Musculoskeletal and Neurologic Disorder Essay

Clay is a 7 year old male who present in your office with complaints of right thigh pain and a limp. The pain began approximately 1 week ago and has progressively worsened. There is no history of trauma. Physical examination is negative except for pain with flexion and internal rotation of the right hip and limited abduction of the right hip.limb lengths are equal.

Post an explanation of the differential diagnosis for the patient in the case study. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis. Then explain a treatment and management plan for the patient including appropriate dosages for any recommended treatments. Finally explain strategies for educating patients and families on the treatment and management of the musculoskeletal or neurologic disorder.

Work related musculoskeletal disorders are a group of painful disorders of muscles, tendons, and nerves. Work activities, which are frequent and repetitive, or activities with awkward postures cause their disorders, which may be painful during, work or rest. People working in the IT sector may experience various musculoskeletal disorders. Around the world it has been shown that about 20 million people were experiencing various musculoskeletal discomforts every year. Literatures state there was a strong association between the long working hours and the musculoskeletal discomfort. Various studies has postulated that work related musculoskeletal disorders are very common in sedentary people, but no study has briefed about the prevalence of WRMSD in office workers and the soft ware professionals. The purpose of the study is to find out the prevalence of various msk disorders in software professionals. Descriptive study design, which includes 300 software professionals with not less than 1 year of work experience were selected. A self reported questionnaire was given to all the participants and asked them to fill it up. The data were later analyzed and evaluated for analysis. The study result shows the Low back pain ranks first in the WRMSD and followed by Neck pain. Musculoskeletal and Neurologic Disorder Essay .

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Work related musculoskeletal injury is an injury that results from a single instantaneous exposure or multiple or prolonged exposure to the work environment leading to death, lost work time, medical treatments, work restriction, or transfer to another job.

Work related musculoskeletal disorders are aggravated by work that can affects the upper limb, low back area and the lower limbs. WMSD can be defined as impairments of bodily structures such as muscles, joints, tendons, nerves and bones.

The risk of male workers suffering from an MSD is 1.3 times higher than the risk to female workers: 35/100,000 compared to 27/100,000. In terms of (self-reported) work-related MSD complaints, the risk is only slightly higher among male workers (1.07 times higher). The work related musculoskeletal complains increases with age. At the age of 55 yr to 64 years the number of self reported symptoms is 1.7 times higher than the age of 25-34 yrs. Permanent disability and absenteeism is due to various musculoskeletal disorders.

Computers are embodiment of modern life and being used in everyday life. IT industry reaches every facet of society. It is a Boom to the world, but long term, uninterrupted computer usage stresses the musculoskeletal system, vision and emotional equilibrium. Sitting in awkward positions or using wrong unfitted chairs in front of the computer for a longer duration may lead to chronic debilities such as stiffness, headache, and back ache. Muscle and tendons become inflamed due to prolonged period of sitting in front of the computers.

Soft ware professionals use excessive force to operate key boards, keeping wrist and hand in wrong positions, undesirable work place environment repeated stress to the joints which may lead to various musculoskeletal disorders.Musculoskeletal and Neurologic Disorder Essay.  Such micro trauma may end up in macro trauma which cause increased sickness, work absenteeism, and decreased job satisfaction.

Physical factors, psychological factors and organizational factors as well as individual factors are all thought to affect the workers musculoskeletal health. Musculoskeletal complains in neck and back are very common in computer professionals and shows increasing trends. Prevalence of these musculoskeletal disorders during recent years leads to sickness absenteeism. The symptoms of the work related musculoskeletal injuries include pain, discomfort, tingling and numbness without evidence of any pathology.

Human body was designed to adapt various physical stress, but repeated stress in an awkward posture potentially end up with various musculoskeletal disorders. So far there is no literature which extensively found the prevalence of self reported musculoskeletal symptoms; this study aims to find out the prevalence of various musculoskeletal disorders in software professionals.

2. Methodology

Study is a descriptive study design, the study includes 300 participants from various IT sectors. The study was carried out for a duration of 6 months from the period May 2008 to October 2008. The study includes the soft ware professionals with the age group of 25-40 years, Both sex were included, IT professionals with at least 2 yrs of work experience. Professionals with msk injuries, work time more than 40 hrs per week, and desk job workers. The study excluded subjects with neurological involvement, any recent fracture, patient with multi joint pain, fibromyalgia like symptoms, professionals with congenital abnormalities, and unwilling subjects. The study uses work analysis for computer professional’s questionnaire. The questionnaire was a self reported one which was created by the researchers and the questionnaire was validated by 2 senior physiotherapists and 2 senior ergonomic consultants. The questionnaire includes Demographic data as Section 1 and musculoskeletal injury data in section 2.

