Geriatric Musculoskeletal Exam

1. Geriatric Musculoskeletal Exam Aubrey L. Knight, MD Edited by Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012

2. Objectives • Execute the adult musculoskeletal examination. • Classify the common musculoskeletal conditions and risks inherent with aging. • Identify methods of examination of frail elderly individuals. • List the values as well as the risks of OMM in the elderly population.

3. Common Musculoskeletal Conditions in the Aging Population • Osteoarthritis • Osteoporosis • Rheumatoid Arthritis • Polymyalgia Rheumatica • Adhesive capsulitis • Spinal Stenosis • Crystal-associated arthritides

4. Normal & Arthritic Joints

5. The shoulder exam

6. Shoulder strength testing Rotator cuff Supraspinatus

7. Glenohumeral laxity and apprehension Shoulder apprehension Neer’s Test

8. Impingement tests Hawkins-Kennedy Test Horizontal adduction with internal rotation

9. Range of Motion Internal rotation External rotation Forward flexion

10. Knee Pain

11. Hip Pain- Pathology by location

12. Hip Exam

13. Hip Fractures

14. Evaluation Tools • Activities of Daily Living • Tinetti Gait and Balance Tool • Get up and go

15. Activities of Daily Living • There are 4 ADL’s • Dressing • Mobility (transferring oneself) • Feeding oneself • Toileting (some split this into 3: grooming, bathing, and continence) • Each ADL is graded on level of dependence • Independent • With assistance • Unable to perform

16. Tinetti Balance Assessment Tool 16 points in 10 dimensions of balance: • Sitting balance: Leans or slumps = 0; Steady = 1 • Rising from Chair: Unable = 0; With arms = 1; Without arms = 2 • Attempts to arise: Unable = 0; >1 tries to do it = 1; 1 try with success = 2 • Initial Standing Balance: Unsteady = 0; Steady with support = 1; Steady without support = 2 • Standing balance: Unsteady = 0; Steady with support = 1; Steady without support = 2 • Balance with a nudge: Begins to fall = 0; Staggers = 1; Steady = 2 • Closed eyes: Unsteady = 0; Steady = 1 • Turning 360° smoothness: Discontinuous = 0; Continuous = 1 • Turning 360° steadiness: Unsteady = 0; Steady = 1 • Sitting down: Unsafe = 0; Using arms = 1; Safe and smooth = 2

17. Tinetti Balance Assessment Tool 12 points in 8 dimensions of gait: • Initiation when told to go: Hesitancy = 0; No hesitancy = 1 • Step length: To other foot = 0; Past other foot, R = 1 & L = 1 • Foot clearance: Foot drop = 0; Clears the floor,, R = 1 & L = 1 • Step Symmetry: Unequal = 0; Equal = 1 • Path: Marked deviation = 0; Mild deviation or with aid = 1; Straight without aid = 2 • Trunk: Marked sway or with aid = 0; No sway, but flexed knees or back or aid for stability = 1; No sway = 0 • Walking stance: Heels apart = 0; Heels close = 1 Score: balance n/16, gait n/12, and total n/28 See geriatrics web site

18. Get up and go 1. Rise from sitting position 2. Walk 10 feet 3. Turn around 4. Return to chair and sit down Interpretation Patient takes <20 seconds to complete test Adequate for independent transfers and mobility Patient takes >30 seconds to complete test Suggests higher dependence and risk of falls

19. OSTEOARTHRITIS

20. OsteoarthritisBackground Information • Osteoarthritis is the most common type of arthritis • Degenerative joint disease is a term synonymous with osteoarthritis: DJD, OA. • Osteoarthritis is a joint disease that primarily affects the cartilage. • Cartilage acts as a lubricating surface and a “shock absorber” for bones. • In osteoarthritis the layer of cartilage breaks down and wears away.

21. DJD of the Hands • Heberden's nodes, bony enlargements of the distal interphalangeal joints, are commonly seen. • A similar process at the proximal interphalangeal joints leads to Bouchard's nodes. • Often, these nodes develop gradually, with little or no discomfort. However, they may present acutely with pain, redness, and swelling, sometimes triggered by minor trauma. • Gelatinous dorsal cysts filled with hyaluronic acid may develop at the insertion of the digital extensor tendon into the base of the distal phalanx.

22. Osteoarthritis MCP PIP DIP Heberden’s node Bouchard’s node Note the involvement of the DIP followed by PIP and relative sparing of the MCP joints.

23. OA of the base of the thumb Swelling, tenderness, and crepitus on movement of the joint are typical. Osteophytes may lead to a "squared" appearance of the thumb base. In contrast to Heberden's nodes, which usually do not interfere significantly with function, thumb base OA frequently causes loss of motion and strength. Pain with pinch leads to adduction of the thumb and contracture of the first web space, often resulting in compensatory hyperextension of the 1stMCP joint and swan-neck deformity of the thumb.

24. Risk Factors for Osteoarthritis • Age- the most powerful risk factor • By age 65, 68% have radiographic evidence of OA • Female gender - especially hand and knee OA • Genetic factors- not well worked out, but there is a correlation • Joint trauma • Repetitive stress • Obesity - highest correlation with knee OA

26. Spine OA • Degenerative disease of the spine can involve the • apophyseal joint • intervertebral disks • paraspinous ligaments • Spondylosis refers to degenerative disk disease. • The diagnosis of spinal OA should be reserved for patients with involvement of the apophyseal joints and not only disk degeneration. • Symptoms of spinal OA include • localized pain and stiffness • Nerve root compression by osteophytes blocking neural foramena • prolapse of a degenerated disk • subluxation of an apophyseal joint causing radicular pain and motor weakness.

27. Degenerative Changes in the Spine: Definitions • Apophyseal joints – the facet joints joining the vertebral bodies posteriorly. This is where DJD occurs in the spine. • Spondylosis- ankylosis (stiffening) of the vertebrae (this term is used generally to refer to any degenerative back problem) • Spondylolysis-a fracture through the pars interarticularis, between the facet joints at the posterior part of a vertebra • Spondylolisthesis- forward movement of the body of one vertebra on the vertebra below it • Spondylitis- inflammation of one or more of the vertebral bodies (infection [TB] or inflammatory disease [RA])

28. DJD of the Knee • DJD of the knee may involve the medial or lateral femorotibial compartment and/or the patellofemoral compartment • Palpation may reveal bony hypertrophy (osteophytes) and tenderness. • Joint movement commonly elicits bony crepitus. • DJD in the medial compartment may result in a varus (bow-leg) deformity • DJD in the lateral compartment it may produce a valgus (knock-knee) deformity. • A positive "shrug" sign (pain when the patella is compressed manually against the femur during quadriceps contraction) may be a sign of patellofemoralDJD.

29. OSTEOPATHIC MANUAL MANIPULATION IN THE ELDERLY

30. OMM in the frail elderly • The basic tenets of Geriatric Medicine and of Osteopathic Medicine are very similar • Function • Multidisciplinary, holistic approach • No absolute contraindication based on age alone • Individualize • Allow your examination to guide you • OMT is, in many cases, safer that other therapies we use on a daily basis

31. OMM in the frail elderly • Be prepared to “adjust” your approach and expectations to fit the special needs of the population. • Clinically apparent osteoporosis should serve to discourage the use of certain high-thrust, high-velocity techniques. • Those with high risk of stroke should be approached more cautiously.

32. On the other hand… • Range of motion, respiratory, muscle energy, myofascial techniques are particularly well suited to the geriatric population. • The judicious use of these techniques might serve to provide relief without the use of potentially dangerous medications.