I.

ASSESSMENT OF PATIENT WITH MUSCULOSKELETAL DISORDERS

Objectives
At the end of this lesson the student should be able to:
- Conduct an interview for a patient with a musculoskeletal disorder
- describe the various areas evaluated for physical examination
- Identify the various diagnostic tests.
The nursing assessment of the patient with musculoskeletal dysfunction includes an evaluation of
the effects of the musculoskeletal problem on the patient.
II.1. Patient history
During the interview the nurse gathers information concerning:
- A general impression of the patient’s health status
- The onset of the problem and how it has been managed,
- The patient’s perceptions and expectations related to health,
- Concurrent health conditions (eg, diabetes, heart disease, chronic obstructive pulmonary
disease, infection, preexisting disability) and
- Familial or genetic abnormalities,
- A history of medication use and response to pain medication
- Note allergies and describe them in terms of the reactions they produce in the patient.
- Assess the patient’s use of tobacco, alcohol, and other drugs to evaluate how these agents
may affect patient care.
- Information concerning the patient’s learning ability, economic status, and current
occupation is needed for rehabilitation and discharge planning.
Common signs and symptoms assessed during the interview are pain, tenderness, tightness, and
abnormal sensations. The nurse assesses and documents this information.
PAIN
Make a distinction between muscles, bones, and joints pain.
- Bone pain is characteristically described as a dull, deep ache that is “boring” in nature,
- Muscular pain is described as soreness or aching and is referred to as “muscle cramps.”
- Fracture pain is sharp and piercing and is relieved by immobilization.
Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory
nerve. Rest relieves most musculoskeletal pain.

1
- Joint sprain or muscle sprain increases with activity, whereas steadily increasing pain
points to the progression of an infectious process (osteomyelitis), a malignant tumor, or
neurovascular complications.
- Radiating pain occurs in conditions in which pressure is exerted on a nerve root.
Pain is variable, and its assessment and nursing management must be individualized.
Note the following about pain: description, localization, if it radiates and direction, intensity,
character, aggravating and relieving factors, onset, duration and frequency.
ALTERED SENSATIONS
Paresthesias - burning, tingling sensations or numbness. These sensations may be caused by
pressure on nerves or by circulatory impairment. Soft tissue swelling or direct trauma to these
structures can impair their function. Areas involve are carefully assessed for onset, pain,
movement, colour, capillary refill and edema.
I.2. Physical examination
Emphasize on the patient’s ability to perform activities of daily living. Techniques of inspection
and palpation are used to evaluate the patient’s posture, gait, bone integrity, joint function, and
muscle strength and size. The skin and neurovascular status must be assessed to complete the
musculoskeletal assessment.
Posture: The normal curvature of the spine is convex through the thoracic portion and concave
through the cervical and lumbar portions. Common deformities of the spine include kyphosis,
lordosis and scoliosis.
- Kyphosis is an increased forward curvature of the thoracic spine. It is frequently seen in
elderly patients with osteoporosis and in some patients with neuromuscular diseases.
- Scoliosis is a lateral curving deviation of the spine. It may be congenital, idiopathic
(without an identifiable cause), or the result of damage to the paraspinal muscles, as in
poliomyelitis.
- Lordosis or swayback, is an exaggerated curvature of the lumbar spine. It is frequently
seen during pregnancy as the woman adjusts her posture in response to changes in her center of
gravity.

2
During inspection of the spine, the entire back, buttocks, and legs are exposed. The examiner
inspects the spinal curves and trunk symmetry from posterior and lateral views. Standing behind
the patient, the examiner notes any differences in the height of the shoulders or iliac crests. The
gluteal folds are normally symmetric. Shoulder and hip symmetry, as well as the line of the
vertebral column, are inspected with the patient erect and with the patient bending forward
(flexion). (Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not
level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward.)
Older adults experience a loss in height due to loss of vertebral cartilage and osteoporosis-related
vertebral fractures. Therefore, an adult’s height should be measured periodically.
Gait: Have the patient walk away from the examiner for a short distance. The examiner observes
the patient’s gait for smoothness and rhythm. Any unsteadiness or irregular movements
(frequently noted in elderly patients) are considered abnormal. When a limping motion is noted,
it is most frequently caused by painful weight bearing. The area of discomfort is noted for further
examination. If one extremity is shorter than another, a limp may also be observed as the
patient’s pelvis drops downward on the affected side with each step. Limited joint motion may
affect gait. In addition, a variety of neurologic conditions are associated with abnormal gaits such
as a spastic hemiparesis gait (stroke), step page gait (lower motor neuron disease), and shuffling
gait (Parkinson’s disease).
Bone Integrity: The bony skeleton is assessed for deformities and alignment. Symmetric parts
of the body are compared. Abnormal bony growths due to bone tumors may be observed.
Shortened extremities, amputations, and body parts that are not in anatomic alignment are noted.