The survey questionnaire was distributed to every individual subject. 10 subjects per day was selected and given the questionnaire and asked them to fill up. Approximately 25-30 mins were given to fill up the questionnaire. There was a clear explanation about the questionnaire was given to the employers prior to the distribution. The employer’s queries were cleared up simultaneously and the filled up questionnaire was collected and assigned for analysis. After collecting the questionnaire the employers were thanked for their active participation and advised to take up treatment in the outpatient department. The study was approved by institutional ethical committee. Musculoskeletal and Neurologic Disorder Essay.

3. Data analysis & Result

Percentage analysis was done using the formula. The table I shows the Demographic data

Table 1

Age group

(years)

25-28

29-31

32-35

36-38

39-40

No of subjects

84

77

62

47

30

Figure 1

Table 2 shows the ratio of male female subjects who participated in the study

Table 2

Age group

(years)

25-28

29-31

32-35

36-38

39-40

Total

Male

45

42

38

32

20

177

Female

39

35

24

15

10

123

Total

84

77

62

47

30

300

Figure 2

Table 3 shows the common areas of musculoskeletal involvement

Table 3

Areas

Back

Neck

Shoulder

Wrist & hand

Elbow

Knee

Others

No of subjects involved

105

82

40

30

18

10

15

Figure 3

4. Result and Discussion

The demographic representations of the participants are mentioned in table 1. Age group of the participants varies from 25 yrs to 40 yrs and about 30 % from 33-34 yrs, 27% from 25-27 yrs, 20% from 25-27 yrs, and 22.5% from 25-27 yrs. The gender classification was mentioned in table2. The male participants were 177and the female participants were 123.

The musculoskeletal analysis was mentioned in table 3. The table shows that Low back pain ranks first of all the musculoskeletal disorders. 35 % of participants complains of back pain where as 27% of participants complains of neck pain. 14 % complains of shoulder disorders, 10% complains of wrist problems, 6% on elbow, 3% on knee, and 5% on others.

The musculoskeletal injury was analyzed in percentile values shows that Low back pain shows 66% of male suffered when compared to 34% of females, the most prone age group is 29yrs -38 yrs. Musculoskeletal and Neurologic Disorder Essay. Neck pain is common in males with 56% and the females with 44%. The shoulder pain was 60% and 40% in male to female comparison, Wrist pain is equal in both the groups 50% each. Elbow and knee pain were shown about 56% and 60% in males where as 44% and 40% in females.

This study identifies that pain related to vertebral column is the most than the peripheral region, the observation by shah et al., 1999, found next to ocular symptoms the musculoskeletal pain symptom are most common. Giri et al., 2010, stated in his study that neck pain ranges 58% in computer professionals next to ocular symptoms. Factors which includes the work procedures, use of equipments and environment that lead to various biomechanical stress on muscles, ligaments, tendons spinal nerves and disc. Multiple causes for musculoskeletal injuries may include Repetitive activity, awkward postures and maintenance of static posture for long duration.

Ferreria et al.,1997, identified in a retrospective study that musculoskeletal disorders are the most common in call centre workers. Toomingas et al., 2003, conducted a year assessment for the computer users in other professionals and found that the musculoskeletal complains was more in the professionals. There is an increase in demand of computer workers in the modern office settings and working in the poor posture may lead to various musculoskeletal disorders. Carter 1994 recommended musculoskeletal discomfort are experienced by many VDT operators in telecommunication industry and that may result in chronic disability.

NIOSH , 1997 studied the epidemiological view on the work related musculoskeletal disorders and found that various body parts includes neck, shoulder , elbow , back and wrist and hand are commonest area which gets frequently involved in WMSD. The physical or task related risk factors includes repetition of force, posture, vibrations, static posture and temperature are the major causative factor for WMSD. (Mc Cauley Bush 2011).

