or more

•    Stiffness aggravated by damp weather or strenuous activity

•    Pain or tenderness in the joints, often symmetrical

•    Swelling in the joints

•    Recurrence of symptoms, particularly when more than one joint is involved

•    Obvious redness and warmth in a joint

•    Unexplained weight loss, fever, or weakness, combined with joint pain

•    Bouchard’s nodes (enlargement of proximal interpha-langeal joints) or Heberden’s nodes (growths on the terminal phalangeal joints) with DJD

Box 77-1 describes goals and pain management in the treatment of arthritis.

Rheumatoid Arthritis

Rheumatoid arthritis is probably the most painful and crippling form of arthritis. It occurs worldwide and, until age 65, is three times more common in women than in men. Theories suggest that a triggering mechanism, possibly a virus, causes the immune system to become overactive. A genetic predisposition to the disorder seems to exist; several members of one family may be affected (Table 77-1).

Signs and Symptoms. Chronic inflammatory changes thicken the synovial membrane. The joint capsule swells, the synovial membrane becomes inflamed, and the cartilage is eaten away. An overgrowth of synovial lining occurs.

BOX 77-1.

Management of Arthritis

Goals

•    Relieve inflammation (medication)

•    Relieve pain (medications, local treatments)

•    Maintain optimal functioning (exercise, adaptive devices)

•    Educate the client (prevention, treatment)

Pain Management

•    Splinting/casting/night splinting/traction

•    Positioning

•    Heat (paraffin baths, diathermy) and cold (ice packs)

•    Physical therapy

•    Massage (if joint is not acutely inflamed)

•    Medications (most commonly salicylates and nonsteroidal anti-inflammatory drugs [NSAIDs])

•    Low-impact exercise; isometric exercises (improves muscle strength without overexerting joints)

•    Rest (physical and emotional); avoidance of fatigue and overexertion (10 or more hours of rest daily)

•    Sleeping on a firm bed

•    Placement of bed and chair at same level, to facilitate transfer; chair that helps client to stand is possibly necessary

•    Chair 3 to 4 inches higher than regular chair to avoid bending too much at hips (Do not use pillow in chair; promotes slouching, which is tiring.)

•    Emotional support

•    Adaptive devices to make activities of daily living easier to perform

A severe dislocation called subluxation of the fingers in rheumatoid arthritis.

FIGURE 77-1 · A severe dislocation called subluxation of the fingers in rheumatoid arthritis.

When the cartilage and bone erode, the joint becomes painful because bone rubs against bone. If the joint becomes calcified, movement is impossible. The condition of an immovable joint is called ankylosis; however, it does not occur in all persons with RA. If the opening in the spinal column becomes calcified, its diameter becomes smaller, a condition called spinal stenosis. Spinal stenosis can place pressure on the spinal cord.

Rheumatoid arthritis often begins with systemic symptoms such as fatigue, weakness, weight loss, and general body aches. Joints become painful, tender, stiff, swollen, and warm. As tendons and ligaments become shortened and less flexible, joint deformities, such as hyperextension, contractures, and subluxation (dislocation), can occur (Fig. 77-1).

Medical Treatment. The goal of treatment is to help the client maintain function and reduce inflammation before joints are permanently damaged. Treatment is multidisciplinary and includes drug therapy (In Practice: Important Medications 77-1), client education (In Practice: Educating the Client 77-1), physical therapy, occupational therapy, and psychosocial therapy. Physical therapists design exercise programs that help clients prevent contractures, strengthen muscles, and improve function. Occupational therapists teach clients how to protect their joints and how to use adaptive devices. Measures to increase body resistance to disease, such as rest and a well-balanced diet, are also helpful.

Nursing Alert Many drugs used to treat arthritis have serious side effects, such as gastrointestinal bleeding. Be sure to check drug reference sources before administering any drugs. Be alert to possible side effects and report any difficulties immediately

Osteoarthritis or Degenerative Joint Disease

Osteoarthritis, believed to have a genetic cause or predisposition, is caused by wear and tear on a joint. The cartilage wears away and exposes the bone (Fig. 77-2). Next, bony hypertrophy (overgrowth) occurs, with the creation of bone spurs. Particles of cartilage break off and float in the joint, making movement painful. Synovectomy, excision of the synovial membrane, helps to prevent further inflammation in some cases. Arthroscopic surgery may be done to remove loose bodies and bone spurs. Total arthroplasty (joint replacement) is the last resort and, in many cases, is effective. In other cases, the joint must be fused to prevent pain (see Table 77-1).

TABLE 77-1. Rheumatoid Arthritis Versus Osteoarthritis

RHEUMATOID ARTHRITIS

OSTEOARTHRITIS (DEGENERATIVE JOINT DISEASE)

Systemic (fatigue, weight loss, anemia)

Not systemic (results from wear and tear)

Fever

No fever

Systemic inflammation

Local inflammation (joint only)

Probably autoimmune origin

Most common type of arthritis

3:1 in women

2:1 in women

Affects young adults (ages 20-30 years)

Affects middle and older adults (>45 years) Common in women after menopause More common in obese people

Affects small and large joints (symmetrical); most common in fingers, knees, elbows, ankles

Affects primarily large weight-bearing joints and knuckles (knees, hips, knuckles, spine)

May remain the same for life

May progress

Causes inflammatory process in other body parts (lungs, kidneys, eyes)

Sets up local inflammation Can be hereditary

Surgery does not help (condition returns)

May surgically replace or fuse joints (last choice for treatment)

May have lumps (nodules) on joints, which are painful

Often have lumps, but they do not restrict activity and are not painful

Fingers may swell; joints feel cold and moist; bluish color to skin; muscles may become weakened

Joints usually do not swell; muscles remain firm

Joints are distorted and dislocated

Not as likely to be disabling; may remain localized in body

Joints may ankylose (fuse)

Joints usually do not ankylose

Abnormal laboratory values (rheumatoid factor, sedimentation rate high; hemoglobin low)

 

Joint changes in osteoarthritis. Notice that the left side shows early changes, with joint space narrowing and cartilage breakdown. The right side shows severe progression, with lost cartilage.

FIGURE 77-2 · Joint changes in osteoarthritis. Notice that the left side shows early changes, with joint space narrowing and cartilage breakdown. The right side shows severe progression, with lost cartilage.

Ankylosing Spondylitis

Ankylosing spondylitis, also called rheumatoid arthritis of the spine, primarily affects the facet joints and the stabilizing ligaments of the spinal column. It mainly affects men and often begins in adolescence or young adulthood. The most common early symptoms are hip and lower-back pain and stiffness. Other symptoms include weight loss, fatigue, fever, and conjunctivitis. Hip contractures and flexion of the neck and back may occur. Breathing may be impaired because chest expansion is impeded. The osteoporotic spine increases the risk of spinal fractures. In severe cases, spinal stiffening also occurs, with resultant humpback and chest curvature. Neck stiffness may make turning the head impossible.

Treatment is similar to that for other types of arthritis. Phenylbutazone (Butazolidin) is sometimes given. Teach the client to refrain from lying on the side, to prevent excess sideways spinal curvature. Light exercise may be more comfortable than prolonged bed rest. The client may wear a back brace.

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