23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

4. Corticosteroid injections
Bursitis Tendonitis  If unresolved, plantar
fasciitis may progress
to fascial tears at the
heel ⇢ heel spurs

Carpal tunnel syndrome

 Entrapment
neuropathy that
occurs when the
 Inflammatory conditions that commonly occur median nerve at
in the shoulder the wrist is
 Bursae are fluid-filled sacs that prevent compressed by a
friction between joints during joint activity and thickened flexor
are painful when inflamed ⇢ bursitis tendon sheath,
 Muscle tendon sheaths also became inflamed skeletal encroachment, edema, or a soft tissue
with repetitive stretching ⇢ tendonitis mass
 Inflammation ⇢ proliferation of synovial  Common in women, 30 – 60 years of age
membrane & pannus formation ⇢ joint  Due to repetitive hand and wrist movements
movement restriction  Associated with RA, DM, acromegaly,
 Conservative treatment: hyperthyroidism or trauma
1. Rest of extremity
2. Intermittent ice and heat to the joint Symptoms:
3. NSAIDs (control inflammation and 1. Pain, numbness, paresthesia, and possible
pain) weakness along the median nerve distribution
 Arthroscopic synovectomy may be considered 2. Night pain &/or fist clutching upon awakening
if shoulder pain and weakness persist (common)
 Most tendon and bursal inflammatory problems 3. (+) Tinel’s sign: tingling or “pins and needles”
are self-limiting feeling when skin over a nerve is tapped
 Treatments are primarily aimed at pain relief,
not cure

Plantar fasciitis
 Inflammation of
the foot-
supporting fascia
 Presents as an
acute heel pain Treatments:
associated with 1. Oral or intra-articular corticosteroid
first steps in the morning injections (not for long term)
 Pain is localized to the anterior medial aspect 2. NSAIDs
of the heel 3. Acupuncture with or without electrical
 Reliever: gentle stretching of the foot and stimulation
Achilles tendon  Application of wrist splints is also effective
 Management:  Surgical managements (if nonsurgical
1. Stretching exercises treatments fail)
2. Wearing shoes with support and 1. Open nerve release (traditional)
cushioning (pain relief) 2. Endoscopic laser surgery
3. Orthotic devices

PRUDENCIADO 1
 23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

Epicondylitis 4. hypertension
 Chronic, painful 5. diuretic use
condition that is
caused by Pathophysiology
excessive,  Primary hyperuricemia: caused by severe
repetitive dieting or starvation, excessive intake of high-
extension, purine foods, or heredity
flexion,  Secondary hyperuricemia: gout is a clinical
pronation, and feature secondary to any of a number of
supination genetic or acquired processes
motions of the forearm
 Lateral epicondylitis (tennis elbow)
o frequently identified in someone who
repeatedly extends the wrist with
supination of the forearm
o Pain develops over the lateral epicondyle
and in the extensor muscles
 Medial epicondylitis (golfer’s elbow)
o Consistent with repetitive wrist flexions
and pronation of the forearm
o Extreme tenderness occurs at the medial
epicondyle
 First line of treatment: rest
 Intermittent application of ice and Clinical Manifestations
administration of NSAIDs usually relieve the  Manifestations of gout syndrome include:
pain 1. Acute gouty arthritis
 Arm is immobilized in some instances 2. Tophi
 Local corticosteroid injection is reserved for 3. Gouty nephropathy
patients with severe pain and do not respond to 4. Uric acid urinary calculi
first-line methods  Four stages of gout can be identified:
 Rehabilitation exercises may also reduce pain 1. Asymptomatic hyperuricemia
and inflammation 2. Acute gouty arthritis
 Multiple electrophysical modalities may 3. Intercritical gout
effectively manage medial epicondylitis but 4. Chronic tophaceous gout
needs efficacy validation  Subsequent development of gout is directly
 Surgical interventions are last resort related to the duration and magnitude of the
hyperuricemia
 Acute arthritis is the most common early
METABOLIC BONE DISORDERS clinical manifestation
 Metatarsophalangeal joint of the big toe is a
Gouty arthritis commonly affected joint
 Most common form
of inflammatory Medical Management
arthritis  A definitive diagnosis is established by
 4x more common in polarized light microscopy of the synovial fluid
men of the involved joint
 Incidence increases  Acute attacks: colchicine, NSAID, or a
with: corticosteroid
1. age  Management of hyperuricemia, tophi, joint
2. body mass index destruction, and renal disorders is usually
3. alcohol consumption