There are various hypothesis describes why the software professionals are more prone to have musculoskeletal injuries. This includes 1) Long duration of sitting in awkward postures. 2) Use of wrong body mechanics during work hours 3) Poor knowledge on working atmosphere (Unaware about the seating, chair design, chair height, monitor positioning ect…) 4) Life style modification 5) Excessive stress at work 6) Incorrect and inappropriate timing of food consumption 7) Shift work (affects sleep style, & sleep cycle).Musculoskeletal and Neurologic Disorder Essay.

The study was limited only to IT professionals and it includes both shift workers, no interventions were given to the participants. Individual problems was not identified, future studies may promote rehabilitation for the patients with musculoskeletal injuries. Other areas are not in considerations like eye, hearing, tension headache and stress.

5. Conclusion

In this study we conclude that the musculoskeletal ailments are very common in software professionals and the most common ailment is Low back pain.

Acknowledgement

We thank my Chairman Padmashri Dr.G.Bakthavathsalam, Mrs.Vaijayanthi M. das, Director of Education, Mr.R.Prabhukumar, HRD manager, Prof.V.Mohan Gandhi, Chief physiotherapist, and Prof. S. Ramesh,MPT, Principal, K.G.College of Physiotherapy, for their continuous support and guidance for completion of this study, and lastly to all Staffs , Friends, Students of K.G.College of Health sciences for their valuable support for this study.

Both of these can reveal levels of various minerals and other substances indicating disease or a musculoskeletal disorder. The levels of certain protein in the blood may also help diagnose a disease. Blood and Urine samples are the most common tests used to diagnose problems within the musculoskeletal system. Also, prior to surgery, blood samples are used to detect bleeding tendencies. Urinary N-telopeptide of type 1 collagen or N-Tx and deoxypyridinoline (Dpd) both reflects increased osteoclast activity and increased bone resorption.

b. Nerve Conduction Studies

It is used to measure the electrical activity of muscles when a muscle fiber contracts to determine if the muscles and nerves are working properly. It is performed by stimulating a peripheral nerve at several points along its course and recording the muscle action potential or the sensory action potential that results. Usually, surface or needle electrodes are used. It is placed on the skin over the nerve to stimulate the nerve fibers. A technique called truax biography will show nerve conduction patterns, which changes in various muscle and nerve diseases.

c. Imaging Procedures

X-Ray Studies

Bone X-Rays determines the bone density, erosion, and changes in bone relationships.Musculoskeletal and Neurologic Disorder Essay.  It is used to diagnose broken bones or joint dislocations, guide orthopaedic surgery such as spine repair or infusion, assist in detection and diagnose of bone cancer, and locate foreign objects around soft tissues and in bones. Joint X-Rays reveal fluid irregularity, spur formation, narrowing and changes in joint structure. It is used to detect degenerative conditions on the joints, fractures, and tumors. Multiple X-Rays with multiple views are also needed for full assessment of the structure being examined.

Computed Tomography

It is used to identify the location and extent of fractures in areas that are difficult to evaluate such as acetabulum. It can be performed with or without the use of contrast agents and can illustrate a detailed specific plane of involved bone and can also reveal tumors of the soft tissues or injuries to the ligaments or tendons.

Magnetic Resonance Imaging

It can demonstrate abnormalities such as tumors and narrowing of tissue pathways through the bone. It is a noninvasive procedure and electromagnets are used that is why patients with any metal implants, clips or pacemakers cannot have an MRI. IV contrast agent are used to enhance visualization.

Arthrography

It identifies acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or wrist. A radiopaque contrast agent or air is used. It is injected into the joint cavity to visualize the irregular surfaces. The joint will be put through its ROM to distribute the contrast agent accompanied by a series of X-Rays. If the contrast agent leaks, it means a tear is present.

2. Discuss musculoskeletal changes associated with the aging process.

Aging leads to changes in balance, cartilage and bone tissue. The normal aging process does not need to have limited movements. Mobility is affected by personal lifestyle and the degree of activity that the individual has maintained throughout their life. Although, some of the limitations of mobility occurs as a result of fear, such as fear of falling. Musculoskeletal and Neurologic Disorder Essay.

a. Changes in Balance

The maintenance of balance relies on integrating responses from the visual system, vestibular system in the inner ear and the proprioceptors in the muscles and joints. And with aging, older people requires greater angular movement in joints for proprioception to be achieved.

