BIOS222 Pathology and Clinical Science 2 & 3
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2 BIOS222 Pathology and Clinical Science 2 & 3 Session 10 Disorders of Musculoskeletal System 1 Bioscience Department
3 Session Learning Outcomes At the end of the session, you should be able to: o Revise and review anatomy and physiology of Musculoskeletal system. o Identify a general clinical examination and investigations of the musculoskeletal system and relate the clinical findings to the underlying pathology. o Describe the major musculoskeletal manifestations, and identify their underlying causes and diagnostic measures. o Describe the causes, diagnostic measures and management for back pain. o Describe the general principles of management of musculoskeletal disorders including the pharmacological and non-pharmacological interventions. Endeavour College of Natural Health 3
4 Session Plan o Overview of the musculoskeletal system o Examination and investigation of the musculoskeletal system o Presenting problems in musculoskeletal disease Acute monoarthritis Polyarthritis Fracture Generalised musculoskeletal pain Endeavour College of Natural Health 4
5 Back pain Session Plan Regional musculoskeletal pain Muscle pain and weakness o Principles of management of musculoskeletal disorders Non pharmacological Pharmacological Endeavour College of Natural Health 5
6 Overview of the Musculoskeletal System Endeavour College of Natural Health 6
7 Musculoskeletal System o o Function of The musculoskeletal system: Movement of the body Provides a structural framework to protect internal organs Acts as a reservoir for storage of calcium and phosphate in the regulation of mineral homeostasis Components of the musculoskeletal system: Bones Joints Skeletal muscles Endeavour College of Natural Health 7
8 Bones o Types of bones: Short bones Irregular bones Flat bones Long bones Endeavour College of Natural Health 8
9 Bones o o o Cells of bone: Osteoclasts Osteoblasts Osteocytes Bone matrix and mineral Bone remodelling Endeavour College of Natural Health 9
10 Joints o Classification of joints: Fibrous joints Fibrocartilaginous joints Synovial joints Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 10
11 o Structure of synovial joint Articular cartilage Synovial fluid Intra articular discs Joint capsule Synovial membrane Joints Endeavour College of Natural Health 11
12 Skeletal muscles o o Skeletal muscles: consists of bundles of myocytes embedded in fine connective tissue containing nerves and blood vessels. Functions of skeletal muscle tissues Producing motions Stabilizing body positions Storing and moving substances within the body Thermogenesis Endeavour College of Natural Health 12
13 Examination and investigation of the Musculoskeletal System Endeavour College of Natural Health 13
14 Examination of Musculoskeletal System o Inspection at rest Skin changes Swelling Wasting of muscle Attitude Deformity o Inspection during movement Restriction Increased range Pain on usage o Palpation with movement Tenderness Increased warmth Swelling Crepitus Stability Resisted active movements Stress tests Endeavour College of Natural Health 14
15 Investigation of Musculoskeletal System Investigation Synovial fluid analysis Plain radiography Radionuclide bone scan Magnetic resonance imaging (MRI) Ultrasonography Conditions detected Acute monoarthritis, suspected septic arthritis, crystal arthritis or intra-articular bleeding. Rheumatoid arthritis, Osteoporosis, Paget s disease, Spondyloarthritis, Osteoarthritis Metastatic bone disease, Paget s disease, stress fracture Intervertebral disc disease, Nerve root entrapment, Spinal cord compression, Spinal stenosis, Malignancy, Fractures Small joint synovitis and erosion, periarticular lesions Endeavour College of Natural Health 15
16 Investigation of Musculoskeletal System Investigation Computed tomography (CT) Bone mineral density Haematology Conditions detected When MRI is contraindicated, for evaluation of articular regions in which an adjacent joint replacement creates image artefacts on MRI Osteoporosis Inflammatory rheumatic diseases Routine biochemistry Serum uric acid metabolic bone disease, Paget s disease, renal bone disease and osteomalacia, muscle diseases and gout Gout C-reactive protein (CRP) Infection and inflammation Serum creatine kinase (CK) Myopathy, inflammatory myositis, Muscular dystrophy, Motor neuron disease Endeavour College of Natural Health 16
17 Investigation of Musculoskeletal System Investigation Synovial biopsy Muscle biopsy Bone biopsy Electromyography Conditions detected Mycobacterial infections Myopathy, Inflammatory myositis infiltrative disorders, Osteomalacia, Chronic infections and Malignancy Myopathy, Inflammatory myositis Endeavour College of Natural Health 17
18 Investigation of Musculoskeletal System Autoantibodies Rheumatoid factor (RF) Anti-citrullinated peptide antibodies (ACPA) Antinuclear antibodies (ANA) Anti-DNA antibodies Conditions associated with positive Autoantibodies Rheumatoid arthritis, Mixed essential cryoglobulinaemia, Primary biliary cirrhosis, Infective endocarditis, Systemic lupus erythematosus, Tuberculosis Rheumatoid arthritis Systemic lupus erythematosus, Systemic sclerosis, Dermatomyositis or polymyositis, Mixed connective tissue disease, Autoimmune hepatitis Systemic lupus erythematosus Endeavour College of Natural Health 18
19 Presenting Problems in Musculoskeletal Disease Endeavour College of Natural Health 19
20 Presenting Problems in Musculoskeletal Disease o Acute monoarthritis o Polyarthritis o Fracture o Generalised musculoskeletal pain o Back pain o Regional musculoskeletal pain Neck pain Shoulder pain Elbow pain Hand and wrist pain Hip pain Knee pain Ankle and foot pain o Muscle pain and weakness Endeavour College of Natural Health 20
