deddy musculoskeletal.ppt
TRANSCRIPT
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 1/59
Musculoskeletal Disorders in
Elderly
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 2/59
Objectives
• Falling: list causes and prevention
strategies in the individual
•Define deconditioning and its relation torest
• Briefly review osteoporosis
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 3/59
etting the scene!
• "n #$ year old wo%an falls in the kitchen&
injuring her right ar%'
• Believing it to be broken& she seeks %edical
care& and is reassured that there is no fracture'• (eturning ho%e she )s afraid to walk and
despite encourage%ent fro% her fa%ily& she
takes to her bed'• One week later she beco%es incontinent and
unable to walk!
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 4/59
Falls in older people
• "bout *+, older people fall each year
• Many healthy younger people also fall
each year but %ost falls areinconse-uential
• , principal reasons for falling
enescent gait )llnesses
Environ%ental ha.ards
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 5/59
Falls in older people
Senescent gait
• lower gait speed
• /ider base of support• 0ower step height
• 1entre of gravity forward
• 0ess ar%swing
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 6/59
)llnesses that cause falls in older
people
0oss of consciousness
• yncope or presyncope 2Ortostatic
3ypotension& arrhyth%ias& blocks!4
• ei.ures 2%ay be akinetic!4
• Endocrine 2hypoglyce%ia!4
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 7/59
)llnesses that cause falls in older
people
5eurological disorders
• Move%ent disorders 2 6arkinson7s
disease& !4• 3e%iparesis and spasticity
• 6eripheral neuropathy 2%otor& sensory''4
• "ta8ia 2 central or peripheral!4• 9estibular disorders
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 8/59
)llnesses that cause falls in older
people
1ognitive disorders
• 1onditions which affect judge%ent
2de%entias& depression''4• 1onditions that affect spatial orientation
2strokes& posterior degenerations!4
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 9/59
)llnesses that cause falls in older
people
Musculoskeletal disorders
• 6ainful lower li%b conditions
• (estriction of joint %ove%ent• Muscular weakness 2sarcopenia& disuse&
%yopathy!4
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 10/59
Muscle and age
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 11/59
Muscle %ass and ageehayias ; et al' "% ; 1lin 5utr *<<=>??:<@A
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 12/59
"ging and loss of %uscle
%ass+strength 2sarcopenia4
• Muscle strength declines by *C per
decade in ?th and =th decade
• Declines by ,@C per decade thereafter
illewich& 0' ;ournal of "%erican 1ollege of urgeons&$@@?& $@,:
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 13/59
)llnesses that cause falls in older
people
pecial senses
• 9ision 2acuity& depth perception!4
• 3earing
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 14/59
Drugs that cause falls in older
people
• "ntihypertensives
• 6sychotropic agents 2antidepressants&
Ben.odiacepine& antipsychotics!4
• "nticholinergics
• "nd %any others
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 15/59
Environ%ental causes of falls
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 16/59
1alculating risk of fallsinetti M et al 5 Engl ; Med *<##> ,*<:*=@*
• 6rospective ) year study
• ,,? co%%unity dwelling people over aged
=
• 1areful %onitoring of falls& detailed
e8a%ination for risk factors
• (isk of falls #C with no risk factors• (isk of falls =#C with A or %ore risk
factors
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 17/59
1alculating risk of falls
(isk factor (elative risk of falling
edative drugs $#',
1ognitive i%pair%ent '@Disability of lower li%b ,'#
6al%ar %ental refle8 ,'@
"bnor%al balance or gait *'<
Foot proble% *'#
inetti M et al 5 Engl ; Med *<##> ,*<:*=@*
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 18/59
1onse-uences of falls in older
people
Fractures ?C
oft tissue injuries $AC
Fear of falling $@C
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 19/59
1onse-uences of falls in older
people
Fear of falling
)%%obility
Muscle weakness
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 20/59
Bed rest and %uscle strength
Muscle strength 2M914 lost at
$C per day
3arper G 0yles' ;"H *<<#> ,?: *@A=
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 21/59
0ower li%b %uscle strength and
unloading for *@ days "cta 6hysiol cand *<<?> *=:?,
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 22/59
DECONDITIONING:
a simple definition
he adverse physiological
conse-uences of
too %uch rest
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 23/59
DE1O5D))O5)5H
1onse-uences
• 1onversion of an individual barely able to
rise fro% a chair to a bedridden state
• (esulting i%%obility pro%otes
incontinence
• )ncreases risk of falls
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 24/59
DE1O5D))O5)5H
1onse-uences
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 25/59
Bedrest: effects on cardiovascular
syste%
(eduction in plas%a volu%e
(educed stroke volu%e and cardiac
output
Orthostatic hypotension
(esults in falls& syncope
1onvertino 9 et al' "% ; Med ci $@@=> ,,A: =$
illewich 0' ; "% 1oll urg $@@?> $@,:
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 26/59
6las%a volu%e and bed rest1onvertino 9 et al' "% ; Med ci $@@=> ,,A: =$
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 27/59
DE1O5D))O5)5H
the essence
• 0oss of %uscle strength
• "ltered cardiovascular responses
But there is %ore& %uch %ore!
