joint impairment

7/24/2019 Joint Impairment

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Impaired Joint Mobility

BPHTI: PTH5201 Jul 2015 1


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At the end of this unit the student will be able to:

Explain the current evidence of age-associated changes

in joint mobility

Analyze the implications of impaired joint mobility forclinical management of older adult patients/ clients.

Learning outcomes:



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perationally defined! joint mobility is the capacity of

a joint to move passively! ta"ing into account the joint

surfaces and surrounding tissue.

#nteractions between muscle! tendon! ligament!synovium! capsule! cartilage! and bone at a joint create

the uni$ue aspects of joint mobility.

%he result of the structural changes can include joint

impairment! activity limitation! and participationrestriction.

JOINT MOBILITY WITH AGING



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&oint structures can be categorized as chondroid!

fibrous! and bony. 'hondroid structures are of cartilaginous ma"e-up and

include articular cartilage! menisci! labra! and

fibrocartilaginous discs.

(ibrous structures include the ligaments and tendons

that surround the joint )i.e.! extraarticular* as well as

ligaments within the joint boundaries )i.e.!

intraarticular*. %he other primary fibrous structure is

the joint capsule of diarthroses.

+one creates the structural segments that move relative

to one another at the articulations.

Change in Joint Structures



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As with all joint structures! there is no clear distinction

between typical aging and pathology of chondroid

structures.

ne factor complicating this delineation is theinfluence of loading history.

%he incidence of osteoarthritis )A* in individuals

involved in sports and occupations with high levels of

traumatic and static joint loading. nce articular cartilage becomes damaged! the capacity

to heal is limited and initial injury may progress to the

development of cartilage lesions )i.e.! cartilage

fibrillation*

Chondroid Structures



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A histologic change specific to articular cartilage is

increased calcification over time.

,ecreased hydration compromises the viscoelastic

properties and load-absorbing capacity of the cartilage. ,istinct changes specific to the intervertebral disc also

occur over time.

%he nucleus becomes more fibrous and less gel-li"e

and the annulus becomes less organized. 'rac"s may also develop in the annulus and nucleus.



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,ecreased water content is also noted in the

intervertebral discs and is associated with shorter disc

heights.

%he loss of disc height can lead to the chronicpathological condition referred to as spinal stenosis! a

major cause of pain and disability for older adults.

'hange of the intervertebral disc also alters

surrounding structures. (or example! the diarthrodialfacet joints may experience greater loads! and elasticity

of the ligamentum flavum may decrease because of

decreasing tensile forces over time.



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#n typical function! fibrous structures absorb and

transfer some level of tensile load! based on collagen

content.

Although orientation and composition of tissuecomponents vary between fibrous structures and

between joints! the overarching similarities in response

to aging are increased stiffness and reduced elasticity.

#n addition! there is evidence in animal models thatcross-sectional area and tensile strength of fibrous

structures decrease with age.

i!rous Structures



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+ony change is both directly and indirectly related to

joint mobility.

,irectly! changes in bone can influence the joint

surfaces to alter joint mechanics. #ndirectly! fractures and other bony structural change

can alter joint alignment and function with possible

secondary influences on joint mobility.

%he thic"ness and density of subchondral bone tends todecrease with advancing age! although this is not

uniform at all joint surfaces.

Bone



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#t is well established that osteopenia is prevalent with

aging! because of increased osteoclast and decreased

osteoblast activity! leading to increased ris" of

osteoporosis.

%he combination of lowered threshold for loading and

increased load demand results in an increased ris" of

bone fracture with aging. (ractures can alter joint mobility in a variety of ways!

such as disrupting circulation to joint structures!

altering loading patterns! and decreasing available

range of motion. #n addition! pain associated with fractures can be a

major problem! interfering significantly with an

individuals activity and participation.



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At the level of the whole joint! changes include

decreased joint space! increased laxity! altered

dispersion of loads! and altered joint moments of force.

ver time! the unloading of surrounding tissues and

joint structures that provide tensile support! because of

decreased joint space! may predispose the joint to

decreased range of motion.

(unctionally! joint changes are reflected by ageassociated changes seen in "inematics at both the

segmental level )i.e.! osteo"inematics* and between

joint surfaces )i.e.! arthro"inematics*.

Who"e Joint Changes



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&oint range of motion )* decreases with increasing

age! although nonuniformly among joints! and is often

direction-specific within a given joint.

0enerally! active and passive motion both decrease!

with active tending to decline more than passive.

(or the cervical spine! gradual decline in is seen

beyond the age of with extension and lateral flexion

demonstrating the greatest decline. Examinations of thoracic and lumbar motion reveal

extension to be most limited in older adults! with

minimal or no age-dependent decline in rotation.

#ange o$ Motion



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,eclines in joint motion occur at the hip and foot/an"le

joint complexes! whereas "nee motion! in the absence

of pathology! remains relatively consistent across the

life span. #t has been postulated that reduced hip extension seen

with aging may directly relate to decreased wal"ing

speed in older adults! especially those with sedentary

lifestyles. ,ecreased an"le sagittal plane motion is also seen with

aging! particularly in the direction of dorsiflexion.