3
Fracture findings may include abnormal angulation of long bones, motion at points other than
joints, and crepitus (a grating sound) at the point of abnormal motion. Movement of fracture
fragments must be minimized to avoid additional injury.
Joint Function: The articular system is evaluated by noting range of motion, deformity,
stability, and nodular formation.
- Range of motion is evaluated both actively (the joint is moved by the muscles
surrounding the joint) and passively (the joint is moved by the examiner). Limited range
of motion may be the result of skeletal deformity, joint pathology, or contracture of the
surrounding muscles, tendons, and joint capsule. In elderly patients, limitations of range
of motion associated with osteoarthritis (degenerative joint disease) may reduce their
ability to perform activities of daily living. If joint motion is compromised or the joint is
painful, the joint is examined for effusion (excessive fluid within the capsule), swelling,
and increased temperature that may reflect active inflammation. An effusion (escape of
fluid into surrounding tissues or cavities) is suspected if the joint is swollen and the
normal bony landmarks are obscured. The most common site for joint effusion is the
knee.
- Joint deformity may be caused by contracture (shortening of surrounding joint
structures), dislocation (complete separation of joint surfaces), subluxation (partial
separation of articular surfaces), or disruption of structures surrounding the joint.
Weakness or disruption of joint-supporting structures may result in a weak joint that
requires an external supporting appliance (eg, brace).
- Palpation of the joint while it is passively moved provides information about the integrity
of the joint. Normally, the joint moves smoothly. A snap or crack may indicate that a
ligament is slipping over a bony prominence. Slightly roughened surfaces, as in arthritic
conditions, result in crepitus (grating, crackling sound or sensation) as the irregular joint
surfaces move across one another.
- The tissues surrounding joints are examined for nodule formation. RA nodules are soft;
the nodules of gout are hard; and osteoarthritic nodules are hard and painless. Often, the
size of the joint is exaggerated by atrophy of the muscles proximal and distal to that joint.
Muscle Strength and Size: The muscular system is assessed by noting the patient’s ability
to change position, muscular strength and coordination, and the size of individual muscles.

4
 Weakness of a group of muscles might indicate a variety of conditions, such as
polyneuropathy, electrolyte disturbances (particularly potassium and calcium), myasthenia
gravis, poliomyelitis, and muscular dystrophy.
- For muscle tone, palpate the muscle while passively moving the relaxed extremity,
- For muscle strength have the patient extend the arm fully and then to flex it against
resistance applied by the nurse, and also, a handshake may provide an indication of grasp
strength.
- Muscle clonus (rhythmic contractions of a muscle) in the ankle or wrist is by sudden,
forceful, sustained dorsiflexion of the foot or extension of the wrist.
- Fasciculations (involuntary twitching of muscle fiber groups) may be observed.
- Measure the girth of an extremity to monitor increased size due to exercise, edema, or
bleeding into the muscle. Girth may decrease due to muscle atrophy. The unaffected extremity is
measured and used as the reference standard. Measurements are taken at the maximum
circumference of the extremity. It is important that the measurements be taken at the same
location on the extremity, and with the extremity in the same position, with the muscle at rest.
Always record measurements to ease evaluation. Variations in size greater than 1 cm are
considered significant.
Inspect the skin for edema, temperature, and color. Palpation of the skin can reveal whether any
areas are warmer, suggesting increased perfusion or infection, or cooler, suggesting decreased
perfusion, and whether edema is present. Cuts, bruises, skin color, and evidence of decreased
circulation or infection can influence nursing management of musculoskeletal conditions.
Neurovascular Status: this is very important because of the risk of tissue and nerve damage. Be
alert for compartment syndrome. This major neurovascular problem is caused by pressure within
a muscle compartment that increases to such an extent that microcirculation diminishes, leading
to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation
continues for longer than 6 hours. Assessment of neurovascular status is frequently referred to as
assessment of CMS (circulation - color: pale or cyanotic, temperature: cool, capillary refill: more
than 3 seconds; motion – weakness, paralysis; and sensation – paresthesia, unrelenting pain, pain
on passive stretch, and absence of feeling).
Special precautions must be taken when assessing a trauma patient. If there is injury to an
extremity, it is important to assess for soft tissue trauma, deformity, and neurovascular status. If

