Musculoskeletal System/

Movement
MARK EBONY C. SUMALINOG, RN MSN
 INTRODUCTION

• Physical activity aids respiratory, circulatory, digestive,

excretory and musculoskeletal functions
• Mental acuity and mood are enhanced by exercise
• Physical activity can be a means to engage in social activity
• A physically fit state support older adults in participating in
social events
 INTRODUCTION

• Multiple health problems such as atherosclerosis, obesity, joint

immobility, pneumonia, constipation, pressure ulcers, depression
and insomnia can be avoided when an active state is maintained

• Maintaining a physically active state is more challenging in late life

due to the effects of aging and the symptoms and restrictions
imposed by chronic health conditions that are highly prevalent
among older adults
 CAUSES AND CONTRIBUTING FACTORS NURSING DIAGNOSIS

Decreased cardiac output Activity intolerance r/t less efficient

management of stress

Reduced breathing capacity and efficiency Activity intolerance r/t shortness of breath

Delayed oxygen diffusion Ineffective peripheral tissue perfusion r/t

delayed oxygen diffusion

Decrease in muscle mass, strength and Activity intolerance r/t muscle weakness and
movements fatigue
 CAUSES AND CONTRIBUTING FACTORS NURSING DIAGNOSIS

Demineralization of bone; deterioration of Impaired physical mobility r/t decreased range

cartilage, surface of joints of motion

Brittleness of bones Risk for injury

Poorer vision and hearing Social isolation r/t sensory deficit

Wrinkling of skin; thinning, loss and change in Disturbed body image r/t age related changes
hair color to appearance
 CAUSES AND CONTRIBUTING FACTORS NURSING DIAGNOSIS

Lower basal metabolic rate Impaired physical mobility r/t slower functions

Risk for injury and infection r/t decreased bodily

functions during resting/sleeping states

Higher prevalence of chronic, disabling disease Risk for ineffective activity planning r/t chronic disease

Chronic Pain r/t chronic disease

Reduced income Deficient diversional activity r/t fewer funds available for
leisure pursuits

Chronic low self-esteem r/t decrease income

Social isolation r/t fewer funds available for
transportation , entertainment and leisure pursuits
EFFECTS OF AGING ON
MUSCULOSKELETAL FUNCTION
• Decline in number and size of muscle fibers and subsequent
reduction in muscle mass decrease muscle strength ; grip
strength endurance declines

• Connective tissue changes reduce the flexibility of joints and

muscles
SARCOPENIA
• Age related reduction of muscle mass and/or function, resulting
from a reduction of protein synthesis and an increase in muscle
protein degeneration

• This can lead to disability, particularly in patients with disease or

organ impairment

• Cause: immobility, lack of exercise, increased levels of

proinflammatory cytokines, increased production of oxygen free
radicals and impaired detoxification, low anabolic hormone output,
malnutrition and reduced neurologic drive
ACTIVITY CAN BE IMPAIRED BY:
• Loss of spouse
• Retirement
• Relocation
MUSCULOSKELETAL HEALTH
PROMOTION
• CARDIOVASCULAR ENDURANCE: Aerobic Training- enhances the ability
of the heart, blood vessels, and lungs to deliver oxygen to all body cells
- Aerobic exercise: walking, swimming, jogging, cycling, rowing, tennis, and
aerobic dancing
- should be done at least 20 minutes , at least 3x a week
- heart rate should fall within the target heart range during exercise

CALCULATING MAXIMUM AND TARGET HEART RATES

- Maximum heart rate: 220- age
- Target heart rate= maximum heart rate x 75%
- Target heart rate range= 65% to 80% of maximum heart rate
Calculating Maximum and Target Heart
Rates
• Example: 70 year old
- Maximum heart rate: 220 – age
220 – 70 = 150 bpm
- Target heart rate: maximum heart rate x 75 %
150 x 75%= 112.5 or 113 bpm
- Target heart rate range: 65%-80% of maximum heart rate
minimum= 150 x 65% = 97.5 or 98 bpm
maximum= 150 x 80% = 120 bpm
Range: 98 bpm to 120 bpm

Commercial heart rate monitors, available at sports supplies stores, can provide feedback
on heart rate during exercise without having the inconvenience of having to stop to palpate
the pulse
MUSCULOSKELETAL HEALTH
PROMOTION
• FLEXIBILITY: The ability to freely move muscles and joints through
their range of motion
- Gentle stretching help maintain flexibility of joints and muscles
- Stretching exercise for about 5-10 minutes before and after
exercise can reduce muscle soreness
- Major muscle groups should be stretched twice a week
MUSCULOSKELETAL HEALTH
PROMOTION
• STRENGTH TRAINING: exercise that challenges the muscles
- Key elements: resistance and progression