21 Acute Monoarthritis o Definition: Sudden pain and swelling in a single joint. o Diagnosis: Clinical assessment Clinical history Pattern of joint involvement Speed of onset Age and gender of the patient Synovial fluid analysis Blood tests Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 21
22 Polyarthritis o Definition: Pain and swelling affecting five or more joints or joint groups. o Diagnosis: Clinical presentation Pattern of joint involvement Extra-articular features Blood tests Ultrasound examination MRI Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 22
23 Polyarthritis o Patterns of joint involvement in different forms of polyarthritis: Rheumatoid arthritis Psoriatic arthritis Ankylosing spondylitis Osteoarthritis Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 23
24 Fracture o Definition: Discontinuity or breech in the bone tissue, breaking of bone o Diagnosis: Clinical presentation bone pain, worsened by movement of the affected part history of trauma Radiographs MRI Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 24
25 Generalised Musculoskeletal Pain o Definition: pain that affects the muscles, ligaments and tendons, and bones. o Diagnosis: Clinical history and examination Radiological skeletal survey Radionuclide bone scanning Routine biochemistry Causes of generalised pain Metastatic bone disease Fibromyalgia Joint hypermobility Paget s disease Osteomalacia Osteoarthritis Polymyalgia rheumatica Myositis Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 25
26 Back Pain o Diagnosis: Clinical assessment MRI Plain radiographs Radionuclide bone scan Routine biochemistry and haematology Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 26
27 Back Pain Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 27
28 Neck Pain Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 28
29 Shoulder Pain Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 29
30 Elbow Pain Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 30
31 Other Regional Pain Region Causes Hand and wrist pain Hip pain Knee pain Ankle and foot pain Osteoarthritis, De Quervain s tenosynovitis, Raynaud s phenomenon, C8/T1 radiculopathy, Reflex sympathetic dystrophy Trochanteric Bursitis, Gluteal enthesopathy, Adductor tendinitis Osteoarthritis, Bursitis, Popliteal cyst Osteoarthritis, Plantar fasciitis, Subcalcaneal bursitis, Achilles tendinitis/bursitis Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 31
32 Muscle Pain and Weakness Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 32
33 Principles of Management of Musculoskeletal Disorders Endeavour College of Natural Health 33
34 General Aims of Management o Educate the patient o Control pain o Optimise function o Modify the disease process where this is possible o Identify and treat related comorbidity Endeavour College of Natural Health 34
35 Education and Lifestyle o Patient education: Interventions Nature of the condition and its investigation, treatment and prognosis o Exercise: Aerobic fitness training Local strengthening exercise o Joint protection: Shock-absorbing footwear A walking stick o Weight loss: Strategies for weight loss and maintenance Endeavour College of Natural Health 35
36 Pharmacological Treatment o Analgesics: Paracetamol o Non-steroidal anti-inflammatory drugs (NSAIDs): Traditional NSAIDs COX-2 selective NSAIDs o Topical agents: Topical NSAID creams and gels Capsaicin Endeavour College of Natural Health 36
37 Non-pharmacological Interventions o Physical and occupational therapy: Local heat, ice packs, wax baths Hydrotherapy Various manipulative techniques Splints Orthoses Aids and appliances o Surgery o Self-help and coping strategies Endeavour College of Natural Health 37
38 Reading and Resources o o o o o o o Crowley LV, 2012, An Introduction to Human Diseases Pathology and Pathophysiology Correlations, 9th edn, Jones and Bartlett Learning Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Hinson, J, Raven, P & Chew, S 2010, The endocrine system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Jamison, JR 2006, Differential diagnosis for primary care: a handbook for health care practitioners, 2nd edn, Churchill Livingstone Elsevier, Edinburgh. Jarvis, C, 2012 Physical Examination & Health Assessment, 6th ed., Elsevier Saunders, Philadelphia. Kumar, P & Clark, M 2012, Kumar and Clark s clinical medicine, 8th edn, Saunders Elsevier, Edinburgh. Kumar, V, Abbas, AK & Aster, JC 2015, Robbins & Cotran pathologic basis of disease, 9th edn, Elsevier Saunders, Philadelphia. Endeavour College of Natural Health 38
39 o o o o o o Reading and Resources Lee, G & Bishop, P 2009, Microbiology and infection control for health professionals, 4th edn, Pearson Education, Frenchs Forest, NSW. McCance, KL, Heuther, SE, & Brashers, VL 2014, Pathophysiology: the biologic basis for disease in adults and children, 7th edn, Elsevier. Michael-Titus, A, Revest, P & Shortland, P 2010, The nervous system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Mosby s dictionary of medicine, nursing and health professions 2013, 9th edn, Elsevier, St. Louis, MO. Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. VanMeter, KC & Hubert, RJ 2014, Gould's pathophysiology for the health professions, 5th edn, Elsevier, St Louis, MO. o Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh. Endeavour College of Natural Health 39
40 COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of the Endeavour College of Natural Health pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Endeavour College of Natural Health 40
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