PRUDENCIADO 2
 23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

initiated after the acute attack ⇢ uric acid Korsakoff syndrome
lowering therapy is considered  Neuropsychiatric disorder associated with
 Xanthine oxidase inhibitor and febuxostat are memory disturbances in which there are
the agents of choice significant deficits in anterograde and
 Management between gout attacks needs to retrograde memory
include:  Immediate memory is maintained, but short-
1. Lifestyle changes (avoiding purine-rich term memory is diminished with intact
foods, weight loss, decreasing alcohol sensorium
consumption, and avoiding certain  Associated with patients fabricating stories in
medications) the setting of clear consciousness
2. Uricosuric agents and medications
3. Corticosteroid Pathophysiology
 Specific treatment is based on:
1. Serum uric acid level
2. 24-hour urinary uric acid excretion
3. Renal function

Nursing Management
 Encourage patient to restrict consumption of
foods high in purines, especially organ meats,
and to limit alcohol intake
 Maintenance of normal body weight should be
encouraged
 During acute episodes, pain management is Clinical Manifestations
essential  Suspected in any patient with chronic alcohol
 Medication adherence is critical abuse or any form of malnutrition and any
of the following:
Wernicke’s-Korsakoff Syndrome 1. acute altered mental status
2. ophthalmoplegia
3. ataxic gait
4. delirium
5. hypotension
 Classic triad of Wernicke encephalopathy:
1. altered mental status (characterize
encephalopathy)
2. ataxic gait (broad-based gait)
3. ophthalmoplegia (hallmark sign)
 Other warning signs: hyperthermia and
hypotension
 Can also present with peripheral neuropathy
and commonly includes the lower extremity
with distal sensory loss
Wernicke encephalopathy
 Acute neurological condition characterized by Assessment and Diagnostic Findings
a clinical triad of ophthalmoparesis with  Thorough patient history with a focused
nystagmus, ataxia, and confusion physical exam and laboratory workup with
 Life-threatening illness caused by thiamine appropriate imaging
deficiency, which primarily affects the  No specific laboratory tests for diagnosis as it
peripheral and central nervous systems is clinical

PRUDENCIADO 3
 23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

 Complete blood count and comprehensive Osteoarthritis
metabolic panel can be completed to exclude  Noninflammatory
other causes of CNS abnormalities degenerative
disorder of the
Risk factors helps in evaluating the patient as WE were joints
classically thought of as a disease exclusively due to  Most common
alcoholism form of joint
 Recent years it is also seen in patients that are: disease
1. chronically malnourished  Classified as:
2. post-bariatric surgery 1. primary (idiopathic), with no prior
3. hyperemesis gravidarum event or disease related to the OA
4. liver disease 2. secondary, resulting from previous
5. hyperthyroidism joint injury or inflammatory disease,
6. severe anorexia nervosa similar to RA
 Pathophysiology does not involve autoimmunity
Medical Management or inflammation
 Aim of treatment:  Distinguishing characteristic is limitation to
o prompt and quick correction of the the affected joints with no associated
thiamine deficiency in the brain symptoms
 WE is a medical emergency and a reversible  Incidence increases with age
condition requiring immediate emergent
attention Pathophysiology
 Parenteral administration of thiamine is most  Risk factors for the disease & progression
effective and provides for rapid administration 1. Older age
o Persistent neurological deficits ⇢ chronic 2. Female gender
Korsakoff syndrome 3. Obesity: most prominent modifiable
 Dose of thiamine may be as high as 500 mg risk factor
given 1 to 3x daily parenterally 4. Certain occupations, requiring
o Malnourished patient may need higher laborious tasks
doses of thiamine 5. Engaging in sport activities
 Thiamine is generally administered before or 6. History of previous injuries, muscle
together with glucose solutions weakness, genetic predisposition, and
o Glucose oxidation can ↓ thiamine levels ⇢ certain diseases
exacerbating the neurological symptoms of  Obesity is the most prominent modifiable risk
Wernicke encephalopathy
 Magnesium deficiency should also be treated
o Result in reduced recovery from WE
especially in alcoholics