5
the patient has a possible cervical spine injury and is wearing a cervical collar, the collar must
not be removed until the absence of spinal cord injury is confirmed on x-ray. When the collar is
removed, the cervical spine area is gently assessed for swelling, tenderness, and deformity. With
pelvic trauma, abdominal organ injuries may occur. The patient is assessed for abdominal pain,
tenderness, hematomas, and the presence or absence of femoral pulses. If blood is present at the
urinary meatus, the nurse should suspect bladder and urethral injury, and the patient should not
be catheterized. Instead, such findings should be reported immediately to the primary health care
provider.
I.3. Diagnostic tests
Nursing care involves preparation for physical examinations, radiographic tests, and other
diagnostic procedures. Be sure to explain the actual procedures to reduce tension or anxiety that
clients may experience. Teach post-procedure activities that ease discomfort and promote
wellness. Carry out physical preparation and document all aspects of care.
Laboratory Tests: Several laboratory tests are available to monitor the condition of bones and
muscles. Complete blood cell count (CBC), uric acid levels, and blood levels of calcium and
phosphorus help indicate the overall condition of the musculoskeletal system. Erythrocyte
sedimentation rate (ESR), rheumatoid factor (RF), and creatine kinase (CK) tests may show
inflammation related to an infection or inflammatory condition.
Radiography (X-ray): Radiography is the most common method of assessing the general state
of bones. An x-ray study visualizes bones and other internal structures noninvasively so that the
healthcare provider can diagnose abnormalities and monitor the effectiveness of treatments. This
diagnostic procedure is particularly valuable for evaluating spinal cord abnormalities caused by
tumors, herniated intervertebral disks, or other lesions.
Computed Tomography: Computed tomography (CT) scanning provides a three dimensional
radiographic view of a body part. CT scanning is painless and can be performed with or without
the use of contrast agents. A CT scan is useful in diagnosing bone, ligament, and tendon injuries,
soft tissue disorders, and tumors.
Other Diagnostic Tests
Magnetic Resonance Imaging
- Arthrogram is an x-ray study of a joint (e.g., knee or shoulder).

6
- Myelogram (myel/o = spinal cord; bone marrow) is an x-ray examination of the spinal
cord and vertebral canal
- Bone Scan is used to detect primary bone tumors, metastatic bone disease, osteomyelitis,
osteoporosis, inflammation, bone or joint infections, and stress fractures.
- Ultrasound technology, which uses sound waves and their echoes to display images,
helps to evaluate soft tissue masses, osteomyelitis, infection, congenital and acquired pediatric
disorders, bone mineral density, sports injuries, and fracture healing. This method is noninvasive,
inexpensive, readily available, and safe because it does not involve ionizing radiation.
- Arthrocentesis is aspiration of synovial fluid, blood, or pus from a joint cavity.
- Arthroscopy is a minimally invasive procedure used in viewing joints for diagnostic and
treatment purposes. It uses a special endoscope, called an arthroscope, which has a lens and a
light source at its end that transmits a picture to a video monitor in the operating room (OR).
- Biopsy of bone, tissue, or muscle may be performed using local anesthesia to diagnose
tumors, infections, muscle inflammation or atrophy, and various other problems.
- Electromyogram (EMG) is a test of electrical conductivity, similar to the
electrocardiogram (ECG) or the electroencephalogram (EEG).

