Chapter 9 – Musculo-Skeletal Function

Structure and function of joints

• Point at which 2 bones are attached
• Provide stability and mobility to the skeleton
• Connections maintained by tendons and ligaments
• A joint that is unstable or immobile is ineffective!
• Nursing diagnoses originate from cause of the ineffective joint:
  • Impaired physical mobility
  • Acute pain or chronic pain
  • Fatigue

Age related changes

• Decreased range of motion
• Shrinking vertebral discs and loss of bone mass contribute to decrease in height
• Muscle atrophy, exacerbated by disuse
• Decrease in lean body mass
• Joint degeneration
• Postural instability contributes to balance difficulties

Nutrition and musculoskeletal health

• Rich protein and mineral diet
• Minimum 1500 mg calcium daily in men and women if not taking estrogen
• Weight reduction to IBW
• Vitamin D supplements (2000 mg/day)

Incredible shrinking people

• After age 40, loss of 1 cm in height every decade is normal 
• Vertebral deterioration due to osteoporosis
• 23 spinal discs compress during the day and reabsorb fluid during night, causing a half-inch variation 
• With age, the discs flatten reducing height permanently

Sarcopenia

• Loss of muscle mass, strength, function
• Maximum muscle strength can decrease by 85%
• Occurs in up to 50% patients 80 years +

Treatment for sarcopenia

• The primary treatment for sarcopenia is exercise
• Resistance training with resistance bands
• Strength training with weights
• Effective for both prevention and treatment of sarcopenia
• Positive influence on
  • Neuromuscular system
  • Hormone concentrations
• Can increase protein synthesis rates in older adults in as little as two weeks.

Normal bone metabolism (remodeling)

• Lifelong process
• Mature bone removed from skeleton by osteoclasts (resorption)
• New bone tissue is formed by osteoblasts (ossification)
• Replace bone in fractures and in micro-damage (during normal activity)
• Activity, particularly weight bearing activity, then, promotes formation of newer, stronger bone!

Wolff’s law

• Healthy bone adapts to the applied physiologic load
• Both internal and external architecture change
• Correlates with the principle of bone remodeling
• If loading increases, bone will remodel to become stronger to resist that load
• Conversely, if loading decreases, bone will become weaker

Osteoporosis
(Metabolic bone disease)

• Altered bone metabolism
• Low bone mass
• Deterioration of bone tissue
• Affects 50% of women
• Contributors to decreased bone mass in the elderly
  • 1) failure to achieve peak bone mass in early adulthood
  • 2) increased bone resorption
  • 3) decreased bone formation

Risk factors for osteoporosis

• Risk factors include:
  • Increased age
  • Female
  • White or Asian
  • Family history
  • Thin body build
• Also implicated:  low calcium intake, smoking, alcohol, caffeine, stress, long term corticosteroids, anticonvulsants, thyroid medications

Diagnostics for osteoporosis

• Bone mineral density study recommended for:
  • Postmenopausal women below age 65 with risk factors for osteoporosis.
  • All women aged 65 and older.
  • Postmenopausal women with fractures
  • Women with medical conditions associated with osteoporosis.
  • Women whose decision to use medication might be aided by bone density testing.
  • Men age 70 or older. 
  • Men ages 50-69 with risk factors for osteoporosis.

Bone mineral density study for patients < 65

• Chronic rheumatoid arthritis
• Fracture
• Early menopause
• Smoking
• Family history of osteoporosis
• Taking corticosteroids
• Consume > 3 drinks of alcohol per day

Lifestyle modifications for the patient with osteoporosis

• Diet with adequate calcium and vitamin D
• Weight bearing exercise (increase bone density)
• Smoking cessation
• Reduction of alcohol,  caffeine

Examples of weight bearing exercise

• Best for bone health
  • Running
  •  Jumping rope
  • Basketball, baseball, tennis, etc.
  • Weightlifting
  • Hiking
• Less effective but beneficial
  • Walking
  • Low-impact aerobics
  • Cardio machines
• Least beneficial
  • Swimming
  • Cycling
  • Yoga, pilates

