Geriatrics
Dr A. Karimi
Process of EBP
• Many of the interventions we use today, have
still to demonstrate much more in the way of
effectiveness.
• They may soon change with the recent
emphasis within many health care professions
on evidence based clinical practice.
Process of EBP
• 1. identify the patient problem. Derive a specific question
• 2. Search the literature
• 3. Appraise the literature
• 4. Integrate the appraisal of literature with your clinical expertise,
experience, patient values, and unique circumstances
• 5.Implement the findings
• 6. Assess outcome and reappraise
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systematic review Clinical Guidelines
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Role of musculoskeletal system in
health and disease
• A coat rack on which the other organs are held?
• Broader context: integral and interrelated part of the
total human organism.
5 basic concepts:
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Holism
Neurologic control
Circulatory function
Energy expenditure
Self regulation
Holism
• Musculoskeletal system should be evaluated
in every patient.
• Our role is to treat patient not to treat
disease.
Neural control 1
• 1) Somato-somato reflex pathway
• 2) Viscero-visceral reflex arc (pilomotor activity of the
skin, vasomotor tone, secretomotor activity of the sweat glands)
• 1 and 2 are interrelated: somatic afferents influence visceral efferents and
visceral affferents influence somatic efferents.
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Ascending and descending pathways from other spinal segments
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And from higher centers of the brain
Neural control 2
• Autonomic nervous system (ANS)
• Parasympathic: some cranial nerves (III, VII, VIII, IX, X and s2, s3, s4).
• The largest parasympathic nerve is Vagues which innervate all of
the viscera and glands and smooth muscles of these organs.
• Sympathetic: preganglionic neurons originating from T1-L3 and
collateral ganglia.
• Sympathetic fibers innervate all of the visceral (segmentally):
visceral above diaphragm from preganglionic fibers above T4 and
T5, viscera below diaphragm from preganglionic fibers below T5 :
Neural control 2
• Through this segmental organisation is the correlation of
certain parts of musculoskeletal system and certain internal
viscera.
• Musculoskeletal system only receive sympathetic division.
• Nervous system are intimately related to endocrine system:
neuroendocrine control.
• By knowledge on neurotransmitters, endorphins,
enkephaline, … we now understand why biomechanical
alteration of musculoskeletal system can alter bodily function.
Neural control 2
• Nervous system is a powerful trophic function as
well, complex protein and lipid substances are
transported antegrade and retrograde along neurons
and across synaps of the neuron to the target end
organ.
• Alteration in the neurotrophin transmission can be
detrimental to the target end organ.
Circulatory function
• The cell is dependent for its function to delivery of oxygen and
glucose, and other substances being supplied by the artery.
• The arterial system has a powerful pump:
• Myocardium of the heart, this pumping is controlled by CNS
particularly ANS.
• Vascular tree receives its vasomotor tone control by sympathetic
division of ANS.
• Anything that interferes with sympathetic , segmentally , can
influence vasomotor to a target end organ.
• Arteries are also encased in facial compartments of the body, and
are subject to compressive and tensional stress that can interferes
with its delivery.
Circulatory function
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End products must be removed.
Venus and lymphatic system are responsible, not a cardiac pump, instead
depending to musculoskeletal system and large muscles of the extremities.
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The major pump however is diaphragm. Its attachment to musculoskeletal system,
negative intrathoracic pressure which provide sucking action of venous and
lymphatic return from vena cava and cisterna chyli. Attachments of diaphragm to
musculoskeletal system also its innervation by phrenic nerve from cervical spine
can interferes to its function, venous and lymphatic return, accumulation of end
products in the cell, and its recovery from injury or disease.
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Lymphatic function, thoracic inlet, and its fascial continuity affect lymph vessels.
Maximal function of the musculoskeletal system affect the circulatory system and
the function of the cells through the body.
Energy expenditure
• Musculoskeletal system is 60% of human
organism and the major expender of body
energy.