A. Resistance:
- Achieved by lifting weights and the use of weight machines
- Isometric Exercise (use of own weight) through calisthenics, such
as push-ups and pull-ups
MUSCULOSKELETAL HEALTH
PROMOTION
B. Progression:
- Increasing the workload on the muscles
- lifting heavier weights (older adult: 8-12 reps at least 2x a week)
EXERCISE PROGRAMS TAILORED
FOR OLDER ADULTS
• Regular exercise can delay or prevent some age related losses in
cardiovascular function and improve maximal oxygen uptake
• It can lower resting systolic and diastolic blood pressure
• Physical activity can increase muscle strength and flexibility and
slow the rate of bone loss
• Exercise can improve body tone, circulation, appetite, digestion,
elimination, respiration, immunity, sleep and self concept
• Exercise is beneficial but may create problems if
adjustments are not made for their age
- Higher systolic and diastolic pressure during rest and exercise
(may rise to 200 mmHg)
- Reduced vital capacity and increased residual capacity limit the
air movement, causing the respiratory muscles to work harder
and respiratory rate to increase
- Susceptible to heat stroke
- Dehydration
• Assess older adults before they start an exercise program and
monitoring their status during physical activity
• Exercise programs are best followed if they match the
individual’s needs and interest (Zumba)
• Daily routines: climbing the stairs, parking car farther away
from the destination to increase walking, walking the dog
outside, house cleaning
• Pacing the exercise throughout the day to avoid fatigue and
muscle pain and cramping
• Stretching exercise in the morning to loosen stiff joints and
muscles
• If not accustomed to great deal of physical activity, begin
gradually and increase them according to progress
• Longer periods must be allowed for the older adult to perform
exercise, with rest periods in between
• Warm water and warm washcloths or towels wrapped around
the joints to ease joint motion and facilitate exercise
• Exercise that stress an immobile joint, strenuous sports and
running and jumping exercise should be avoided to prevent
trauma
• Seek advice from a physician to identify best exercise that suits
the capacity and limitation
• Tai chi and yoga (complementary and alternative treatment/
modality)
• Less aggressive exercise into their daily routine:
- Foot, leg, shoulder and arm circling while watching television
- Deep breathing and limb exercises between awakening and rising from
bed
- Wash dishes and do laundry (warm water)
- When greeting a patient in the hall, ask the patient to raise both arms
as high as possible and wave
- When giving a medication, ask the patient to bend each extremity
several times
- During bathing exercise, ask the patient to flex and extend all body
parts
THE MIND-BODY CONNECTION
• Cognitive and emotional states can influence the
physical activity
• Depressed individuals may be poorly motivated to engage in
exercise
• Persons with Alzheimer’s may lack memory, judgment and
coordination to safely exercise
• Inactive states may lead to the ill effects of immobility that can
affect the mind
• Promotion of physical activity can have positive
effect on mood and cognition

• Activities must be planned according to patient’s interest: art,

crafts, culinary, travel, classes, gardening, auto repair, dancing,
listening to music, people watching, and collecting

• Pets (companionship for older adults)

• Therapeutic recreation: clay (exercise fingers), painting (express

feelings), cooking (restore or maintain roles)
PREVENTION OF INACTIVITY
• Educate the public, especially caregivers, about the importance
of physical activity for older adults

• Families believe they are assisting their older relatives by “doing

for” and allowing them to be sedentary

• Promotes a sense of worth by providing an opportunity for them

to be productive
 NURSING DIAGNOSIS
HIGHLIGHT

• Overview:
Impaired physical mobility is a state in which movement is limited.
Some degree of mobility limitation is observed, ranging from the use of
special equipment for movement to total dependency on others for
movement. Other signs associated with this diagnosis could include
decreased muscle strength or control, restricted range of motion,
impaired coordination, altered gait, decreased level of consciousness,
pain, paralysis, and imposed restrictions on movement.
 NURSING DIAGNOSIS
HIGHLIGHT
• Causative or contributing factors
Arthritis, malnutrition, neuromuscular disease, sensory deficits, edema,
missing limb, cardiovascular disease, pulmonary disease, obesity, side
effects of medications, altered mood or cognition.

