Joint, Connective Tissue, and Bone Disorders and Physiotherapy management

from :therapeutic exercises book by kisner
Made by :Dr Ammar Kakar Physiotherapist .

1. Joint, Connective Tissue, and Bone Disorders and Management CAROLYN KISNER, PT, MS ■ KAREN HOLTGREFE, PT, DHS, OCS By Dr.Ammar.pt Lecturer physiotherapy Alhamd University ,Quetta.

2. Arthritis: Arthrosis Arthritis is inflammation of a joint . There are many types of arthritis , both inflammatory and noninflammatory , that affect joints and other connective tissues in the body. The most common types treated by therapists are rheumatoid arthritis and osteoarthritis. Arthrosis is limitation of a joint without inflammation . Unless the cause of the joint problems is known, such as recent trauma or immobility , medical intervention is necessary to diagnose and medically manage the pathology. Traumatic arthritis may require aspiration if there is bloody effusion . The therapist manages the impairments, activity limitations, and participation restrictions that result from the underlying pathology

3. Clinical Signs and Symptoms: Signs and symptoms common to all types of arthritic conditions generally include the following impaired Mobility The patient usually presents with signs typical of joint involvement that include a characteristic pattern of limitation (called a capsular pattern ), usually a firm end-feel (unless acute—then the end-feel may be guarded ), decreased and possibly painful joint play, and joint swelling (effusion). Additional signs and symptoms may be present depending on the specific disease process. Table 11.1 summarizes the characteristic signs and symptoms of osteoarthritis and rheumatoid arthritis. 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.

4. Impaired Muscle Performance: Weakness from disuse or reflex inhibition of stabilizing muscles occur when there is joint swelling or pain. Muscle weakness or inhibition leads to imbalances in strength and flexibility and poor support for the involved joints . Asymmetry in muscle pull may be a deforming force to the joints, poor muscle support allows the joint to be more susceptible to trauma; conversely, good muscle support helps protect an arthritic joint .

5. Impaired Balance: Patients may develop balance deficits because of altered or decreased sensory input from joint mechanoreceptors and muscle spindle. This is particularly a problem with weight bearing joints . Activity Limitations and Participation Restrictions The ability to carry out 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.

6. 1)Rheumatoid Arthritis : Rheumatoid arthritis (RA) is an autoimmune , chronic , inflammatory , systemic disease primarily of unknown etiology 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. The onset and progression vary from mild joint symptoms with aching and stiffness to abrupt swelling, stiffness, and progressive deformity . The criteria for classification of RA are summarized in Box 11.1.

7. Characteristics of RA : ■ Characterized by symmetric, erosive synovitis with periods of exacerbation (flare) and remission . Joints are characteristically involved with early inflammatory changes in the synovial membrane, peripheral portions of the articular cartilage, and subchondral marrow spaces. In response, granulation tissue (pannus) forms , covers , and erodes the articular cartilage , bone , and ligaments in the joint capsule .

8. 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 (Figs. 11.1, 11.2, 11.3). ■ Inflammatory changes also occur in tendon sheaths (tenosynovitis ); if subjected to recurring friction, the tendons may fray or rupture .

9. ■ Extra-articular pathological changes sometimes occur; they include rheumatoid nodules, atrophy and fibrosis of muscles with associated 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 weaknes s is often seen, leading to major economic loss and significant impact on families.

10. ■ 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.

11. Signs and Symptoms: Periods of Active Disease ■ With synovial inflammation, there is effusion and swelling of the joints , which cause aching and limited motion. Joint stiffness is prominent in the morning. Usually there is pain on motion, and a slight increase in skin temperature can be detected over the joints. Pain and stiffness worsen after strenuous activity. ■ Onset is usually in the smaller joints of the hands and feet , most commonly in the proximal interphalangeal joints. Usually symptoms are bilateral .

