Hello and welcome. We're going to be talking about musculoskeletal problems. We're going to be talking about muscular dystrophy, a lot of acute back problems and back management, especially for patients when they're having acute episodes, and then also spine surgeries.
You know, after conservative therapy doesn't work, do they have to have some sort of surgical intervention? Now going back to muscular dystrophy, you know, just trying to understand the musculoskeletal system, you know, you think about just muscles and bones themselves, but it's a lot more than that. In fact, there's three things that have to be in place in order for us to actually have movement, be able to move a muscle. One, you have to have an intact central nervous system. Two, you need to have an intact peripheral nervous system.
And three, you have to have the muscles and bones that are healthy and they receive those impulses. impulses so that they can be told what to do. Now if any of those three systems does not work, right, I've got a stroke, that means that I may have weakness in an arm, or maybe I have Lou Gehrig's disease, so now my peripheral nervous system doesn't work, and so the impulses from my brain can't get to my muscle, or I can have muscle disease, where the brain sends a signal, it travels in the spinal cord. to the muscle itself but the muscle is diseased itself and it cannot respond due to atrophy or other disease processes so like i said so let's keep that in mind especially as we move from musculoskeletal and transition into neuro so discussing muscular dystrophy You know these patients often in pediatrics, we see them at young ages and you may be studying this in your pediatric specialty class, but we also introduce this from an adult standpoint too because these patients are receiving medical care and maybe living into adulthood and then we will be seeing the devastating effects of it.
So just understanding a little bit more about muscular dystrophy. It is a genetic group of diseases that affect the skeletal muscles and because of that then the neurologic system is affected they're unable to move the muscles they have profound atrophying and shrinking of the muscles themselves but as time goes on it's not just the skeletal muscles that are affected other muscles are affected too the muscles of the heart system and the diaphragm that control breathing are also affected. Now, typical types of muscular dystrophy, we talk about Duchesne's and Becker, especially Duchesne's.
That happens in the young population. Most people who get it are of that younger age. But Becker's also is another type too. But always remember that muscular dystrophy causes breakdown of the muscles themselves. And muscles are required in some of our basic processes.
You know, we think about ABCs all the time. We've been talking about dysrhythmias, especially when this starts affecting the heart. And then we talk about the breathing and people going into respiratory failure or not having good respiratory effort while the muscles of the diaphragm are affected in this disease. So how do we know somebody has muscular dystrophy? You know, what type of tests do we do to confirm it?
You know, we may see things on our assessment and be concerned, but they will do things like genetic testing. they also do a lot of muscle serum enzymes you know our creatinine kinase is a measurement of all of the metabolites of our muscles generally from our body emg electro uh myography it's where they actually put electrical impulses into the muscle itself to try and study it is it coming from the muscle is it coming from the nervous system and they look at the muscle itself muscle fiber biopsy so by doing a biopsy of the muscle They're able to look at the cellular structure and see if it has those patterns that might be more common with muscular dystrophy. EKGs need to be done on these patients.
Like I mentioned, the cardiac muscle can also be affected profoundly. So unfortunately, this disease process does not have a cure. What we try to do is slow the process of it maybe, but a lot of it is supportive care.
So we may use corticosteroids. it delays it but the disease does progress itself some disease modifying medications are are now being researched and they have for a long time you know is it the body that's actually destroying the muscles themselves so Like I said, so a lot of it does depend on supportive care. So what we want to do with these patients is try and preserve their quality of life, their mobility, their independence.
They're going to have a lot of physical therapy and occupational therapy. They're going to have a lot of assistive devices also and supportive things. Now, as the muscles decline, like we saw in the first pictures, they will have a lot of curvature.
and collapsing of the thoracic cage too, which can also limit their breathing. And so we're also, especially some of our priorities when we talk about ABCs, cardiac and respiratory functions in these patients. And so lots of cardiomyopathy, heart failure, because the muscle fibers are being attacked. And then because of the diaphragm problems are going to be on CPAPs. They may even be permanently trached because they need to have that positive airway pressure.
And As they have exacerbations, they may even have to be stepped up and actually put on a ventilator because of that. So this is actually a case study of twins that had muscular dystrophy. And you can see all the supportive devices that they have. They've got their CPAP to keep their airways open. And they've got the devices to help support their spine and then the wheelchairs and other devices.
But really trying to help them achieve the best quality of life. possible with the disease process. So the family needs to have a lot of support with the patient who has muscular dystrophy because they will be guiding the care, making decisions in the care, and working as a team.
So really range of motion, nutrition, and what can they do to support that quality of life. Really keeping the client as active as possible, avoiding prolonged periods of bed rest because that only causes more muscular atrophy. I mean we know that our muscles atrophy from lying in bed and we don't have muscle disease. Any hospital patient more than two days in bed will start having shrinking of the muscles. Muscular dystrophy, it just gets worse and happens so much faster.
So limit those sedentary periods. A lot of skin breakdown risks and of course because of the immobility respiratory complications too. So Lifelong medical care as they continue and as the disease progresses.
And there are resources. So teaching the family about those public resources and organizations that help families and clients who have muscular dystrophy is very, very helpful. Starting with acute low back pain. This particular topic, unfortunately, affects so many people. the workforce around the world not just the US and there are a lot of people who end up disabled or unable to perform their job so we really want to focus on trying to get them healing trying to prevent future injuries too so a lot of education on prevention and back care and dynamics lifting dynamics is very very important with this topic All right, now let's change here.