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 28/59
Bed rest and calciu% balance
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 29/59
Bone Mineral 1ontent and rest(ittweger ; et al' ; 6hysiol $@@?> ==: ,,*
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 30/59
DECONDITIONING
• Muscle weakness
• 1irculatory changes
• Many other conse-uences includingnegative calciu% balance 2effects on bone4catabolic state 2effects on nutrition4pressure effects on skin 2risk of ulceration4
insulin resistance& infla%%atory responsesetc'
• 1hanges %ay occur soon after rest
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 31/59
DE1O5D))O5)5H
" co%ple8 process of physiological
change following a period of inactivity&bedrest or sedentary lifestyle& which
results in functional losses'
Brand 1 et al' $@@, www'%h'org'au+1linicalEpide%iology
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 32/59
DECONDITIONING:
Similar terms
• Functional decline
• Dysfunction syndro%e• /eightlessness effects
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 33/59
/hat do they have in co%%onI
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 34/59
i%ilarities!
Bedrest paceflight
Orthostatichypotension
)ncreased
Balance& stability (educed
1oordination& gait (educed
Muscle strength (educed
M9 @2 (educed $@$C
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 35/59
i%ilarities!
Bedrest paceflight
Orthostatichypotension
)ncreased )ncreased
Balance& stability (educed (educed
1oordination& gait (educed (educed& wide
Muscle strength (educed (educed
M9 @2 (educed $@$C (educed *$C
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 36/59
o& how do we treat the lady who
fell at ho%eI
• (esistance training increases %uscle
strength and volu%e by *C per day
2re%e%ber that it is lost at $C per day4
•More i%portantly& resistance trainingincreases spontaneous activity
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 37/59
Effect of # weeks resistance
e8ercise on spontaneous activity
Multi factorial intervention to reduce
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 38/59
Multi factorial intervention to reduce
falls
• a%e co%%unity dwelling cohort
• )ntervention by protocols targeting riskfactors identified in previous study
• )nvolving nurse& physiotherapist G
physician
inetti M et al 5 Engl ; Med *<<A> ,,*:#$*
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 39/59
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 40/59
Multi factorial intervention to reduce
falls
inetti M et al 5 Engl ; Med *<<A> ,,*:#$*
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 41/59
Multi factorial intervention to reduce
falls
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 42/59
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 43/59
Osteoporosis and fractures
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 44/59
Osteoporosis definitions
• Osteopenia score * to $'
• Osteoporosis score $'• evere osteoporosis score$' plus
fragility fracture
reva ence o steopen a an
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 45/59
reva ence o steopen a anOsteoporosis 2;a%%u4
/o%en7s clinic G welfare
har%a et al' )nd ; Med ci $@@?> ?@24:*#,
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 46/59
Osteoporosis: (isk factors
• Hender 2* in A wo%en& * in # %en over age @4
• "ge
• Jnderweight
• Early %enopause• 1aucasian or "sian
• Diet 2low calciu%&I high ani%al protein& coffee'''4
•)nactivity• %oking
• Medications 2anticonvulsants& corticosteroids''4
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 47/59
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 48/59
9ita%in D levels in "ndhra 6radesh
• 1onvenience sa%ple
• <A, healthy urban adults
• $@ healthy rural adults
9ita%in D levels:
• Deficient K $@ ng+%l 2@ n%ol+04
• )nsufficient $@,@ ng+%l 2@= n%ol+04
• ufficient ,@ ng+%l 2= n%ol+04
3arinaryan 1 et al' )ndian ; Med (es $@@#> *$=:$**
5 t i l 63 d 9it i D
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 49/59
5ter%inal 63 and 9ita%in D
levels
3arinaryan 1 et al' )ndian ; Med (es $@@#> *$=:$**
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 50/59
9ita%in D levels: "ndhra 6radesh
3arinaryan 1 et al' )ndian ; Med (es $@@#> *$=:$**
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 51/59
Bone %ineral density and fracture risk
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 52/59
reat%ent of osteoporosis
• "de-uate calciu% in diet 2total *@@ %gele%ental calciu% per day4
• 9ita%in D #@@*@@@ units daily
• Bisphosphonates 2%oving towards %orepotent drugs in 5" alendronate&risedronate& .oledronic aci
• (alo8ifene 23(4• riperidide 2634
• 1alcitonin
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 53/59
)ndications for bisphosphonates
• BMD scores tscore less than $ or $'
•Over age = with fragility fracture
• 1hronic corticosteroid use , %onths
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 54/59
(isedronate
•3arris & /atts 5B& Henant 3& et al' ;"M" *<<<'
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 55/59
(alo8ifene
Ettinger B et al ;"M" *<<<
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 56/59
1alcitonin
1hesnut 13 et al "% ; Med $@@@
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 57/59
6rogress in osteoporosis
• (ate of hip fractures is stabili.ing
• 6ublic awareness is increasing
•6rogra%s being established 2e'g' FO6Fracture: think osteoporosisL4
• 3ope to see as a historical disease in a
generation 2or two4
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 58/59
JMM"(
• Falls are co%%on and serious: structuredapproach to investigation and%anage%ent
• Deconditioning is co%%on and serious:aggressive %obili.ation is essential
• Osteoporosis is a loo%ing threat: %ost
i%portant point: 9ita%in D supple%ents forall older people #@@*@@@ units daily atleast
7/23/2019 Deddy musculoskeletal.ppt
http://slidepdf.com/reader/full/deddy-musculoskeletalppt 59/59
3ow did we doI