12. ■ With progression, the joints become deformed and may ankylose or subluxate . ■ Pain is often felt in adjoining muscles , and eventually muscle atrophy and weakness occur . Asymmetry in muscle strength and alterations in the line of pull of muscles and tendons add to the deforming forces. ■ The person often experiences nonspecific symptoms such as low-grade fever, loss of appetite and weight, malaise, and fatigue.

13. Principles of Management: ■ Patient Education . Because periods of active disease may last several months to more than a year, begin education in the overall treatment plan, safe activity, joint protection ( Box 11.3) 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 potential deforming stresses during activities and when exercising. ■ Joint protection and 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.

14. Because inflamed joints are easily damaged and rest is encouraged to protect the joints , teach the patient how to rest the joints in nondeforming positions and to intersperse rest with ROM. ■ Joint mobility . Use gentle grade I and II distraction and oscillation techniques to inhibit pain and minimize fluid stasis. Stretching techniques are not performed when joints are swollen .

15. ■ Exercise. The type and intensity of exercise vary depending on the symptoms. Encourage the patient to do active exercises through as much 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, progress exercises as if subacute ■ Functional training . Modify any activities of daily living (ADL) needed in order to protect the joints. If necessary , use splints and assistive devices to provide protection

16. Management guidelines are summarized in Box 11.2

17. CLINICAL TIP CLINICAL TIP : Therapeutic exercises cannot positively alter the pathological process of RA, but if administered carefully, they can help prevent, retard, or correct the mechanical limitations and deforming forces that occur and therefore, help maintain function

18. PRECAUTIONS: Secondary effects of steroidal medications may include osteoporosis and ligamentous laxity, so use exercises that do not cause excessive stress to bones or joints. CONTRAINDICATIONS: Do not perform stretching techniques 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

19. Principles of Management: Subacute and Chronic Stages of RA As the intensity of pain, joint swelling, morning stiffness, and systemic effects diminish, the disease is considered subacute . Often medications can decrease the acute symptoms, so the patient can function as if in the subacute stage. The chronic stage occurs between exacerbations. This may be very short in duration, or it may last many years.

20. ■ Treatment approach. The treatment approach is the same as with any subacute and chronic musculoskeletal disorder, except appropriate precautions must be taken because the pathological changes from the disease process make the tissues more susceptible to damage. ■ Joint protection and activity modification . Continue to emphasize the importance of protecting the joints by modifying activity, using splints, assistive devices, and environmental adaptations for safe function .

21. ■ Flexibility and strength. To improve function, exercises should be aimed at improving flexibility, muscle strength, and muscle endurance within the tolerance of the joints . ■ Cardiopulmonary endurance. Nonimpact or low-impact conditioning exercises—such as aquatic exercise, cycling , aerobic dancing, and walking/running — 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. One randomized review suggested that aerobic training also has a positive impact on the cardiovascular status of patients with RA.6

22. PRECAUTIONS: The joint capsule, ligaments, and tendons may be structurally weakened by the rheumatic process ( also as a result of using steroids), so the dosage of stretching and joint mobilization techniques used to counter any contractures or adhesions must be carefully graded . CONTRAINDICATIONS : Vigorous stretching or manipulative techniques.

23. RESEARCH: in a carefully supervised intensive exercise program showed greater improvement in function and muscle strength, a greater decrease in the number of clinically active joints, and a faster rate of diminished disease activity compared to the control group of patients who participated in a program of ROM and isometric exercise . The intensive exercises included isokinetic resistance to the knees at 70% maximum voluntary contraction and angular velocity at 60˚/sec, isometric exercises at 70% maximum voluntary contraction , bicycling at 60% of the age-predicted maximum for 15 minutes, and ROM exercises.

24. All exercises were adjusted to the pain tolerance of the individual when needed. The primary conclusion of this study was that there is no evidence that patients with active disease should be prevented from vigorous exercise so long as fatigue and pain are respected . The study did not look at joint erosion or cartilage damage.

