General guidelines and principles for developing exercise interventions for patients with soft tissue lesions were presented in the previous chapter. The purpose of this chapter is to present principles of management of selected pathologies that affect joints, connective tissue, and bone. Characteristics of arthritis, fibromyalgia, myofascial pain syndrome, osteoporosis, and fractures are described in conjunction with the effects of therapeutic exercise on impairments associated with these pathological conditions.
Arthritis is inflammation of a joint. There are many types of arthritis, both inflammatory and noninflammatory, that affect joints and other connective tissues in the body. The most common types treated by therapists are rheumatoid arthritis and osteoarthritis. Arthrosis is limitation of a joint without inflammation. Unless the cause of the joint problems is known, such as recent trauma or immobility, medical intervention is necessary to diagnose and medically manage the pathology. Traumatic arthritis may require aspiration if there is bloody effusion.
The therapist examines, integrates, and evaluates the presenting information and then develops a plan of care by selecting interventions to safely meet the goals. Knowledge of the underlying pathology is important in order to understand the prognosis and safely manage the patient's impairments, activity limitations, and participation restrictions.61,75
Clinical Signs and Symptoms
Signs and symptoms common to all types of arthritic conditions generally include the following.
The patient usually presents with signs typical of joint involvement that include a characteristic pattern of limitation (called a capsular pattern), usually a firm end-feel (unless acute—then the end-feel may be guarded), decreased and possibly painful joint play, and joint swelling (effusion).79 Additional signs and symptoms may be present depending on the specific disease process. Table 11.1 summarizes the characteristic signs and symptoms of osteoarthritis and rheumatoid arthritis.
TABLE 11.1Comparison of Osteoarthritis and Rheumatoid Arthritis6,23,68,140 |Favorite Table|Download (.pdf) TABLE 11.1 Comparison of Osteoarthritis and Rheumatoid Arthritis6,23,68,140
|Characteristics ||Osteoarthritis ||Rheumatoid Arthritis |
|Age of onset ||Usually after age of 40 ||Usually begins between age 15 and 50 |
|Progression ||Usually develops slowly over many years in response to mechanical stress ||May develop suddenly, within weeks or months |
|Manifestations ||Cartilage degradation, altered joint architecture, osteophyte formation ||Inflammatory synovitis and irreversible structural damage to cartilage and bone |
|Joint involvement || |
Affects a few joints (usually asymmetrical); typically:
—DIP, PIP, 1st CMC of hands
—Cervical and lumbar spine
—Hips, knees, 1st MTP of feet
Usually affects many joints, usually bilateral; typically:
—MCP and PIP of hands, wrists, elbows, shoulders
—MTP, talonavicular and ankle
|Joint signs and symptoms ||Morning stiffness (usually < 30 min), increased joint pain with weight-bearing and strenuous activity; crepitus and loss of ROM ||Redness, warmth, swelling, and prolonged morning stiffness; increased joint pain with activity |
|Systemic signs and symptoms ||None ||General feeling of sickness and fatigue, ...|