b. Cartilaginous Changes

There is loss in the normal elastic properties of cartilage due to an increase in water loss and deposition of fibers. The increased fiber density in connective tissue and cartilage produces a mesh or interconnection for the deposition of calcium. And this accounts fot the increased calcification of cartilage with aging. The hyaline cartilage also loses fluid and is converted to fibrocartilage. The articular cartilage changes with the elasticity being lost. Thinning occurs over the weight bearing areas which affects functioning such as the changes in the menisci of the knee joint that will inhibit free movement. The loss of water from cartilage in the intervertebral discs leads to compaction of the vertebrae and shrinkage of the spinal column, which is seen as a loss in height. Many joint of the body becomes stiffened with aging. The height loss is also affected by joint changes and by the flattening of the arc of the foot.

c. Bone Changes

Osteoporosis is a normal aging process as the androgen decreases. It is an imbalance between bone reabsorption and formation.Musculoskeletal and Neurologic Disorder Essay.  If it is severe, it may cause fractures and may lead to bowing of the long bones and to an increase in spinal curvature due to vertebral collapse.

3. Discuss patient preparation for an arthroscopy.

Arthroscopy is a procedure used to directly visualize a joint to diagnose joint disorders. Various treatments can also be performed through the arthroscope such as treatment of tears, defects, and disease processes.

Arthroscopy is most often performed as an outpatient procedure. It is a essentially a bloodless procedure with generally few complications. It is performed in the operating room under sterile conditions. Injection of local anesthesia into the joint or general anesthesia, a spinal or epidural anesthesia is used. The patient should be able to tolerate the anesthetic agent used. Heart and lung function should be adequate. Existing problems such as emphysema should be optimized as possible prior to surgery. Anticoagulants should be carefully adjusted prior to surgery if the patient is taking them.

Preoperatively, physical examination, blood tests and urinalysis will be performed. If the patient has a history of heart or lung problems, and is above the age of 50, an ECG and chest X-ray is obtained. The patient should also have instruction on exercises and postoperative mobilization such as crutch walking. Patients are generally encouraged to mobilize the affected part following surgery with adequate analgesia. Musculoskeletal and Neurologic Disorder Essay.

4. Discuss components of a musculoskeletal physical assessment.

a. Posture

Spine is assessed for normal curvature. It is convex through the thoracic portion and concave through the cervical and lumbar portions. Kyphosis, lordosis and scoliosis are common deformities of the spine. Kyphosis is mostly seen in elderly patients with osteoporosis and in some with neuromuscular disease. The entire back, buttocks and legs should be exposed during inspection of the spine. Spinal curves and trunk symmetry are inspected from posterior and lateral views. Differences in the height of the shoulders or iliac crest are noted. Symmetry of the shoulders and hips, line of the vertebral column are inspected at erect position and patient bending forward. Height should be measured especially in adults because in older adults, loss of height occurs due to loss of vertebral cartilage and osteoporosis.

b. Gait

Have the patient walk away for a short distance and observe the patient’s gait for smoothness and rhythm. Unsteadiness and irregular movements which are frequently seen in elderly patients are abnormal.

c. Bone Integrity

Deformities and alignments are assessed in the bony skeleton. Symmetric parts are compared. Abnormal bone growths are observed. Shortened extremities, amputations, and body parts that are not in anatomical alignments are documented. If fractures are present, movement must be minimized to avoid additional injuries and some may include abnormal angulation of long bones, motion at points other that joints and crepitus.

d. Joint Function

ROM, deformity, stability and nodular formation are noted. ROM is done both actively and passively. Goniometer can be used for precise measurement of ROM. If the joint is compromised or painful, it should be examined for effusion, swelling and increase in temperature for it may reflect active inflammation. If there is positive inflammation on the joints, a physician is consulted. Palpation of the joint while it is in passive movement will provide information on joint integrity. The joint normally moves smoothly; snap or crack indicates a ligament is slipping over a bony prominence. The slightly roughened surfaces results in crepitus. Tissues around the joints are examined for nodule formation. The size of the joint is often exaggerated by atrophy of the muscle proximal and distal to that joint which is seen in rheumatoid arthritis.

e. Muscle Strength and Size

Muscular strength and coordination, size of individual muscles, and patient’s ability to change position are assessed. Muscle tone is determined by palpating the the muscle while passively moving the relaxed extremity while muscle strength is assessed by having the patient perform certain maneuvers with and without added resistance. Muscle clonus may also be elicited by sudden, forceful, sustained dorsiflexion of the foot or extension of the wrist. Involuntary twitching of muscle fiber groups may be observed. The girth of an extremityis measured to monitor increased size. It may decrease due to muscle atrophy. Musculoskeletal and Neurologic Disorder Essay. It is important that the measurement be taken at the same location of the extremity and with the extremity in the same position, with the muscles at rest. Distance from a specific landmark must be indicated. Variations in size greater than 1cm are considered significant.