• Goals
The patient will increase mobility to optimal level. The patient will be
free from complications associated with impaired mobility.
 NURSING DIAGNOSIS
HIGHLIGHT

• Interventions
1. Assess muscle strength and tone, active and passive range of motion,
and mental status.
2. Review history for conditions that can limit mobility or require
alteration in level of mobility. Consult with the physician as to
restrictions on mobility and any necessary modifications for exercises
3. Develop an individualized exercise program, which could include
passive or active ROM exercises
4. Assist the patient in maintaining good body alignment and
hourly position changes
5. Promote a good nutritional status
6. Refer for canes, walkers, wheelchairs, braces, traction devices,
and other aids to increase mobility, if necessary
7. Collaborate with other members of the interdisciplinary team
8. Encourage family and SO to assist in efforts to increase patient’s
mobility
9. Provide diversional activities based on patient’s interest and
level of function
10. Observe for complications of immobility and seek prompt
correction
NUTRITION
• Well balanced diet rich in protein and minerals will help
maintain the structure of bones and muscles
• 1500 mg calcium for both men and women (supplements): 1000
mg from diet and 500 mg from supplement
• Weight reduction to each musculoskeletal discomfort for obese
older adults
SELECTED MUSCULOSKELETAL DISORDERS
Fractures
• NECK OF THE FEMUR: most common site, especially in older
women
• Colles’ fracture: break of the distal radius (attempt to stop a
fall)
• COMPRESSION FRACTURE OF THE VERTEBRAE: carrying
heavy objects
• Older adults heal at a slower rate compared to younger adults
- Predisposing them to many complications related to immobility
• Aim of the gerontology nurse is PREVENTION
• Poor coordination and equilibrium:
• Avoid risky activities (climbing the ladders
or chairs to reach high places)
• Rise from a sitting or kneeling position
slowly (postural hypotension)
• Properly fitting shoes with a low, broad heel can prevent stumbling
and loss of balance
• Handrails for stairs or rising from the bath tub for support and
balance
• Place both feet at the edge of the curb before going up and down on
and from a bus
• Avoid damaged sidewalks
• Wear sunglasses to avoid glare
• Nightlight during night visits to bathroom
• Symptoms of fracture:
• Pain
• Change in shape or length
of limb
• Abnormal or restricted motion of limb
• Edema
• Spasm
• Discoloration of tissue
• Bone protruding through the tissue

• The absence of this symptoms does not rule out fracture

• Complications:
• Pneumonia
• Thrombus formation
• Pressure ulcers
• Renal calculi
• Fecal impaction
• contractures
• Nursing Intervention:
• Activity within limits determined by the physician
• Deep breathing and coughing exercises
• Isometric exercise and ROM
• Fluids should be encouraged; note urine output
• Frequent turning positions (TTS)
• Good nutrition (facilitate healing, increase resistance
against infection, decrease likelihood of other
complications)
• Joint exercise to prevent contractures
• Use of foot boards, trochanter roll, and sandbags to
maintain body alignment
• Keep skin dry, prevent pressure, massage (stimulate
circulation)
• Patient should be mobilized as early as possible
(explanation and reassurance needed)
• Progress in small steps for tolerance (bedside, nearby chair,
bathroom); assisted by two persons at first because
weakness and dizziness is common
OSTEOARTHRITIS
• Progressive deterioration and abrasion of joint cartilage
• It occurs more in women more than in men
• 55 years old and above
• Leading cause of physical disability in older adults
 Myth
• Unlike rheumatoid arthritis, osteoarthritis does not cause:
• Inflammation, deformity, and crippling
• Reassure older adults who fears the effect of rheumatoid arthritis
(severe disability)
• Wear and tear of the joints was responsible; however, recent studies
show that disequilibrium between destructive (matrix
metalloprotease enzymes) and synthetic (tissue inhibitor of
metalloprotease) elements leads to a lack of homeostasis necessary
to maintain cartilage, causing the joint changes.
• Excessive use of the joint
• Trauma
• Obesity
• Low vitamin D and C levels
• Patients with acromegaly
• Weight bearing joints are most affected (knee, hips, vertebrae and
fingers)
• Symptoms:
- Crepitation on joint motion
- Bony nodules at the distal joints (Heberden nodes)
- Joint more uncomfortable during damp weather and periods of
extended use
- Excessive exercise will cause more pain and degeneration (advice
isometric and mild exercise)
• Management:
- Analgesics (DOC: Acetaminophen)
- Rest
- Heat
- Tai chi
- Aquatherapy
- Gentle massage
- Splints, braces and canes provide support
- Acupuncture for short-term relief
- Oral calcitonin for post menopausal women effectively protects them
from pain and disability of joint
• Management:
- Proper body alignment and body
mechanics
- Foods high in essentially fatty acid
have anti-inflammatory effects
- Vitamin A, B, B6, C and E and zinc,
selenium, niacinamide, calcium and
magnesium supplements
- Glucosamine and chondroitin
supplements
• Management:
- Weight reduction
- Occupational and physical therapy can be
done (seek consult for assistive devices and
promote independence in self-care
activities)
- Arthroplasty, or joint replacement, to
restore joint motion, improve function and
reduce pain
- Contraindications: obese, joint sepsis,
dementia, neurotrophic joints, diabetes
(poor wound healing), PVD
- Complications of arthroplasty:
- DVT
- Pulmonary emobolism (warfarin is used as prophylaxis)