• Any increase in activity of MS system cause internal viscera to
develop and deliver energy
• Dysfunction alters the efficiency of MS system and cause increase
demand for energy
• Ankle sprain in a chronic congestive heart failure patient cause
rapid deterioration of the compensation because of increased
energy demand by the alter gait of the sprain ankle:
• We should treat MS system (ankle sprain) not dosage of medication
controlling congestive heart failure
Energy Expenditure
• Restriction of one major joint in a lower
extremity can increase the energy expenditure
of normal walking as much as 40% and for two
major joints restriction it can increase as much
as 300%.
Self Regulation
• thousands of self regulating mechanism operative within the body
at all times
• If alter by disease or injury they should be restored.
• Any foreign substance is given to a patient the beneficial and
detrimental potential must be considering
• Multiple medication in hospital environment and the action of
interaction of each must be understood
• One of the top ten leading causes of death in the United States
osteoporosis
• Porous bone.
• A systemic skeletal disease charecterized by low bone
mass and microstructural deterioration of bone tissue
with a consequent increase in bone fragility and
suceptibility to fracture.
• Disease not normal aging process (preventable and treatable)
• 2. suceptible to FX not occurance of FX (diagnosis and
treatment before FX)
Epidemiology and economics
• 25 million citizen in US, 1.5 million FX annually.
• 2 in 5 female and 1 in 8 male sustain osteoporotic FX
in their lifetime.
• Medical care cost: 13.8 billion annually
• By the year 2020, treatment of its sequelae will cost
30-60 billion per year.
prevention
• Adequate calcium and vitamin intake as well as exercises
during adolescent years.
• Prolonged Immobilization leads to irreversible bone loss.
• Weight bearing exercise prevent osteoporotic FX
• Walking program of 2 to 3 miles three days per week is
recommended.
Treatment
• Range from simple behavior modification to extensive drug therapy
• Multidiciplinary approach should be used.
• education by team or individual clinician.
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Standard treatment regimen:
Calcium and vitamin Doptimization
An exercise program
Avoidance of tobacco and alcohol use
Additional treatment may be:
Prevention strategy, physical therapy, medication
PT
• Muscle strength, endurance and balance
• Reduce risk of fall, and maintain mobility and function.
• In vertebral Fx: 1 week bed rest
• Then exercise include stretching and back extensor
strengthening
• Generalized strengthening exercise lead to
coordination and prevent falling.
PT
• Long term program of physical activity, include
weight bearing and aerobic exercise.
• Safe movement: good body mechanics
• In some cases Assistive device to keep mobility and
prevent falling
• Balance assessment and training.
• Decrease the medication by modalities such as pain.
PCP
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Andrew Still:
• Against drug
• Wendell Holmes: if all of the materia medica were thrown to
the oceans, it will be all the better for mankind, and worse for
the fishes
• One of the first duties of physicians is to educate the masses
not to take medicine.
Vertebra-bone
• Morphology: Cortical bone, cancellous bone
• Cortical: outer shell
• Cancellous: epiphyseal and metaphyseal regions of long bones
and throughout the interior of short bones.
• Trabecula- wedge shaped compression fracture
• The strength of a bone is related directly to its density
Low back pain in elderly
Structure versus function
Radiologic anomalies
Cause and effect of anatomic coincidence?
• Red hair logic!
• Anesthetic blocks or specific treatment should
relive the pain.
Disk prolapse?
End of search for cause of back pain?!
Stimulation of PLL and dura can produce back pain.
60% back pain while 3-5% disk prolapse
Disk degeneration
• Iresistable X-ray and MRI changes
Aging or Degeneration?
• We know about gross changes, histology,
biochemistry, and biomechanics of disk.
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Increase changes with age
Degenration
How to distinguish them: aging or degeneration?
Adams (2002): normal aging: biochemical and
functional changes in the composition of disk
• Pathologic Degeneration: structural changes
• But they go together
cause and effect
Van Tulder (1997) compared X-ray in people with or
without symptoms: Weak association between
degenerative changes and back pain,
But
1. Asymptomatic people show the same changes. 2.
They had the symptoms in the
past and back pain at present.