25. Several systematic reviews looking at best evidence for the use of therapeutic exercise in the treatment of RA have been published. Although there are few randomized well-controlled studies looking at the outcome of exercise, studies of various strength do support that therapeutic exercise, including functional strengthening aerobic exercise, are beneficial = relief of pain, improved muscle strength, and functional status . In one of the reviews, investigators found that moderate- or high-intensity exercise in patients with RA has a minimal effect on disease activity and radiological evidence of damage in the hands and feet , but that there is insufficient radiologica l evidence to determine the effect in large joints .

26. The reviewers also reported that long-term moderate- or high-intensity exercises (individualized to protect radiologically damaged joints ) improve aerobic capacity, muscle strength , functional ability, and psychological well-being in patients with RA .

27. 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) (Fig. 11.4). There is also progression of synovial and capsular thickening and joint effusion . The impairments from OA lead to activity limitations and participations restrictions in a substantial number of people with a significant social and financial impact as a result of surgical and medical interventions.

28. Characteristics of OA: ■ With degeneration , there may be capsular laxity as a result of bone remodeling and capsule distention, leading to hypermobility or instability in some ranges of joint motion. pain decreased willingness to move, contractures eventually develop in portions of the capsule and overlying muscle, so as the disease progresses, motion becomes more limited.

29. ■ Although the etiology of OA is not known , mechanical injury to the joint due to a major stress or repeated minor stresses poor movement of synovial fluid when the joint is immobilized are possible causes. Rapid destruction of articular cartilage occurs with immobilization, because the cartilage is not being bathed by moving synovial fluid and is thus deprived of its nutritional supply

30. ■ OA is also genetically related, especially in the hands and hips and to some degree in the knees. Other risk factors that show a direct relationship to OA are obesity , weakness of the quadriceps muscles , joint impact, sports with repetitive impact and twisting (e.g., soccer, baseball pitching, football), and occupational activities such as jobs that require kneeling and squatting with heavy lifting. ■ 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

31. T here is increased density of the bone along the joint line, with cystic bone loss and osteoporosis in the adjacent metaphysis. During the early stages , the joint is usually asymptomatic because the cartilage is avascular and aneural , but pain becomes constant in later stages. ■ Affected joints may become enlarged . Heberden’s nodes (enlargement of the distal interphalangeal joints of the fingers) and Bouchard’s nodes (enlargement of the proximal interphalangeal joints) are common. ■ Most commonly involved are weight-bearing joints (hips and knees), the cervical and lumbar spine, and the distal interphalangeal joints of the fingers and carpometacarpal joints of the thumbs (Figs. 11.5 and 11.6).

32. Principles of Management: Osteoarthritis Pain, joint stiffness, decreased muscle performance, and decreased aerobic capacity affect the quality of life and increase the risk for disability for the individual with OA. Therapeutic exercise and manual therapy interventions are important in the comprehensive management of OA. Management guidelines are summarized in Box 11.4. ■ Patient instruction. Education includes teaching the patient about the disease of OA, how to protect the joints while remaining active, how to manage the symptoms. Instruct the patient in a home program of safe exercises to improve muscle performance, ROM, and endurance.

33. ■ Pain management—Early stages. Pain and feelings of “stiffness” are common complaints during the early stages. Pain usually occurs because of excessive activity and stress on the involved joint and is relieved with rest . Brief periods of stiffness occur in the morning or after periods of inactivity . This is due to gelling of the involved joints after periods of inactivity. Movement relieves the stasis and feelings of stiffness. Help the patient find a balance between activity and rest and correct biomechanical stresses in order to prevent, retard, or correct the mechanical limitations. ■ Pain management—Late stages. During the late stages of the disease, pain is often present at rest. The pain is probably from secondary involvement of subchondral bone, synovium, and the joint capsule . In the spine, if boney growth encroaches on the nerve root , there may be radicular pain

34. Emphasize activity modification and use of assistive devices and/or splints to minimize joint stress. Pain that cannot be managed with activity modification (as described in the following bullet) and analgesics is usually an indication for surgical intervention. ■ Assistive and supportive devices and activity. With progression of the disease , the boney remodeling , swelling, and contractures alter the transmission of forces through the joint, which further perpetuates the deforming forces and creates joint deformity. Functional activities become more difficult. Adaptive or assistive devices, such as a raised toilet seat, cane, or walker, may be needed to decrease painful stresses and maintain function. Shock-absorbing footwear may decrease the stresses in OA of the knees. Aquatic therapy and group-based exercise in water decreases pain and improves physical function in patients with lower extremity OA.