- Post-operative care:
- Analgesics round the clock for post-operative pain (monitor closely for effects)
- Patient informed of precautions needed when taking anticoagulants
- Specific instruction pertaining toe exercise, weight-bearing, and activity
restrictions
RHEUMATOID ARTHRITIS

• 20-40 years old

• Major cause of arthritic disability in later life
• The synovium becomes hypertrophied and edematous with
projections of synovial tissue protruding into the joint cavity
• Signs and symptoms:
o Affected joints is painful, stiff, swollen, red and warm to touch
o Pain is present during REST and activity
o Subcutaneous nodules over bony prominences and bursae may be present
o Systemic: fatigue, malaise, weakness, weight loss, wasting, fever and anemia
• MANAGEMENT:
• Rest
• Limb support to avoid pressure
ulcers and contractures
• Splints to avoid deformities
• ROM exercise
• Physical and occupational
therapy
• Heat and gentle massage
• Analgesics and anti-
inflammatory agents
(prostaglandins)
• Corticosteroids
• Rheumatic heart disease (RHD) patients
are sensitive to “nightshade” foods”
(they prefer to grow in shady areas)
• Potatoes
• Peppers
• Eggplant
• Tomatoes
• Herbs that may help: turmeric, ginger,
skullcap and ginseng
• Patient education/ Home visit
• Consult a physician before using any
dietary supplement sold by salespeople
(elderly are easy target)
OSTEOPOROSIS
• INACTIVITY OR IMMOBILITY
• DISEASES:
• Cushing syndrome (excessive production of glucocorticosteroids by the adrenal
gland inhibits the formation of bone matrix)
• Increased metabolic activity of hyperthyroidism causes more rapid bone
turnover and the faster rate of bone resorption to bone formation causes
osteoporosis
• Excessive diverticulitis causes malabsorption of calcium
• REDUCTION OF ANABOLIC SEX HORMONES
• Loss of estrogens and androgens (postmenopausal)
• DIET
• Insufficient amount of calcium, vitamin D, vitamin C, protein, and other nutrients
• Excessive consumption of caffeine or alcohol decreases calcium absorption
• DRUGS THAT CAN CAUSE OSTEOPOROSIS
• Heparin
• Furosemide
• Thyroid supplements
• Corticosteroids
• Tetracycline
• Magnesium and aluminum based antacids
• Osteoporosis may cause kyphosis and reduction of height
• Spinal pain, especially in the lumbar region
• Bones fracture easily
• Bone mass density can be measured by:
• CT scan, Dual Energy X-ray Absorptiometry (most widely used), single or dual
photon absorptiometry
• TREATMENT:
• Calcium supplements
• Vitamin D supplements
• Progesterone
• Estrogen
• Anabolic agents
• Synthetic form of calcitonin (reabsorb calcium)
• Biphosphonates (antiresorptive)
• Diet rich in protein and calcium
• Avoid heavy lifting, jumping and other activities that results to fracture
• Potential complication: compression fracture
• ROM exercise and ambulation to maintain function and prevent greater
damage
GOUT