II. CARE OF PERSONS WITH MUSCULOSKELETAL DISORDERS

Objections
At the end of this lesson the student should be able to:
- Describe and give the causes of common musculoskeletal disorders
- Explain the signs and symptoms of common musculoskeletal disorders
- Discuss the management of patients different musculoskeletal disorders
II.1. Septic Arthritis
SA is a painful infection in a joint. The infection can come from germs that travel through your
bloodstream from another part of your body (septicaemia, mainly staphylococcal). Septic
arthritis can also occur when a penetrating injury delivers germs directly into the joint. Infants
and older joints are most likely to develop septic arthritis. The infection can quickly and severely
damage the cartilage and bone within the joint, so prompt treatment is crucial. Risk factors
include advanced age, diabetes mellitus, rheumatoid arthritis, and preexisting joint disease or
joint replacement.

7
Clinical Manifestations
The patient with acute septic arthritis usually presents with a warm, painful, swollen joint with
decreased range of motion. Systemic chills, fever, and leukocytosis are present. Other joints may
involve but half of all cases affect the knees.
Elderly patients and patients taking corticosteroids or immunosuppressive medications
may not exhibit typical clinical manifestations of infection. Therefore, they require ongoing
assessment to detect infection as early as possible in the infectious process.
Assessment and Diagnosis
Diagnostic studies include aspiration, examination, and culture of the synovial fluid. Computed
tomography and MRI may disclose damage to the joint lining. Radioisotope scanning may be
useful in localizing the infectious process.
Management
Prompt treatment is essential and may save a joint prosthesis for patients who have one.
- Broad-spectrum IV antibiotics are started promptly and then changed to organism-
specific antibiotics after culture results are available. The IV antibiotics are continued
until symptoms disappear.
- The joints can be aspirated with a needle to remove excessive joint fluid, exudate, and
debris. This promotes comfort and decreases joint destruction caused by the action of
proteolytic enzymes in the purulent fluid. Occasionally, arthrotomy or arthroscopy is used
to drain the joint and remove dead tissue.
- The inflamed joint is supported and immobilized in a functional position by a splint that
increases the patient’s comfort. Analgesics, such as codeine, may be prescribed to control
pain. After the infection has responded to antibiotic therapy, NSAIDs may be prescribed
to limit joint damage.
- The patient’s nutrition and fluid status is monitored. Progressive range-of-motion
exercises are prescribed after the infection subsides.
- The patient is assessed periodically for recurrence.
Nursing management
The nurse educates the patient and family about the physiologic process and explains the
importance of supporting the affected joint, adherent to the prescribed antibiotic regimen,
inspecting the skin under any splints that may be prescribed and observing weight bearing and

8
activity restrictions. Also educate the patient on possible recurrence of the disease and signs and
symptoms to observe. The patient is then encouraged to perform range-of-motion exercises after
the infection subsides.
II.2. Osteoarthritis or Degenerative Joint Disease
Osteoarthritis occurs when the protective cartilage on the ends of your
bones wears down over time. The cartilage wears away and exposes
the bone (Fig. 77-2). Next, bony hypertrophy (overgrowth) occurs,
with the creation of bone spurs. Particles of cartilage break off and
float in the joint, making movement painful. Any joint in the body
can be affected but most commonly the hands, knees, hips and spines.
Risk factors include: old age, female gender, obesity, joint injuries,
certain occupations, genetics, born deformities and diseases like
diabetes, RA, gout.
Signs and symptoms
Pain, tenderness, stiffness, loss of flexibility, grating sensation and bone spurs
Complications
Joint pains and stiffness becomes so severe enough to make daily tasks difficult
Assessment and diagnosis
Physical examination; x-rays; MRI; blood test; and joint fluid analysis
Treatment and management
There is no known cure for the disease. Treatment is geared towards reducing pain and maintains
joint movement.
- Analgesics and NSAIDS
- Physical and occupational therapy
- Braces or shoe inserts
- Surgical procedures
- Lifestyle changes
II.3. Osteomyelitis
Osteomyelitis is an infection of the bone. The bone becomes infected by one of three modes:
• Extension of soft tissue infection (e.g. infected pressure or vascular ulcer, incisional infection)