35. ■ Resistance exercise. Progressive weakening in the muscle occurs either from inactivity or from inhibition of the neuronal pools. Weak muscles may add to the joint dysfunction . Strong muscles protect the joint Use resistance exercises, within the tolerance of the joint, as part of the patient’s exercise program. Avoid deforming forces and heavy weights that the patient cannot control or that cause joint pain. Adaptations include the use of multiple-angle isometrics in pain-free positions , applying resistance only through arcs of motion that are not painful, and use of a pool to decrease weight-bearing stresses and improve functional performance . ■ Stretching and joint mobilization. Use stretching and joint mobilization techniques to increase mobility. Teach the patient self-stretching/flexibility exercises and the importance of movement to counteract the developing restrictions

36. ■ Balance activities. Joint position sense may be impaired for principles and description of balance exercises. Nontraditional forms of exercise, such as Tai Chi, have been found to be effective for improving balance in patients with OA ■ Aerobic conditioning Instruct the patient in exercises designed to improve cardiopulmonary function. The choice of exercise should have low impact on the joints, such as walking, biking, or swimming. Avoid activities that cause repetitive intensive loading of the joints, such as jogging and jump

37. Fibromyalgia and Myofascial Pain Syndrome Fibromyalgia (FM) and myofascial pain syndrome (MPS) are 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 and individuals with MPS have localized changes in the muscle. Although there are some similarities, the differences are significant and determine the method of treatment . They are summarized in Table 11.2.

38. Fibromyalgia: Fibromyalgia, as defined by the American College of Rheumatology in 1990 , is a chronic condition characterized by widespread pain that covers half the body (right or left half, upper or lower half) plus the axial skeleton, and has lasted for more than 3 months. Additional symptoms include 11 of 18 tender points at specific sites throughout the body (Fig. 11.7) nonrestorative sleep, morning stiffness

39. A final common problem is fatigue with subsequent diminished exercise tolerance. Prevalence of FM : It is estimated that 2% of the population — nearly 5 million adults 18 years old or older—have FM, with women affected far more than men (3.4% to 0.5%). In addition, the prevalence increases with age, with 7.4% of women ages 70 to 79 affected.

40. Characteristics of FM The characteristics of FM include the following: ■ The first symptoms of FM can occur at any age but usually appear during early to middle adulthood. ■ For many of those diagnosed, the symptoms develop after physical trauma such as a motor vehicle accident or a viral infection . ■ Although the symptoms vary from individual to individual , there are several hallmark complaints. Pain is usually described as muscular in origin and is predominantly reported in the scapula, head, neck, chest, low back .

41. ■ Another common report is a significant fluctuation in symptoms . Some days an individual may be pain-free, whereas other days the pain is markedly increased . Most individuals report that, when they are in a cycle in which the symptoms are diminished, they try to do as much as possible. This is usually followed by several days of worsening symptoms and an inability to carry out their normal daily activities. This is often the response to exercise.

42. ■ 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 .

43. Factors Contributing to a Flare: Although FM is a noninflammatory , nondegenerative , nonprogressive disorder , several factors may affect the severity of symptoms. These factors include environmental stresses , physical stresses , and emotional stresses. FM is not caused by these various stresses, but it is aggravated by them. ■ Environmental stresses include weather changes, especially significant changes in barometric pressure, cold, dampness, fog, and rain. An additional environmental stress is fluorescent lights. ■ Physical stresses include repetitive activities, such as typing, playing piano, vacuuming; prolonged periods of sitting and/or standing; and working rotating shifts. ■ Emotional stresses are any normal life stresses.