%he shoulder complex is most influenced! with flexion

and external rotation being the primary motions

affected.

At the elbow and wrist! no age-associated declines in

motion have been noted in absence of disease.BPHTI: PTH5201 Jul 2015 15


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%he connective tissue changes previously described can

potentially alter arthro"inematics through such

mechanisms as increased fibrous structure stiffness!

decreased chondroid structure volume and

viscoelasticity! and altered bone structure.

Although isolated arthro"inematic motions cannot be

performed volitionally! limitations can have a direct

influence on joint mobility.

Arthro%inematics



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#t has already been noted that connective tissue

structures demonstrate altered capacity to transmit

tensile and compressive loads in older adults.

%hese alterations can result in increased demands on

specific regions within joints! possibly leading to

disease.

%he changes in posture relate to alterations in joint

alignment and mobility. As a conse$uence of alignmentchange! static and dynamic demands on joints are

altered.

orce Transmission



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1ostural control during activities such as wal"ing!

position transfers! and reaching are "nown to decline

with age.

Age-associated activity limitation often culminates in

decreased participation in life events.

%he relationship also wor"s in the opposite direction!

with changes in activity and participation leading to

more sedentary lifestyles and secondary changes tojoint structure and function.

In$"uence on Acti&it' and (artici)ation



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2istory Activity and participation

3ymptoms

ccupation/Activity 2ealth condition/3urgery

(amily history

4iving Environment

3ystems eview

Joint *+amination



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5 bservational tas" analysis 5 3elf-report measures of activity and participation

5 1erformance-based measures of activity

5 &oint-specific mobility testing

our Ma,or T')es o$ Tests and Measure Categories

to Consider When Assessing Joint Mo!i"it'



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(or example! consider an older adult presenting with

impaired hip mobility that limits wal"ing.

#f this individual see"s intervention after a proximal

femur fracture! 6#mpaired joint mobility! muscle

performance! and range of motion associated with

fracture7 is an appropriate diagnostic classification. #n contrast! consider the patient who presents with hip

mobility impairment in addition to several other

ipsilateral symptom manifestations from a cerebral

vascular accident. #n this case! the musculos"eletal diagnostic

classification of the hip is secondary to a primary

neuromuscular diagnosis.

0oals

*&a"uation and -iagnosis



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emediation- Education! therapeutic exercise! and

manual therapy techni$ues

'ompensation- use of assistive devices

1revention-prevent onset or progression of problems.

Inter&ention



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Education on activity modification 8se of assistive devices

(atient education



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3tretching-the longer the hold of stretch! up to 9

seconds! the greater the benefit.

3trengthening- joint mobility improvement can be

achieved partly as a result of improved muscle

function. 3trengthening also influences joint mobility

by loading the joint structures.

Endurance training! and

+alance training-stabilization exercises! %ai 'hi! yoga

Thera)eutic e+ercise



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Age is not a contraindication to joint mobilization andmanipulation.

#n relation to older adults with osteoporosis! the use of

manual intervention techni$ues is controversial.

(or individuals with spinal osteoporosis! grade ;

mobilization )i.e.! manipulation* has been

contraindicated based on concerns for fracture ris".

Manua" Inter&ention Techni.ues



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Assistive and adaptive devices can be used ascompensatory or preventive approaches to protect joint

structure and assist with load transfer across joints.

,evices such as canes and wal"ers are useful

components to physical therapy intervention for

individuals with joint mobility impairment.

+races designed to alter joint alignment have also been

used with older adults. (indings indicate that alignmentcan be altered and joint loading decreased across

painful areas of osteoarthritic joints during gait

function.

Assisti&e/Ada)ti&e -e&ices and *.ui)ment



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3election of appropriate footwear! designed tostrategically cushion and support! may be a simple way

to provide immediate relief of symptoms by decreasing

loads across lower extremity joints.

Additionally! shoe orthotics may improve lower

extremity alignment and bring about changes in joint

loading



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3elf-eport utcome #nstruments-3*!

%he >estern ntario otator 'uff #ndex )>'* %he otator 'uff =uality of 4ife =uestionnaire )'-

=4*!

Outcomes



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Australian/'anadian steoarthritis 2and #ndex

)A83'A


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%he functional reach test %imed up and go test

(ive times sit-to-stand test

3ix-minute wal" test 3tair climb test

0ait speed

(er$ormance0Based Outcome Instruments



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Andrew A. 0uccione! ira A. >ong! ,ale Avers! @@0eriatric 1hysical %herapy! Brded! Elsevie

%imothy 4. ?auffman! &ohn . +arr! ichael 4. oran

@C 0eriatric ehabilitation anual! @nded! 'hurchill

4ivingstone

A'3s guidelines for exercise testing and

prescription.Dthedition.

#e$erences:



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Than% 'ou

joint impairment

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