9
• Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg, gunshot
wound)
• Hematogenous (bloodborne) spread from other sites of infection (e.g. infected tonsils, boils,
infected teeth, upper respiratory infections).
Patients who are at high risk for osteomyelitis include those who are poorly nourished,
elderly, or obese. Also at risk are patients with impaired immune systems, those with chronic
illness (eg, diabetes, rheumatoid arthritis), and those receiving longterm corticosteroid therapy.
Bone infections are more difficult to eradicate than soft tissue infections because the infected
bone becomes walled off. Natural body immune responses are blocked, and there is less
penetration by antibiotics. Osteomyelitis may become chronic and may affect the patient’s
quality of life.
Etiology and Pathophysiology
Staphylococcus aureus causes 70% to 80% of bone infections. Other pathogenic organisms
frequently found in osteomyelitis include Proteus and Pseudomonas species and Escherichia coli.
The incidence of penicillin-resistant, nosocomial, gram-negative, and anaerobic infections is
increasing. The initial response to infection is inflammation, increased vascularity, and edema.
After 2 or 3 days, thrombosis of the blood vessels occurs in the area, resulting in ischemia with
bone necrosis. The infection extends into the medullary cavity and under the periosteum and may
spread into adjacent soft tissues and joints. Unless the infective process is treated promptly, a
bone abscess forms. The resulting abscess cavity contains dead bone tissue (the sequestrum),
which does not easily liquefy and drain. Therefore, the cavity cannot collapse and heal, as occurs
in soft tissue abscesses. New bone growth (the involucrum) forms and surrounds the sequestrum.
Although healing appears to take place, a chronically infected sequestrum remains and produces
recurring abscesses throughout the patient’s life. This is referred to as chronic osteomyelitis.
Clinical Manifestations
When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical
manifestations of septicemia (eg, chills, high fever, rapid pulse, general malaise). The infected
area becomes painful, swollen, and extremely tender as the periosteum gets involve. The patient
may describe a constant, pulsating pain that intensifies with movement as a result of the pressure
of the collecting pus. When osteomyelitis occurs from spread of adjacent infection or from direct
contamination, there are no symptoms of septicemia. The area is swollen, warm, painful, and

10
tender to touch. The patient with chronic osteomyelitis presents with a continuously draining
sinus or experiences recurrent periods of pain, inflammation, swelling, and drainage. The low-
grade infection thrives in scar tissue, because it has a reduced blood supply.
Assessment and Diagnosis
In acute osteomyelitis, early x-ray findings demonstrate soft tissue swelling. In about 2 weeks,
areas of irregular decalcification, bone necrosis, periosteal elevation, and new bone formation are
evident. Radioisotope bone scans, particularly the isotope labeled white blood cell (WBC) scan,
and magnetic resonance imaging (MRI) help with early definitive diagnosis. Blood studies reveal
elevated leukocyte levels and an elevated sedimentation rate. Wound and blood culture studies
are performed to identify appropriate antibiotic therapy. With chronic osteomyelitis, large,
irregular cavities, raised periosteum, sequestra, or dense bone formations are seen on x-ray. Bone
scans may be performed to identify areas of infection. The sedimentation rate and the WBC
count are usually normal. Anemia, associated with chronic infection, may be evident. Bone
biopsy is also done to know the germ and determine the right antibiotic therapy.
Complications
Bone death, septic arthritis, impaired growth and skin cancer.
Prevention
Prevention of osteomyelitis is the goal. Elective orthopedic surgery should be postponed if the
patient has a current infection (eg, urinary tract infection, sore throat) or a recent history of
infection. During orthopedic surgery, careful attention is paid to the surgical environment and to
techniques to decrease direct bone contamination. Prophylactic antibiotics, administered to
achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful.
Urinary catheters and drains are removed as soon as possible to decrease the incidence of
hematogenous spread of infection. Treatment of focal infections diminishes hematogenous
spread. Aseptic postoperative wound care reduces the incidence of superficial infections and
osteomyelitis. Prompt management of soft tissue infections reduces extension of infection to the
bone. When patients who have had joint replacement surgery undergo dental procedures or other
invasive procedures (eg, cystoscopy), prophylactic antibiotics are frequently recommended.
Medical Management:
The initial goal of therapy is to control and halt the infective process.