44. Management: Fibromyalgia Research supports the use of exercise , particularly aerobic exercise , to reduce the most common symptoms associated with FM. In addition to exercise, interventions include: ■ Prescription medication ■ Over-the-counter medication ■ Instruction in pacing activities, in an attempt to avoid fluctuations in symptoms ■ Coginitive Behavior therapy ■ Avoidance of stress factors ■ Decreasing alcohol and caffeine consumption ■ Diet modification

45. CLINICAL TIP : When beginning any type of exercise with individuals with FM it is best to begin at lower levels than recommended by the American College of Sports Medicine for aerobic and strengthening and to slowly increase the activity. If the exercise leads to an increase in FM symptoms, reduce the intensity , while encouraging continued participation in the exercise.

46. is defined as a chronic, regional pain syndrome . The hallmark classification of MPS comprises the myofascial trigger points ( MTrPs ) in a muscle that have a specific referred pattern of pain (Fig. 11.8), along with sensory, motor, and autonomic symptoms. The trigger point is defined as a hyperirritable area in a tight band of muscle. The pain from these points is described as dull, aching, and deep . 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. The trigger points may be active (producing a classic pain pattern) or latent (asymptomatic unless palpated). Myofascial pain syndrome (MPS)

47. Possible Causes of Trigger Points: Although the etiology of trigger points is not completely understood , some potential causes are: ■ 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

48. Management: Myofascial Pain Syndrome Treatment consists of three main components: ■ Correct contributing factors to chronic overload of the muscle. ■ Eliminate the trigger point . Several techniques are used to eliminate trigger points: Contract-relax-passive stretch done repeatedly until the muscle lengthens Contract-relax-active stretc h also done in repetition Trigger point release Spray and stretch Modalities Dry needling or injection ■ Strengthen the muscle .

49. CLINICAL TIP: If the cause of the trigger point in myofascial pain syndrome is a chronic overload of the muscle, eliminate the contributing factor prior to addressing the trigger point. Initiate muscle strengthening when ROM is restored and the trigger point has been addressed

50. 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 . Approximately 10 million Americans have osteoporosis, 80% of them women , and an additional 34 million individuals are at increased risk due to decreased bone mass. The diagnosis of osteoporosis is determined by the T-score of a bone mineral density (BMD) scan. The T- score is the number of standard deviations above or below a reference value (young, healthy Caucasian women).

51. Health Organization (WHO) has established the following criteria. ■ Normal: –1.0 or higher ■ Osteopenia: –1.0 to –2.4 ■ Osteoporosis: –2.5 or less A decrease of 1 standard deviation represents a 10% to 12% loss of BMD.

52. Risk Factors: Primary osteoporosis . Risk factors for developing primary osteoporosis include being postmenopausal, Caucasian or Asian descent, family history, low body weight, little or no physical activity, diet low in calcium and vitamin D , and smoking . Additional risk factors include prolonged bed rest and advanced age .

53. Secondary osteoporosis. Secondary osteoporosis develops owing to other medical conditions gastrointestinal diseases, hyperthyroidism , chronic renal failure, excessive alcohol consumption and the use of certain medications such as glucocorticoids. Regardless of etiology, osteoporosis is detected radiographically by cortical thinning, osteopenia (increased bone radiolucency), trabecular changes, and fractures (Figs. 11.9 and 11.10)

54. Prevention of Osteoporosis The National Osteoporosis Foundation (NOF) recommends five ways to prevent osteoporosis: ■ Diet rich in calcium and vitamin D ■ Weight-bearing exercise ■ Healthy lifestyle with moderate alcohol consumption and no smoking ■ Talking to a health care provider ■ 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..

55. 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 a shift to greater resorption . For women, resorption is accelerated during menopause owing to the decrease in estrogen

56. Physical Activity Physical activity: has been shown to have a positive effect 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 ; in the elderly, it has been shown to reduce the effects of age-related or disuse-related bone loss . Maintenance of, or an increase in, bone density is important for preventing fractures associated with osteoporosis

57. 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.

