109 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults
before the age of 45 and is characterized by morning stiff- ness, and pain, which worsens with inactivity and is relieved with movement [73]. The common pathology is inflamma- tion of the tendons and ligaments of the joints at their inser- tion into bone, or enthesitis.
Physical Examination Findings and Interventions
During the early stages AS may cause sacroiliitis, plantar fasciitis, achilles tendonitis or patellar tendonitis and back pain [74]. Sacroiliitis often presents as concomitant buttock pain. Peripheral joints may be effected especially hip, shoul- der, or knee. As the disease progresses there is loss of spinal motion, flattening of the spinal segments, and exaggerated kyphosis. Stiffness, pain, and restrictions/loss of spinal mobility limit function. Occasionally skin lesions and aortic valve involvement may be present. Spinal ankylosis may occur, dramatically impacting spinal ROM, chest expansion and pulmonary compliance. Eventually, the spine may fuse in a permanent flexed posture. A rigid thorax may be noted on examination likely associated with kyphosis due to bony ankylosis and osteopenia of the thoracic vertebrae, costover- tebral, costotransverse, sternoclavicular, and sternomanu- brial joints [43]. Table 12.1 provides clinical features and physical therapy interventions for AS [9].
Goals of therapy are to maximize ROM, maintain and maximize spinal mobility, and a neutral posture. Exercises should include passive ROM activity, strengthening of the muscles of the trunk, the back, the abdomen, the legs, and improving overall fitness. Ankylosing spondylitis is associ- ated with exercise limitation and breathlessness attributed to poor chest expansion, deconditioning, and decreased periph- eral muscle function secondary to pain and limited motion.
Inspiratory muscle training should be considered to improve cardiovascular pulmonary performance. Short interval train- ing may be most effective. Rehabilitation is most effective if it is started before significant ankylosis occurs. In a cohort study of patients with AS, exercise was associated with sig- nificant improvements in pain, stiffness and functional dis- ability only in patients who had AS for less than 15 years [75].
Aquatic therapy combined with exercise provides short- term benefits on pain, stiffness, and spinal mobility [76].
Patient education regarding proper (neutral) spine position during activities of daily living, and avoidance of flexed pos- tures, coupled with information about the disease process and its physical management appears to enhance spinal flex- ibility [77]. Results of studies from supervised physical ther- apy interventions yield greater benefits than individually tailored programs [78].
The key to long-term improvement is self-management and hence patients should be advised to incorporate regular exercise such as recreational activities and regular back stretching as part of their daily routine. Uhrin et al. [75] have demonstrated that unsupervised recreational exercise is ben- eficial in decreasing pain, stiffness, and functional disability in patients with AS only when patients performed at least 30 min/day (200 min/week) and back exercises are useful is performed at least 5 days/week.
Conclusions
Physical therapy is a recognized, comprehensive, and essen- tial component of the management of arthritis. Older adults with arthritis may be greater risk of complications from their disease due to the concurrent changes with aging. Frequent monitoring of cardiovascular pulmonary systems during exercise is recommended along with a prolonged warm-up and cool down. Special attention to bone integrity is also warranted. Initiated early and consistently, physical therapy may maximize function and independence and reduce impairments associated with arthritic conditions.
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Y. Nakasato and R.L. Yung (eds.), Geriatric Rheumatology: A Comprehensive Approach, 113 DOI 10.1007/978-1-4419-5792-4_13, © Springer Science+Business Media, LLC 2011
Abstract Joints aspiration and injections are common practice in the elderly medicine and can be used to diag- nose and treat some of the musculoskeletal conditions.
Joint injection is a relatively safe procedure if associated with good knowledge of anatomy and awareness of the potential complications and contraindications. Different approaches can be used for arthrocentesis, but the dis- cussed techniques in this chapter are the ones used most commonly by the authors. Appropriate training involves knowledge of anatomy and practical skills are key requirements.
Keywords Arthrocentesis • Joints injections • Joints aspira- tion • Soft tissue injection • Intra-articular injection
Introduction
In elderly care, arthrocentesis (joints injections and aspiration) is common practice and can be used to diagnose and treat many musculoskeletal conditions. Joint injection is usually a very effective and well-tolerated procedure. However, to be performed safely and effectively, it requires a good knowledge of regional anatomy, indications for treatment, and awareness of the potential complications and contraindications, which are described in this chapter. This chapter also describes the pharmacological agents, and different techniques and approaches used for most common injections, which are necessary to practice joint injection with confidence.