No cause and effect.
MRI
• Nachemson: Review of 14 studies of MRI in
normal asymptomatic people
• Disk bulging, annular tear, narrowing,
degeneration, stenosis
increased with
age.
• MRI is useful for Red flag conditions but don’t
help diagnosis of back pain.
X-ray and MRI
• There is strong evidence that X-ray and MRI
findings have no predictive value for future low
back pain or disability.
• Back pain does not increase with age but peaks in
middle life.
• Patients with LBP and normal, asymptomatic
people show similar age related findings in their
disks.
Disk degeneration
• Adams (2002):
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Links between back pain and mechanical loading and aging and dysfunction
and degeneration are complex and require further research.
• That research must include clinical data.
• Do not fall in to the trap of blaming back pain on
incidental radiographic findings.
• Regard them as normal, age related change, like
gray hair.
Spinal stenosis
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Effects of aging
Narrowing of spinal canal, nerve root canal, and intervertebral foramina, all of which cause nerve
root entrapment.
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It can be central or lateral, congenital or acquired.
Etiology:
Degenerative changes in facets, intervertebral discs and soft tissues decrease the size of spinal
canal. (congenital or degenerative)
Narrowing due to soft tissue: disc protrusion, fibrotic scars, or joint swelling.
Bony narrowing: osteophyte formation or spondylolisthesis.
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Patients feel back pain, transient motor deficit, tingling, and intermittent pain in one or both legs.
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Worsened by standing or walking (neurogenic cludication)
Relieved by sitting
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Pain of neurologic claudication does not relive quickly by rest (may persist for several hours) despite
vascular claudication which rekieve quickly with rest).
Neurologic symptoms
• Radiculopathy:
• When protrusion compress against cord or root.
• When decrease disk height(DJD) or tranlation of vertebra cause foraminal
space.
• When inflammatory response to a trauma, DJD, disease cause edema
and stenosis.
• When facet j subluxes and nerve root impinged between facet and pedicle
• Osteophyte growth
• spondylolisthesis., scar, adhesion formation after injury or surgery..
Spinal stenosis-Treatment
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Physiotherapy is directed at increasing mobility:
Flexion-distraction mobilizations, manual streching exs, or traction)
Improving posture to reduce lordosis (lordosis tends to decrease the size of
intervertebral foramen and increase the symptoms).
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Lumbar spinal capasity and dural sac was enlarged during flexion and decreased
with extension.
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Modification of activities of daily living,
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Achieving ideal lumbar posture through the principles of dynamic lumbar
stabilization,
Spinal stenosis-treatment
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Endurance Exs,
Back school,
Stretching
Techniques for unloading the spine
Regaining neural mobility
Side posture spinal manipulations (for lateral
recess stenosis and central canal stenosis)
Spinal stenosis-treatment
• NSAIDs to control the symptoms
• Lumbosacral corset to prevent excessive movement
• In some patients symptoms may be relived by surgical correction:
• When obvious motor and sensory symptoms are present.
• Most patients respond to physical and pharmacological interventions
without requiring surgery.
points
• Cycling to differentiate claudication
• Findings such as hairless lower extremities, coldness of the feet, or absent
pulses are signs of peripheral vascular disease (PVD).
• Sensory defects in a stocking-glove distribution are more suggestive of
diabetic neuropathy.
Active role of patient
“Most current treatment are really only dealing with symptoms and giving
short lived relief. They are usually received by a passive patients, from a
therapist who very much gives a treatment.”
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DJD /Cervical spondylosis
• Chronic and progressive degeneration of facet j. or
intervertebral disc.
• Cause: unknown but may be accelerated by trauma, overuse,
genetic predisposition. Heavy Lifting, smoking, diving, driving
and working with vibratory equipment.
• Usually affect C5-C7, facet joints and disc.