11
 - Antibiotic therapy depends on the results of blood and wound cultures. To enhance
absorption of the orally administered medication, antibiotics should not be administered
with food.
- General supportive measures (eg, hydration, diet high in vitamins and protein, correction
of anemia) should be instituted.
- The area affected with osteomyelitis is immobilized to decrease discomfort and to
prevent pathologic fracture of the weakened bone.
- Warm wet soaks for 20 minutes several times a day may be prescribed to increase
circulation.
Surgical management
- Drain the infected area. The purulent and necrotic material is removed, and the area is
irrigated with sterile saline solution.
- Remove diseased bone and tissue. All dead, infected bone and cartilage must be removed
before permanent healing can occur. A closed suction irrigation system may be used to
remove debris.
- Restore blood flow to the bone. The debrided cavity may be packed with cancellous bone
graft to stimulate healing.
- Remove foreign objects
- Amputate the limb
II.4. Osteoporosis
It is characterized by reduction of bone density and a change in bone structure, both of which
increase susceptibility to fracture. The normal homeostatic bone turnover is altered: the rate of
bone resorption is greater than the rate of bone formation, resulting in a reduced total bone mass.
Suboptimal bone mass development in children and teens contributes to the development of
osteoporosis. With osteoporosis, the bones become progressively porous, brittle, and fragile; they
fracture easily under stresses that would not break normal bone. Osteoporosis frequently results
in compression fractures (see fig.) of the thoracic and lumbar spine, fractures of the neck and
intertrochanteric region of the femur, and Colles’ fractures of the wrist. Osteoporosis is a costly
disorder not only in terms of health care management but also in terms of human suffering, pain,
disability, and death. The gradual collapse of a vertebra may be asymptomatic; it is observed as
progressive kyphosis. With the development of kyphosis (“dowager’s hump”), there is an

12
associated loss of height. Frequently, postmenopausal women lose height from vertebral
collapse. The postural changes result in relaxation of the abdominal muscles and a protruding
abdomen. The deformity may also produce pulmonary insufficiency. Many patients complain of
fatigue.
Causes
- Primary osteoporosis occurs in women after menopause and later in life in men, but it is
not merely a consequence of aging.
- Secondary osteoporosis is the result of medications or other conditions and diseases that
affect bone metabolism. Specific disease states (eg, celiac disease, hypogonadism) and
medications (e.g. corticosteroids, antiseizure medications) that place patients at risk need
to be identified and therapies instituted to reverse the development of osteoporosis.
- Failure to develop optimal peak bone mass during childhood, adolescence, and young
adulthood contributes to the development of osteoporosis without resultant bone loss.
Prevention
- Early identification of at-risk teenagers and young adults, increased calcium intake,
participation in regular weight-bearing exercise, and modification of lifestyle (e.g.
reduced use of caffeine, cigarettes, and alcohol) are interventions that decrease the risk
for development of osteoporosis, fractures, and associated disability later in life.
- Elderly people absorb dietary calcium less efficiently and excrete it more readily through
their kidneys; therefore, postmenopausal women and the elderly actually need to
consume liberal amounts of calcium. As much as 1500 mg daily for postmenopausal
women may be prescribed.
- Most residents of long term care facilities have a low bone mineral density (BMD) and
are at risk for fracture.
- Hip protectors have been found to reduce the incidence of hip fracture in the elderly;
however, compliance in wearing these hip protectors is low.
Pathophysiology
Normal bone remodeling in the adult results in gradually increased bone mass until the early 30s.
Gender, race, genetics, aging, low body weight and body mass index, nutrition, lifestyle choices
(eg, smoking, caffeine and alcohol consumption), and physical activity influence peak bone mass
and the development of osteoporosis. Although the consequences of osteoporosis (eg, fractures)