58. Recommendations for Exercise: The NOF recommends weight-bearing exercise in the prevention of osteoporosis but does not specify what type of exercise or how often it should be done. Based on current research, the following recommendations are made . ■ Weight-bearing exercise: such as walking, jogging, climbing stairs, jumping ■ Nonweight -bearing exercise: such as with a bicycle ergometer ■ Resistance (strength) training : of 8 to 10 exercises that target major muscle group

59. Mode : Aerobic Frequency . Five 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 . Mode : Resistance Frequency. Two to three days per week with a day of rest in between each bout of exercise . Intensity . Eight to 12 repetitions that lead to muscle fatigue

60. CLINICAL TIP: The Borg rate of perceived exertion scale (RPE ) is a good indicator of how difficult an exercise is for an individual . 12 A score of 16/20 is based on a 15-grade RPE scale (6 to 20). The individual rates how hard he or she is working 7 = very, very light ; 13 = somewhat hard ; 19 = very, very hard

61. Precautions and Contraindications: ■ Because osteoporosis changes the shape of the vertebral bodies (they become more wedge-shaped ), leading to kyphosis , flexion activities and exercise supine curl-ups and sit-ups, 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 intervertebral discs . ■ When performing resistance exercise, it is important to increase the intensity progressively but within the structural capacity of the bone .

62. CLINICAL TIP: Utilizing a multimodal program of weight-bearing exercise, balance activities, and strengthening may help reduce the risk of falls and subsequent hip fractures in individuals with osteoporosis.

63. Fractures and Posttraumatic 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 Causes and types of fractures are summarized in Table 11.3 and are illustrated in Figures 11.11, 11.12, and 11.13 . A fracture is identified by:

64. A fracture is identified by: ■ 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

65. the therapist must be aware of symptoms and signs of a potential fracture . If a fracture is suspected, refer the patient for radiographic examination, medical diagnosis, and management. Box 11.5 summarizes the typical symptoms and signs of a possible fracture.

66. Risk Factors: Risk factors for fracture include: ■ Sudden impact (e.g., accidents, abuse, assult ) ■ Osteoporosis (women > men ) ■ History of falls ( expecially 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 in which there is hematoma formation and cellular proliferation; ( 2) a reparative phase in which there is callous formation uniting the breach and ossification; and ( 3) a remodeling phase in which there is consolidation and remodeling of the bone.

67. Cortical Bone Healing Inflammatory Phase When the dense cortical bone of the shaft of a long bone is fractured , the tiny blood vessels are torn at the site , resulting in internal bleeding followed by normal clotting. The amount of bleeding depends on the degree of fracture displacement and amount of soft tissue injury in the region. Reparative Phase The early stages of healing take place in the hematoma . Osteogenic cells proliferate from the periosteum and endosteum to form a thick callus , which envelopes the fracture site. At this stage, the callus does not contain bone and is, therefore, radiolucent . As the callus starts to mature, the osteogenic cells differentiate into osteoblasts and chondroblasts . Initially , the chondroblasts form cartilage near the fracture site, and the osteoblasts form primary w oven bone.

68. Remodeling Phase : ■ Stage of clinical union . When the fracture site is firm enough that it no longer moves , it is clinically united. This occurs when the temporary callus consisting of the primary woven bone and cartilage surrounds the fracture site . The callus gradually hardens as the cartilage ossifies ( endochondral ossification). On radiographic examination , the fracture line is still apparent, but there is evidence of bone in the callus . Usually at this stage, immobilization is no longer required . Movement of the related joints is allowed with the caution of avoiding deforming forces at the site of the healing fracture. When assessing the site, no movement of the fracture site or pain should be felt by the patient or therapist. ■ Stage of radiological union . The bone is considered radiographically healed , or consolidated , when the temporary callus has been replaced by mature lamellar bone . The callus is resorbed, and the bone returns to normal.