• It is a normal aging process: fissuring of disc begins in first
decade, progress by 20 to 30 years of age. Mostly
asymptomatic unless sustained extension or FLX (posture).
DJD/Lateral canal stenosis
• Lateral canal stenosis or cervical spondylosis cause
radiculopathy and cause neck pain, shoulder pain, radiating
pain in arm, numbness in extremity or muscle weakness.
• Cause: Degenerative process: hypertrophic spurs along
margins of the disc, luschka j, articular facet j. often
associated with hypertrophy of lig. Flavum.
• If it compresses spinal canal: central stenosis, leads to
myelopathy
• If it narrows intervertebral foramen: lateral stenosis, leads to
radiculopathy.
Paradox of DJD
• Lateral stenosis for many years without symptoms, suddenly
neurologic signs and symptoms, treatment with traction or
passing of time, resolve signs.
• We did not change the bony change, why suddenly appeared
and disappeard?
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Complex: ligatures around the nerve root in surgery:
Healthy nerve root: pressure caused no pain and paresthesia
Injured NR: anesthesia, diminished reflex, motor weakness
Ischemic nerve root: light pressure produced immediate pain
and paresthesia in the arm.
Paradox of DJD
• A model: unusual activity like ext. and sidebending cause
nerve root to swell, impingement of blood supply to nerve
root cause extremely sensitivity.
• When pressure is removed by traction or positioning, swelling
diminish and symptoms disappear.
• That is why compression of nerve root and ischemic, nerve is
more sensitive to pressure at shoulder, wrist or carpal tunnel.
Evaluation
• Straight forward:
• Age over 50, X-ray, CT, MRI, hypomobility of lower cervical spine,
(loss of EXT. and rotation cause difficult driving), forward head
posture, kyphotic of cervicothoracic spine.
• Pain is sever at morning which improves with activity.
• Area over the fecet j are tender
• Compressure worsens symptoms and distraction may relieve them.
• Symptoms stabilize and lessen in time.
• May be: diminish reflex, motor weakness, anesthesis, atrophy
because of osteophyte irritation and compression of nerve root.
Treatment
• Successful in uncomlicated DJD:
• ROM exs, NSAIDs, modalities, cervical pillow.
• Cervical traction, positional traction in nerve root pain (FLX
and sidebending of head away from painful side). Mobilization
of hypomobile segments, self mobilization Exs. Segmental
stabilization for hypermobile (midservical).
• Forward head posture: bilateral suboccipital release, soft
tissue manipulation, teach to keep neck in neutral position by
towel under the occiput. Active nodding, and EXT. in neutral
position, Avoid long extension, avoid working above the head.
Headache
• A common complaint, 85%-95% of adult population in USA
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experience it in 1-year period.
Benign or nonbenign Primary or secondary
Primary: result of underlying structural abnormality or disease process
Secondary: result of underlying pathologic process.
Benign: post traumatic, musculoskeletal (tension headache, cervical
headache, occipital headache), vascular (migraine), disease of sinus
(sinusitis), disease of eye, infection and inflammation of the ear.
C2
• Trigeminal: start from Pons, pass midbrain, decend to C3, C4
then returns up
• Send a branch to ear (tensor tmpani)
• Impairment of C2 cause headache, facial pain, ringing ear so
C2 could be a source of headache
C2-Trigeminal
Cervicogenic headache
• Cervical headache (definition): headache arising from
dysfunction or inflammation of musculoskeletal
structure of upper cervical spine (AO, AA, C2-C3 facet
j. or disk, muscle, lig or capsule which cross these
joints).
• Most common cause: DJD or trauma (wiplash),
sudden or gradual (repetitive occupational, postural).
More common with low velocity crashes.
Causes
• Involvement of greater occipital nerve:
supplies
posterior aspect of skull, vertex and extrasegmental
headache. The nerve is compressed by the muscles passed
the joint or altering the joint mechanics. It passes through the
semispinalis muscle and in many cases the upper trapezius.