Nursing Management
 Place the patient in a safe, quiet environment
 Vital signs monitoring, assessment of mental
status, cognition & memory, and monitoring of I
&O
 Ensure adequate oxygenation
 Check blood work for electrolytes, glucose and
thiamine levels
 Administration of intravenous thiamine &
magnesium
 Encourage a healthy diet
 Educate caregiver on the disorder

PRUDENCIADO 4
 23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

 Exercise: CV aerobic exercise and LE strength
training
 Weight loss: extremely beneficial
 Occupational & physical therapy: help patient
adopt self-management strategies

Pharmacologic Therapy
 Directed toward symptom management and pain
control
 Selection of medication is based on:
1. Patient’s needs
Clinical Manifestations 2. Stage of disease
 Main clinical manifestations: 3. Risk of side effects
o Pain: aggravated by movement or  Medications are used in conjunction with
exercise & relieved by rest nonpharmacologic strategies
o Stiffness: usually in the mornings and  Medications commonly used:
is usually brief, lasting < 30 minutes 1. Acetaminophen: initial analgesic
o Functional impairment 2. Nonselective NSAIDS
 PE: affected joint may be enlarged with a 3. COX-2 enzyme blockers: given to
decreased ROM patients susceptible to GI
 Occurs most often in weight-bearing joints complications like bleeding
 Proximal and distal 4. Opioids
interphalangeal joints 5. Intra-articular corticosteroids
are also often 6. Topical analgesics
involved causing bony 7. Glucosamine & chondroitin: modify
enlargements of the cartilage structure
DIP and PIP 8. Viscosupplementation: aim to prevent
 Crepitus may be the loss of cartilage and repair
palpated chondral defects
 Joint effusion is mild
Surgical Management
Assessment and Diagnostic Findings  Used in moderate to severe OA and presence
 Blood tests and examination of joint fluid of loss of function
o Useful in the diagnosis of OA  Osteotomy & arthroplasty
o Occasionally indicated to rule out an  Rehabilitation with PT within 24 hours from
autoimmune cause for the joint pain, such surgery ⇢ ↓ length of hospital stay & improved
as RA balance and gait
 X-ray may show:
o Narrowing of Nursing Management
the joint space  Major goals of nursing intervention:
o Osteophyte 1. Pain management
formation 2. Optimal functional ability
o Dense,  Includes:
thickened 1. Pharmacologic
subchondral 2. Nonpharmacologic, including education
bone  Patient’s understanding of the disease process
and symptoms pattern is critical to the plan of
Medical Management care
 Goals:  Weight loss and exercise are important
1. Decrease pain and stiffness approaches to lessen pain and disability
2. Improve joint mobility

