Joint, Connective Tissue,

and Bone Disorders

and Management

Dr. Momena Shahzad

Arthritis: Arthrosis

 Arthritis is inflammation of a joint

 Arthrosis is limitation of a joint without inflammation.
 Clinical Signs and Symptoms
 Impaired mobility (capsular pattern, firm end-feel, decreased
and painful joint play, joint swelling)
 Impaired muscle performance (Weakness from disuse or reflex
inhibition of stabilizing muscles)
 Impaired balance (altered or decreased sensory input)
 Activity Limitations and Participation Restrictions

Dr. Momena Shahzad

 Arthritis

inflammatory noninflammatory

most common types treated by therapists are rheumatoid

arthritis and osteoarthritis

Dr. Momena Shahzad

 Rheumatoid Arthritis

Dr. Momena Shahzad

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

Dr. Momena Shahzad

Characteristics of RA
• symmetric, errosive synovitis with periods of exacerbation
(flare) and remission
• Synovitis
• Pannus formation
• Fibrosis, ossific ankylosis, or subluxation may eventually
cause deformity and disability
• tenosynovitis

Dr. Momena Shahzad

Dr. Momena Shahzad
Dr. Momena Shahzad
Dr. Momena Shahzad
 Signs and Symptoms: Periods of
Active Disease
 Effusion and swelling of the joints, which cause aching and limited
motion
 Onset is usually in the smaller joints of the hands and feet, most
commonly in the proximal interphalangeal joints.
 Usually symptoms are bilateral.
 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.
 Nonspecific symptoms such as low-grade fever, loss of appetite and
weight, malaise, and fatigue.

Dr. Momena Shahzad

Dr. Momena Shahzad
Principles of Management: Subacute
and Chronic Stages of RA

 Treatment approach.
 Joint protection and activity modification (using splints,
assistive devices, and environmental adaptations)
 Flexibility and strength (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)

Dr. Momena Shahzad

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.

Dr. Momena Shahzad

 Osteoarthritis

Dr. Momena Shahzad

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.

Dr. Momena Shahzad

 Characteristics of OA
• Limited motion due to pain and contractures
• Rapid destruction of articular cartilage
• Crepitation of loose bodies
• Heberden’s nodes (enlargement of the distal
interphalangeal joints of the fingers)
• 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

Dr. Momena Shahzad

Dr. Momena Shahzad
Dr. Momena Shahzad
Dr. Momena Shahzad
Dr. Momena Shahzad
 FIBROMYALGIA

Dr. Momena Shahzad

FIBROMYALGIA

 Fibromyalgia
 chronic condition characterized by widespread pain that
covers half the body (right or left half, upper or lower
half) and has lasted for more than 3 months.
 Additional symptoms include 11 of 18 tender points at
specific sites throughout the body
 Prevalence of FM
 Prevalent in 2% of the population
 women affected far more than men
 Prevalence increases with age

Dr. Momena Shahzad

Dr. Momena Shahzad
  Characteristics of FM
 First symptoms usually appear during early to middle
adulthood.
 Symptoms develop after physical trauma such as a
motor vehicle accident or a viral infection.
 Pain is usually described as muscular in origin.
Predominantly reported to be in the scapula, head,
neck, chest, and low back.
 Fluctuation in symptoms
 Individuals with FM have a higher incidence of
tendonitis, headaches, irritable bowel, TMJ
dysfunction, restless leg syndrome, mitral valve
prolapse, anxiety, depression, and memory
problems.

Dr. Momena Shahzad

  Contributing Factors to a Flare
 Non-inflammatory, non-degenerative, non
progressive disorder
 Environmental stresses (weather changes)
 Physical stresses (repetitive activities)
 Emotional stresses
 Management—Fibromyalgia
 Research supports the use of exercise, particularly
aerobic exercise
 In addition to exercise, interventions include:
 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

Dr. Momena Shahzad

 MYOFASCIAL
PAIN SYNDROME

Dr. Momena Shahzad

Myofascial Pain Syndrome

 Myofascial pain syndrome (MPS) is defined as a chronic, regional

pain syndrome.
 Myofascial trigger points (MTrPs) in a muscle which have a specific
referred pattern of pain
 decreased ROM when the muscle is being stretched
 decreased strength in the muscle
 increased pain with muscle stretching
 Possible Causes of Trigger Points
 Chronic overload of the muscle
 Acute overload of the muscle
 Poorly conditioned muscles
 Postural stresses
 Poor body mechanics
Dr. Momena Shahzad
Dr. Momena Shahzad
Management—Myofascial Pain
Syndrome
 Treatment consists of three main components:
 1. Correct contributing factors to chronic overload of the muscle.
 2. 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 stretch also done in repetition
 Trigger point release
 Spray and stretch
 Modalities
 Dry needling or injection
 ■ Strengthen the muscle.

Dr. Momena Shahzad

Dr. Momena Shahzad
 OSTEOPOROSIS

Dr. Momena Shahzad

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.
 Determined by the T score of a bone mineral density (BMD)
scan
 The World Health Organization (WHO) has established the
following criteria
 Normal: –1.0 or higher
 Osteopenia: –1.1 to –2.4
 Osteoporosis: –2.5 or less

Dr. Momena Shahzad

Risk Factors

• Primary osteoporosis:
Risk factors include postmenopausal, Caucasian or Asian
descent, family history, low body weight, little or no
physical activity, diet low in calcium and vitamin D, and
smoking, prolonged bed rest and advanced age.
• Secondary osteoporosis:
Secondary osteoporosis develops owing to other medical
conditions (i.e., gastrointestinal diseases, hyperthyroidism,
chronic renal failure, excessive alcohol consumption) and
the use of certain medications such as glucocorticoids.

Dr. Momena Shahzad

osteoporosis is detected
radiographically by cortical
thinning, osteopenia (increased
bone radiolucency), trabecular
changes, and fractures

Dr. Momena Shahzad

Prevention of Osteoporosis

 Diet rich in calcium and vitamin D

 Weight-bearing exercise
 Healthy lifestyle
 no smoking
 Testing bone for its density and medication if needed
Recommendations for Exercise
 Weight-bearing exercise, such as walking, jogging,
climbing stairs, jumping
 Non weight-bearing exercise, such as with a bicycle
ergometer
 Resistance (strength) training of 8 to 10 exercises that
target major muscle groups
Dr. Momena Shahzad
 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.

Dr. Momena Shahzad

 Fractures and
Posttraumatic
Immobilization

Dr. Momena Shahzad

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.

Dr. Momena Shahzad

 • 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)

Dr. Momena Shahzad

Dr. Momena Shahzad
Dr. Momena Shahzad
Dr. Momena Shahzad
Symptoms and Signs of a Possible
Fracture
The following should alert the therapist to a possible fracture.
 History of a fall, direct blow, twisting injury, accident
 Localized pain aggravated by movement
 Muscle guarding with passive movement
 Decreased function of the part
 Swelling, deformity, abnormal movement (may or may not be
obvious)
 Sharp, localized tenderness at the site

Dr. Momena Shahzad

Dr. Momena Shahzad
Dr. Momena Shahzad
Abnormal Healing and Complications of
Fracture

Dr. Momena Shahzad

Dr. Momena Shahzad