• Symptoms: pain in occipital, retroorbital, temporal and
parietal area.
Extrasegmental headache
• Extrasegmental headache (dural headache):
results from compression of dura at any cervical level. Cranial
and cervical dura is innervated and could be a source of pain.
• The pain radiate from midneck to up, forehead, and behind
one or both eyes. Even downward radiation to scapular area.
• It occurs after trauma, wiplash, epidural block,
lumbar puncture.
Evaluation
• Dull aching pain of moderate intensity that begins in
the neck and spreading forward. Usually:
• Unilateral, or dominates on one side.
• When sever may felt on contra lateral side.
• May radiate to one or both eyes.
• Signs in neck (reduced ROM), ipsilateral shoulder,
arm sensation or pain.
Evaluation
• Aggravating factors: certain neck movements, sustained
posture (such as Ext) and abnormal posture. Sometimes weakness and
loss of endurance of upper cervical muscles (FHP).
• Origin of radiate pain to head: C0-C1, C1-C2, C2-C3 and TMj. These should
be examined:
• Active, passive and resistive movement and palpation to provoke
symptoms. Or find responsible dysfunction
Assessment
• Postural assessment, manual exam of cervical and
thoracic J., selected muscle length, activation and
endurance capacity of neck Flx and lower Trapezius .
• FHP, ROM of shoulder j, Jaw movement
• Upp. cervical J exam with passive, accessory
movement for quantity and quality of movement and
reproduction of symptoms.
Assessment
• Myofacial: should be examined as a direct source of pain
due to trauma or trigger points. (TP in upp trapez, SCM,
masseter, temporalis, other muscles of face and neck).
• As an indirect source: length and strength.
• Imbalance in Length and strength of muscles:
cause mechanical stress on other pain sensitive tissues.
• Low strength and endurance of upp cervical FLX, tightness of
upp cervical Ext. (sub occipitalis, upp trapezius)
• Tight pectoral and weakness of middle and lower trapezius:
(imbalance of shoulder girdle)
Dural irritation
• Dural headache: does not get better with
manual treatment.
• Perform tension test: SLR, slump test to
reproduce pain.
Treatment
• Accurate diagnosis of a cervical musculoskeletal origin of
headache is the key success of manual therapy.
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Passive mobilization and manipulation
Posture
Mobility: Generalized ROM exs, segmental mobility
Muscle stretch, soft tissue manipulation (upp cervical
Extensors) to address myofacial restriction and trigger points.
• Re education of neuromuscular control of deep FLX
Treatment 2
• Irritability of dura:
• Movement to mobilize nervous system
• Sensitizing maneuver such as slump test
• Identification of headache triggers: caffeine, red wine, food
products, emotional stress, changes in sleeping pattern.
Deconditioning
• Health and fitness depend on continued use:
Use it or lose it.
Normal musculoskeletal function depends on: movement, physical activity,
and regular exercise.
They are essential for development, maintenance and continued function of
musculoskeletal system throughout life.
Box 9.6
Cont
• They stimulate and maintain bone and mus.
Mass and strength, aid nutrition, maintain
articular cartilage and joint range, and
improve endurance and coordination.
• They promote neuromuscular function and
increase pain tolerance.
Disuse
• Immobilization leads to deterioration of the
musculoskeletal, cardiovascular, and CNS:
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Disuse syndrome or
deconditioning
Deconditioning
• In chronic low back pain: atrophy of erector spine and increase of fat.
• Local wasting of Multifidus: 30% reduction in cross sectional area.
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localised, segmental, unilateral and correspond to the level and side of
symptoms.
• Suggested: Due to segmental inhibition instead of general effect of disuse.
• Symptoms settles but they don’t recover spontaneously: recurrence
• Stabilizing Exs. And multifidus: pain relief in CLBP
Movement impairment syndrome
• Altered pattern of movement:
• Rotation Ext. syndrome.
Thank you