69. Rigid Internal Fixation: Sometimes it is necessary to surgically apply an internal fixation device , such as a rod or a plate with screws, to protect a healing bone. This allows the bone to be kept stable as it heals , but disuse osteoporosis of the bone under the device occurs because normal stresses are transmitted through the device and bypass the bone . Usually the fixation device is removed once the fracture is united in order to reverse the osteoporosis. Following removal of the rod or plate, the bone must be protected from excessive stress for several months until the osteoporosis is reversed

70. Healing Time 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, adults within 10 to 18 weeks . Several types of abnormal healing may occur . These are summarized in Box 11.6

71. Cancellous Bone Healing: When the sponge-like lattice of the trabeculae of cancellous bone fractures (in the metaphysis of long bones and bodies of short bones and flat bones), healing occurs primarily through formation of an internal callus ( endosteal ) callus . There is a rich blood supply and a large area of boney contact, so union is more rapid than in dense cortical bone. Cancellous bone is more susceptible to compression forces, resulting in crush or compression fractures . If the surfaces of the fracture are pulled apart, which may occur during reduction of the fracture, healing is delayed .

72. Epiphyseal Plate Healing: If a fracture involves the epiphyseal plate , there may be growth disturbances boney deformity as the skeleton continues to mature. The prognosis for growth disturbances depends on the type of injury, age of the child, blood supply to the epiphysis , method of reduction, and whether it is a closed or open injury.

73. Principles of Management: Period of Immobilization: Local Tissue Response: With immobilization , there is connective tissue weakening, articular cartilage degeneration , muscle atrophy, contracture development as well as sluggish circulation. addition, there is soft tissue injury with bleeding and scar formation . Because immobilization is necessary for bone healing, the soft tissue scar cannot become organized along lines of stress as it develops Early , nondestructive motion within the tolerance of the fracture site is ideal but usually not feasible unless there is some type of internal fixation to stabilize the fracture site. 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 . The therapist must be alert to complications that can occur following a fracture (summarized in Box 11.7).

74. 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, alternative modes of ambulation , such as the 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. Management guidelines are summarized in Box 11.8.

75. Management: Postimmobilization Management guidelines are summarized in Box 11.9. Consultation with the referring physician is necessary to determine if there is clinical or radiological healing. Until the fracture site is radiologically healed, care should be used any time stress is placed across the fracture site, such as when applying resistance or a stretch force or during weight-bearing activities. Once radiologically healed, the bone has normal structural integrity and can withstand normal stress. The patient is examined to identify impairments and determine the current functional status, activity level, and desired outcome. ROM, joint mobility, and muscle performance as well as any other impairments are measured and documented. Usually all of the joint and periarticular tissues are affected in the region that was immobilized. Typical interventions include : ■ Joint mobilization . Joint mobilization techniques are effective for regaining lost joint play without traumatizing the articular cartilage or stressing the fracture site. Intervention begins with gentle stretches and progresses in intensity as joint reaction becomes predictable. ■ PNF Stretching. Hold-relax and agonist-contraction techniques are used during the postimmobilization period because the intensity can be controlled by the patient. It is

76. important to monitor the intensity of contraction and to not apply the resistive or stretch force beyond the fracture site until there is radiological healing of the bone in order to avoid a bending force across the fracture site. Once the bone is radiologically healed, the stretch force can be applied beyond the fracture site. ■ Functional activities. The patient can resume normal activities with caution. During the early postimmobilization period, it is important to not traumatize the weakened muscle, cartilage, bone, and connective tissue. Partial weight bearing must be continued for several weeks after a lower extremity fracture until the fracture site is completely healed and able to tolerate full weight bearing. ■ Muscle performance: Strengthening and muscle endurance . For 2 to 3 weeks following immobilization, because neither the bone nor cartilage can tolerate excessive compressive or bending forces, exercises are initiated with light isometrics . As joint play and ROM improve, progression is made to light resistance through the available range. The resistive force should be applied proximal to the fracture site until the bone is radiologically healed. Once healed, PRE and other more intense dynamic exercises can be initiated. ■ Scar tissue mobilization. If there is restricting scar tissue, manual techniques to mobilize the scar are used. The choice of technique depends on the tissue involved