13
occur with aging, osteoporosis is not a disease of the elderly. Rather, its onset occurs earlier in
life, when bone mass peaks and then begins to decline. Loss of bone mass is a universal
phenomenon associated with aging. Age-related loss begins soon after the peak bone mass is
achieved (ie, in the fourth decade). Calcitonin, which inhibits bone resorption and promotes bone
formation, is decreased. Estrogen, which inhibits bone breakdown, decreases with aging. On the
other hand, parathyroid hormone (PTH) increases with aging, increasing bone turnover and
resorption. The consequence of these changes is net loss of bone mass over time. The withdrawal
of estrogens at menopause or with oophorectomy causes an accelerated bone resorption that
continues during the postmenopausal years. Women develop osteoporosis more frequently and
more extensively than men because of lower peak bone mass and the effect of estrogen loss
during menopause. More than half of all women older than 45 years of age show evidence of
osteopenia. World Health Organization (WHO) diagnostic categories for osteoporosis are based
on BMD scan findings (Walker-Bone et al., 2001).
Secondary osteoporosis is associated with many disease states, nutritional deficiencies, and
medications. Coexisting medical conditions (eg, malabsorption syndromes, lactose intolerance,
alcohol abuse, renal failure, liver failure, Cushing’s syndrome, hyperthyroidism, and
hyperparathyroidism) contribute to bone loss and the development of osteoporosis. Medications
(eg, corticosteroids, antiseizure medications, heparin, tetracycline, aluminum containing
antacids, and thyroid supplements) affect the body’s use and metabolism of calcium. The degree
of osteoporosis is related to the duration of medication therapy. When the therapy is discontinued
or the metabolic problem is corrected, the progression of osteoporosis is halted, but restoration of
lost bone mass usually does not occur.
Risk Factors
- Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis.
- Women have a greater risk for osteoporosis because of sudden estrogen reduction.
- Nutritional factors contribute to the development of osteoporosis.
Assessment and Diagnosis
- Osteoporosis may be identified on routine x-rays when there has been 25% to 40%
demineralization. There is radiolucency to the bones.
- Low bone mineral density (BMD) studies are useful in identifying osteopenic and
osteoporotic bone and in assessing response to therapy.

14
- Laboratory studies (eg, serum calcium, serum phosphate, serum alkaline phosphatase,
urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation
rate) and x-ray studies are used to exclude other possible medical diagnoses (eg, multiple
myeloma, osteomalacia, hyperparathyroidism, malignancy) that contribute to bone loss.
Medical Management:
- An adequate, balanced diet rich in calcium and vitamin D throughout life, with an
increased calcium intake during adolescence, young adulthood, and the middle years, protects
against skeletal demineralization. Such a diet would include three glasses of skim or whole
vitamin D–enriched milk or other foods high in calcium (eg, cheese and other dairy products,
steamed broccoli, canned salmon with bones), daily. To ensure adequate calcium intake, a
calcium supplement 0`may be prescribed and taken with meals or with a beverage high in
vitamin C to promote absorption.
- Regular weight-bearing exercise promotes bone formation. From 20 to 30 minutes of
aerobic exercise (eg, walking), 3 days or more a week, is recommended. Weight training
stimulates an increase in BMD. In addition, exercise improves balance, reducing the incidence of
falls and fractures.
- Through early screening (using both assessment of risk factors and BMD scans),
promotion of adequate dietary intake of calcium and vitamin D, encouragement of lifestyle
changes, and early institution of preventive medications, bone loss and osteoporosis can be
reduced, resulting in a reduced incidence of fracture.
Pharmacologic therapy
- At natural or surgical menopause, hormone replacement therapy (HRT) with estrogen and
progesterone has been the mainstay of therapy to retard bone loss and prevent occurrence of
fractures.
- Other medications that may be prescribed to treat osteoporosis include bisphosphonates
(eg, alendronate [Fosamax]; risedronate [Actonel]) and calcitonin. Alendronate offers an
alternative to HRT and produces increased bone mass (by inhibiting osteoclast function) and
decreased bone loss. Bisphosphonates reduce spine and hip fractures associated with
osteoporosis. A weekly dosage strength of alendronate is available and has been shown to be as
effective as previously used daily dosing. Adequate calcium and vitamin D intake is needed for