• Excess uric acid accumulates in the blood

• Uric acid crystals around the joints
• Severe pain and tenderness in the joints
• Warm, swelling, redness of the surrounding tissue
• Acute attack: pain is severe, may not be able to bear weight and have
a blanket or clothing rest on the affected joint
• TREATMENT:
• Low purine diet: avoid bacon, turkey, liver,
kidney, brain, anchovy, sardines, mackerel,
salmon, legumes, all alcoholic beverages,
shellfish, scallops)
• Colchicine can be used to manage acute
attacks
• Long term management: colchicine,
allopurinol, probenecid, indomethacin
• Precipitated by the use of thiazide
diuretics (increases uric acid in blood)
• Dietary supplements: vitamin E, folic acid
and eicosapentaenoic acid
• Herbs: yucca and devil’s claw
• EOF
PODIATRIC CONDITIONS
• Foot problems
• 90% of 65 years old and above have foot problems
• Podogeriatrics (specializing in foot problems in old age)
• Conditions: lifelong foot problem, changes in gait, gout, diabetes, PVD
and age related loss of fat padding of the foot contribute to foot
problems
• Shaving, cutting and chemical treatment of podiatric conditions can
cause serious problems
• Refer to a podiatrist

• PROPER FOOT CARE (keep feet clean, wear safe and properly fitting
shoes, exercising feet, cutting nails straight)

• Foot massage to aid in circulation, reduce edema and promote

comfort (contraindicated if with PVD or lesions)
 A. Calluses
• Plantar keratosis
• Friction creating layers of thickened skin
• Reduced fat padding, dryness, decreased toe function
and poor fitting shoes can cause callus formation
• Usually appears in the heels and soles
• People attempt to shave or cut off calluses
• Massage and apply lotions and oils to prevent callus
 B. Corns

• Cone shaped layers of thick dry skin

that forms over a bony prominence
• Pressure on the area causes
discomfort/ pain
• Do not attempt to remove corns on
their own
 C. Bunions

• Hallux Valgus
• Bursa, bony prominence over the first metatarsal
head
• Medial deviation of the first metatarsal with
abduction of the great toe
• Occur more in women (shoes)
• Causes difficulty in finding shoes (widen)-
custom made shoes
• Surgery can be indicated
D. Hammer Toes
• Digiti Flexus
• Hyperextension of the
metatarsophalangeal joint with flexion
and often corn formation at the
proximal interphalangeal joint
• Toe resembles the shape of the
hammers inside a piano
• Orthotics can provide relief
• Surgery is necessary for correction
E. Plantar Fasciitis

• Common cause of heel pain

• Plantar fascia is a ligament that runs from
the ball of the foot to the heel
• Inflammation of the plantar fascia/ band at
its heel attachment
• Prolonged walking and standing
• Ttt: stretch exercise (pull up ball of foot),
apply ice for 30 mins., wear cushion in the
heel, custom made orthotics
 F. Infections

• Onychomycosis; fungal infection of

the nail or nail bed
• Toenails become enlarged, thick,
brittle, and flaky (fungus displaces the
nails up); the side of the nails are
pushed into the skin and causes pain
• Antifungal preparation
F. Infections

• Tinea pedis or athlete’s foot

• Burning and itching
• Skin surface peel, crack and be often
red, often with vesicular eruptions
G. Ingrown Nails

• Tight fitting shoes

• Cutting of nails excessively short
• Nails cut deep into the tissues
leading to inflammation
• Soaks and topical antibiotics can be
prescribed
• Podiatrist to remove ingrown nails
POLYMYALGIA
RHEUMATICA
• A rheumatic disease characterized by muscular pain
and stiffness that lasts a month or more
• Muscle pain that begins in the posterior neck
muscles and spreads to the shoulders and pelvic
girdle
• Muscle stiffness may last for an hour
• Muscle atrophy, joint deformity and low grade fever
• Cause: unknown, genetics
GIANT CELL
ARTERITIS
• An immune-mediated condition
that involves large and medium
sized arteries
• Manifestation: throbbing unilateral
temporal headache, fever, visual
disturbance, jaw claudication
• Others: weight loss, anorexia, night
sweats, malaise, depression
GIANT CELL ARTERITIS and
POLYMYALGIA RHEUMATICA

• Diagnosis: ESR and CRP

• Management: Corticosteroids and NSAIDs
OSTEOMALACIA
• Softening of the bone with an excessive
accumulation of bone matrix resulting from
impaired mineralization with calcium and
phosphorus
• Causes: vitamin D deficiency, renal failure,
hypophosphatemia, less exposed to sunlight
• Manifestation: pain, tenderness, proximal
muscle weakness, waddling gait, hypotonia
• TTT: calcium and vitamin D supplements
PAGET’S DISEASE
• Characterized by excessive resorption
and deposition of bone
• Cause: genetics
• Manifestations: bone pain frequently occurs at rest, under pressure and
during the night
• Dx: imaging studies
• Management: bisphosphonates (Risedronate, Clodronate)
Musculoskeletal System/
Movement
MARK EBONY C. SUMALINOG, RN MSN