f. Skin

Skin is inspected for edema, color, and temperature. Palpation is performed to reveal if any areas are warmer which suggests increased perfusion of inflammation, or vice versa. Cuts, bruises, skin color, and evidence of decreased circulation or inflammation are noted.

g. Neurovascular Status

Frequent neurovascular examination is important for patient with musculoskeletal disorders due to the risk for tissue and nerve damage. Circulation, motion and sensation are assessed.

SOURCES:

Brunner and Suddarth’s textbook of Medical-Surgical Nursing 12th Edition

Julia Kneale et. al. (2005) Orthopaedic and Trauma Nursing 2nd Edition

Clinical Assignment

1. Complete a musculoskeletal physical assessment.

a. Temporomandibular joint

Inspection:

No swelling

3 fingers can be inserted sideways

Palpation:

No swelling and tenderness

Both side firm, same strength

There was a snap during opening

Muscle strength

The jaw can move in all directions and can move against resistance

b. Cervical spine

Inspection:

Neck is straight and head is erect

Palpation:

No swelling and tenderness

No spasms

Both side firm, same strength

Patient was able to do the following: flexion, extension, lateral bending and rotation

Muscle strength

Can oppose resistance applied

c. Thoracolumbar spine

Inspection:

No deformity

Vertically aligned

Palpation:

No swelling and tenderness

No spasms

Percussion

No tenderness

Muscle strength

Can flex, extend, laterally bend and rotate spine

Can oppose resistance applied

d. Upper extremities

Inspection:

No deformity on both sides

Symmetrically aligned

No deviations

Palpation:

No swelling and tenderness

No spasms

No atropy

Fat pads fairly solid

No synovial thickening

Percussion

Negative tinel’s sign

Muscle strength

Can perform ROM in shoulders, elbows, wrists and hands

Can oppose resistance

e. Lower extremities

Inspection:

No deformity on both sides

Symmetrically aligned

No deviations

Palpation:

Hip joint not swollen

No swelling and tenderness

No spasms

No atrophy

Muscle strength

Can perform ROM in shoulders, elbows, wrists and hands

Can oppose resistance

Web Assignment

1. Summarize an article discussing techniques used in assessing the musculoskeletal system. How do the components of the health history guide the assessment?

http://www.medkaau.com/videos/peguide.pdf

There are general and regional considerations in the article. The general considerations are as follows; the patient should be undressed and gowned as needed, some parts of the exams may not be appropriate depending on the clinical situation. Examining the musculoskeletal system is all about anatomy. When taking the patient’s history for acute problems, we should always inquire about the mechanism of injury, loss of function and onset of swelling or edema.Musculoskeletal and Neurologic Disorder Essay.  Also, the initial treatment should be asked. Meanwhile, when taking the patient’s history for chronic problems, we should ask the patient about past injuries and treatments, effect of function, and current symptoms. There are cardinal signs of musculoskeletal disease which are pain, swelling, redness, increased warmth, deformity, and loss of function. We should always begin with inspection, palpation, and ROM regardless of the region being examined. A complete evaluation will include a focused neurologic exam of the affected area.

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IPPA is first used in examination then active and passive ROM exercises in specific joints. After this, vascular status, pulses, capillary refill, erythema, cyanosis, clubbing, and lymphatic are assessed. The last things to be examined are the specific tests for Upper Extremities Snuffbox Tenderness, Drop Arm Test, Impingement Sign, Flexor Digitorum Superficialis Test, and Flexor Digitorum Profundus. And these are the vascular and neurologic tests; Allen Test, Phalen’s Test, and Tinel’s Sign. And these are for the lowe extremities; Collateral Ligament Testing, Lachman Test, Anterior/Posterior Drawer Test, Ballotable Patella, and Milking the Knee. For the Back are the following tests Straight Leg Raising, FABER Test which stands for Flexion, ABduction, and External Rotation of the hip. It is used to differentiate hip or sacroiliac joint pathology from spine problems. Musculoskeletal and Neurologic Disorder Essay.