15
maximum effect, but these supplements should not be taken at the same time of day as
bisphosphonates.
Fracture management
- Fractures of the hip are managed surgically by joint replacement or by closed or open
reduction with internal fixation (e.g. hip pinning).
- Surgery, early ambulation, intensive physical therapy, and adequate nutrition result in
decreased morbidity and improved outcomes. Evaluate and treat for osteoporosis if indicated.
- Osteoporotic compression fractures of the vertebra are managed conservatively.
- A new procedure, percutaneous vertebroplasty/kyphoplasty (injection of
polymethylmethacrylate bone cement into the fractured vertebra), is reported to provide rapid
acute pain relief and improved quality of life.
II.5. Kyphosis
It is the forward rounding of the back. It occurs at any age and most common in older women.
Age related kyphosis occurs as osteoporosis weakens the spinal bones to the point that they crack
and compress. In infants, it is due to malformation of the spine or wedging of the spinal bones
overtime.
Causes
- Osteoporosis
- Disk degeneration. Soft circular disk acts as cushions between spinal vertebrae, so with
age the disk dry out and shrink, which worsens the kyphosis
- Sheurmanns disease begins during growth spurts that occur during puberty, boys are
more affected.
- Birth defects
- Syndromes such as the marfan syndrome
- Cancer and its treatment
Signs and symptoms
Curved spine, back pain and stiffness
Complications
Body image problems, back pain, and decrease in appetite because the curve may cause the
abdomen to be compress.
Assessment and diagnosis

16
 - Physical examination, neurological examination for reflexes and muscle strength
- X-rays to determine the degree of curvature and deformity
- CT scan
- MRI to detect any tumors
- Nerve test to check the transmission of nerve impulses between spinal cord and
extremities
Treatment and management
- Pain relievers
- Osteoporosis drugs
- Exercise like stretching to improve spinal flexibility and back pain
- Bracing
- Healthy lifestyle. Check on weight and physical activity
- Maintaining good bone density. Diet rich in calcium and vitamin D, screening for BMD.
- Surgical done when curve is pinching the spinal cord and nerve roots
- Spinal fusion
II.6. Scoliosis
Scoliosis is a sideway curvature of the spine occurring most often during growth spurts before
puberty. Severe cases become disabling and reduce amount of space within the chest making it
difficult for the lungs to function properly.
Causes
- Hereditary
- Neuromuscular conditions such as celebral palsy and muscular dystrophy
- Birth defects
- Infections of the spine
Risk factors
- Age, sex and family history
Signs and symptoms
Uneven shoulders, uneven waist, back pain and difficult breathing in severe cases. The spine
rotates and twists.
Assessment and diagnosis

17
 - History related to growth; physical examination; neurological examination will reveal
muscle weakness, numbness and abnormal reflexes.
- X-rays, MRI,CT scans and bone scan
Treatment and management
Factors to consider when deciding on the treatment include:
 Sex: usually more progressive in girls than boys.
 Severity of the curve.
 Location of the curve: curves located at the centre-thoracic region worsen more often
than those of the upper and lower sections of the spine.
 Maturity: braces have effect on children whose bones are still growing. When the bones
stop growing progression becomes low.
The following comprises of the treatment and management:
- Checkups every 4-6months for children with mild scoliosis
- Braces
- Surgery: spinal fusion. Complications of surgery are bleeding, infection, pain and nerve
damage.
II.7 Herniated discs
This refers to a problem with one of the rubbery cushions (disks) between the individual bones
(vertebrae) that stack up to make your spine. A spinal disk if a little like a jelly donut, with a
softer centre encased within a tougher exterior. Sometimes called a slipped disk or a ruptured
disk, a herniated disk occurs when some of the softer jelly pushes out through a crack in the
tougher exterior. This most often occurs in the lower back or in the neck.
Causes
- Disk degeneration i.e. the wear and tear to the disk
- When the back muscles are used for lifting large heavy objects
Risk factors
- Weight, occupation and genetics
Signs and symptoms
- Worsening symptoms
- Bladder or bowel dysfunction
Assessment and diagnosis

18
 - Physical examination (back examination for tenderness); neurological examination
(reflexes, muscle strength, walking ability, pinpricks or vibrations and the ability to feel
light touches).
- X-rays to rule out other causes of back pain
- CT scan
- MRI to confirm the location and show nerves affected
- Myelogram
- Nerve tests
Treatment and management
Conservative treatment- avoiding painful positions, following planned exercises and pain
medications will relieve symptoms in 9 out of 10 people.
- NSAIDS
- Narcotics like codeine
- Tramadol for nerve pain
- Muscle relaxants
- Cortisone injections
- Physical therapy (position and exercises)
- Surgery: partial or complete removal of the disk; spinal fusion.
- Lifestyle: pain relievers; use heat/cold packs; avoid too much bed rest.
Prevention
- Exercise
- Maintain good posture
- Maintain healthy weight

19