PRUDENCIADO 5
 23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

 Adequate pain management is important for the Clinical Manifestations
success of an exercise program  Most frequently identified on x-ray studies ⇢
 Open discussion regarding the use of sclerotic changes and cortical thickening of the
complementary, alternative, and integrative long bones
health therapies is important to maintain safe  In most patients, skeletal deformity involves
and effective practices for patients looking for the skull associated with impaired hearing
relief  Femurs and tibia tend to bow ⇢ waddling gait
 Tenderness and warmth over bones may be
Paget’s disease noted due to increased bone vascularity
 High-output cardiac failure may develop in
patients with large, highly vascular lesions
 Pain is mild to moderate, deep and aching and
increases with weight bearing
 Pain and discomfort precedes skeletal
deformities

Assessment and Diagnostic Findings

 ↑ serum ALP and urinary hydroxyproline ⇢ ↑
osteoblastic activity & higher values suggest
more active disease
 X-rays: local areas of demineralization and
bone overgrowth in the characteristic mosaic
pattern

 Normal calcium levels

 Osteitis deformans  Bone scans demonstrate the extent of the
 Disorder of localized rapid bone turnover disease
(skull, femur, tibia, pelvic bones, and vertebrae  Bone biopsy: differential diagnosis with other
 Occurs 2 – 5% in the population older than 50 bone diseases
years
 Incidence slightly greater in aging men Medical Management
 Cause is unknown but has familial history  Pain: responds to NSAIDs
 Gait problems: walking aids, shoe lifts, physical
Pathophysiology therapy
Primary proliferation of osteoclasts  Weight is controlled to reduce stress on
⇣ weakened bones and misaligned joints
Bone resorption  Asymptomatic patients: calcium and Vit D
⇣ adequate diets and periodic monitoring
Compensatory increase in osteoblastic activity  Fractures: managed according to location
⇣  Severe degenerative arthritis: total joint
Classic mosaic pattern of bone develops replacement
(highly vascularized, structurally weak)  Hearing loss: hearing aids and communication
⇣
techniques
Pathologic fracture, arthritis, back & joint pain

PRUDENCIADO 6
 23: LOCOMOTIVE DISORDERS NCM 116

Lecturer: Doc. Esther Sunday C. Faller, RMT, MD || July 12, 2022

Pharmacologic therapy  Bone biopsy: increased amount of osteoid (pre-
 Those with moderate to severe disease may bone), demineralized cartilaginous bone matrix
benefit from specific anti-osteoclastic therapy
 Medications reduce bone turnover, reverse the Medical Management
course of the disease, relieve pain, and improve  Physical, psychological, and pharmacological
mobility measures are used to reduce the patient’s
 Biphosphonates discomfort and pain
o Cornerstone of Paget therapy  If osteomalacia is dietary in origin,
o Stabilize rapid bone turnover interventions are similar to that of
o ↓ serum ALP & hydroxyproline levels osteoporosis
 Plicamycin (Mithracin)  Long-term monitoring is appropriate to ensure
o Cytotoxic antibiotic stabilization or reversal of osteomalacia
o Reserved for severely affected  Persistent orthopedic deformities may need to
patients with neurologic compromise be treated with braces or surgery
and resistant to other therapy
o Clinical remissions may continue for
months after medication is
discontinued

Osteomalacia
 Characterized by
inadequate bone
mineralization ⇢
skeleton softens &
weakens ⇢ pain,
tenderness to touch,
bowing of the bones,
and pathologic fractures
 PE: skeletal deformities (spinal kyphosis and
bowed legs) and a waddling gait

Pathophysiology
 Major defect: deficiency of activated Vit D
 Result from failed calcium absorption or from
excessive loss of calcium from the body
o GI disorders (fats are inadequately
absorbed)
o Liver and kidney diseases
o Severe renal insufficiency
o Hyperparathyroidism
o Prolonged us of anticonvulsant
medications
o Malnutrition

Assessment and Diagnostic Findings

 X-ray studies show generalized
demineralization of bones or a compressive
fracture with indistinct vertebral end plates
 Laboratory studies: ↓ serum calcium and
phosphorus levels and a moderately ↑ ALP; urine
excretion of calcium and creatinine is ↓

PRUDENCIADO 7