Exercise programs for the elderly

• Must include:
  • Cardiovascular endurance
  • Flexibility
  • Strength training
• Performance is affected by:
  • Decreased stroke volume causes accelerated heart rate
  • Reduced vital capacity
  • Increased body fat—susceptible to heat stroke
  • Decreased total body fluid—susceptible to dehydration
• Must match the individual’s interests and needs!
• Accommodations
  • Avoid fatigue and muscle cramping
  • Longer recovery time

Pharmacological prevention & treatment of osteoporosis

• Ibandronate (Boniva)
  • Once a month or IV every 3 months
• Alendronate (Fosamax)
  • 35-75 mg once weekly, or
  • 5-10 mg once daily
  • Empty stomach in the morning
  • Upright for at least 30 minutes
• Raloxifene hydrochloride (Evista)
  • 60 mg once daily
  • May take without regard for food
  • May cause flushing
  • Increased risk of thromboembolic events
• Weight bearing exercise important in all cases!

Osteoarthritis (Joint disease—noninflammatory)

• Most common form of arthritis in the US
• Chronic
• Women > men
• Progressive erosion of articular cartilage of the joint
• New bone forms in the joint space

Diagnostics for osteoarthritis

• Xray—joint space narrowing, spur formation

Treatment goals

• Maintain function
• Maintain independence
• Prevent complications

Pharmacological interventions for osteoarthritis

• NSAIDs are most common treatment
• Acetaminophen 500 mg—2-4 grams per day
• Capsaicin—topical analgesic

Nonpharmacological treatment of osteoarthritis

• Weight reduction
• Active range of motion daily
• Weight bearing exercise
• Rest to control symptoms
• Use of assistive devices if necessary

Importance of exercise

• Maintain overall function
• Maintain muscle strength
• Maintain coordination
• Maintain balance
• Maintain flexibility
• Maintain endurance

Exercise programs…

• Require clearance by PCP
• Start slow, low impact, gradually increase

Rheumatoid arthritis (Joint disease—inflammatory)

• Most common inflammatory arthritis of any age group
• Women:men = 3:1
• Chronic syndrome
• Symmetrical inflammation of peripheral joints
• Likely an autoimmune response to unidentified antigen:
  • Patient has high levels of rheumatoid factor (RF, antibody to immunoglobulin G [IgG])
  • RF interacts with circulating IgG to  form immune complexes
  • Complexes deposit in the synovial fluid of joints
  • Lysosomal enzymes are released that destroy surrounding tissue
  • Synovial space fills with scar tissue

Clinical manifestations of rheumatoid arthritis

• Commonly occurs in:
  • Joints of upper extremities
  • Knees
  • Ankles
  • Feet
• Systemic symptoms:
  • Fatigue, malaise
  • Weight loss
  • Fever

Diagnostics for rheumatoid arthritis

• Xray—symmetrical disease
• Synovial fluid aspiration
• WBC and ESR ↑ in 80% of cases
• Rheumatoid factor (RF) ↑ in 50% of cases

Pharmacological interventions for rheumatoid arthritis

• Corticosteroids (e.g., prednisone) to decrease inflammation
• May have long-term adverse effects
• NSAIDs
• Quick relief important to preserve independence

Nonpharmacological treatment of rheumatoid arthritis

• Strength training to address muscle wasting
• Range of motion of joints
• Regular exercise if no inflammation or exacerbation
• Rest to reduce joint stress and fatigue

Gout (joint disease—inflammatory)

• Excessive uric acid in blood
• Crystals accumulate in joints
• Warmth, redness, swelling, pain
• Low purine diet
• Diagnosis—urate crystals in affected joint 

Treatment of gout

• Acute attacks: 
  • NSAIDs
  • Colchicine
  • Steroids
• Long term management: 
  • Colchicine
  • Allopurinol (Zyloprim)
  • Probenicid
  • Indomethacin (Indocin)