Our topic is now going to be the back, the spine. Now, we are talking about orthospine, very different than neurospine, right? So, orthospine is all the bones, the ligaments, the tendons, the muscles that actually support the back and everything coming from the spine itself. Now, one of our greatest concerns about this is when the Ortho-spine now turns into ortho-neuro, and so now the nerves are being involved, and they aren't able to innervate the muscles, and now we've got weakness, and we've got radiation to other parts of the body.
So this is a huge concern when we're talking about BACs, and we're always on guard watching for it to see if it is going to worsen and become neurological. So differentiating some of the types of pain these patients may have, you know, localized pain, you know, more in the ortho area or where the area is damaged. But once we start getting to that diffuse pain and also radicular pain, and that's an important concept to understand, radiculopathy means that the nerve has been involved or the nerve root has been irritated and now the pain is being radiated to another part of the body like sciatica.
Referred pain, the source of pain comes from a different area. So maybe it may be the low back, but yet you're having pain behind the knee or in the calf itself. But that doesn't come from that particular area. It actually comes from the spine itself.
So we can have those different terminologies for pain. So looking at some of the risk factors that our patients may have when they either an initial episode or recurrent episodes, you know, even studying your specialty classes like OB, pregnancy causes a huge amount of pressure on the low back and can worsen existing back problems or create new ones themselves. Excess body weight, especially the truncal adiposity or the abdominal adiposity, they have so much fat in the trunk itself that it's actually pulling forward on the back causing disruption in the structures and possible nerve irritation.
Cigarette smoking is horrible on collagen. Cigarette smoke itself actually breaks down collagen. It's been found that people who smoke have a lot of wrinkles, their skin, their joints, everything start breaking down.
So and then talk about those patients that are that may have symptoms that may be doing a job that puts them at risk, even nursing. Nursing, we lift a lot. They're trying to institute a lot of strategies to try and help nurses not do that direct lifting to take the pressure off their back so it reduces the amount of back injuries they have. But any job that requires heavy lifting, moving, bending and twisting especially, right?
When we lift, talk about your body mechanics. You need to take your back out of the equation for lifting. you tighten your core, you lift with your legs, you do not lean over or bend over using those back muscles because it actually magnifies something that weighs 50 pounds lifted improperly may end up having an impact of 200 or 300 pounds on the back. Most pain comes from the lower part of the back.
It bears most of the body weight it has less supportive structures I mean at least in our thoracic cage we've got the sternum and our ribs to support thoracic lumbar the thoracic discs but the lumbar doesn't have it it's basically like the trunk of a tree and so a lot of changes and degenerative diseases can happen between straining it you can get arthritis on the facets you can get disc disease also and then herniation of the discs in between it. Now to term something acute low back pain versus chronic low back pain, it's a matter of time. Typically acute low back pain is less than four weeks.
There's some sort of trauma or something that happens but it not may not necessarily happen initially. I mean we think about musculoskeletal injuries, don't they swell? over the next 24 to 48 hours.
So same thing with the back. If you have an injury, it may be a little twinge when it actually happens. But then as time goes on, you're going to have more swelling and edema in the area.
And the pain will actually get much worse as it starts putting pressure on all those areas, a lot more muscle spasms and things like that. They get limited flexibility, inability to stand upright. And you'll see these patients leaning forward. it's because they can't establish that normal lumbar curve because the facets and the muscles and everything back there are in so much pain. When they squish them together, the pain gets much, much worse.
We are going to be needing to do a lot of testing on these patients to find out where the incident is. We can use things like MRIs and CAT scans also, especially if there's any trauma, if there was any sort of impact. or if they think that there's some degenerative disease that may be causing the structural problems.
So during this acute episode, like I said, assess your patients. Is this really what's going on? Was there an incident of it?
Are they using medications over the counter? So maybe they haven't seen a medical provider regarding their low back pain. Maybe they've been trying to medicate themselves.
medicate themselves by NSAIDs or Tylenol or other things like patches that they can get at the drugstore? Have they had other types of procedures too? Maybe previous back surgeries or epidural injections and now this is just a worsening of that.
And then ask them about any limitations. Can they not work at this time? Do they have limitations in their activity?
And then also understand about Between taking the medications and the injury, what about their bowels? The bowels are so important at this point because a lot of times due to the pain, the muscle spasms, the patients won't want to bear down. They get very, very constipated from the medications that they're using. And then they're probably not sleeping very well also because maybe laying in the bed for prolonged periods hurts and they're getting up. So it's very, very interrupted then too.
But always assess their neuro status. Do they have pain that's radiating, burning, numbness, tingling, things like that in other parts of the body rather than just where the intense focal pain is. So when you assess them objectively, we'll see things like guarding.
They won't want you to move them or move too quickly. They may be moving very slowly. Like I said, they have that kind of bent forward posture also. Check their reflexes too.
I mean if it's a back strain or injury, you know, the nerve should be intact and then our reflexes, our patellar and our Achilles tendon reflexes should be intact. If it is pressing on the nerve then those things may be depressed. They do things like Trendelenburg tests and leg raises and things like that, but they will definitely have limited range of motion, the inability to move forward.
And then, like we mentioned, the different tests that need to be done to evaluate the source of it. So these patients typically are treated with things like anti-inflammatories. Like I mentioned, there's lots of swelling in the area or Tylenol.
They may have muscle relaxants, especially if they've got that strong shooting pain as the muscle grabs in the back itself. Other complementary things like acupuncture, cold. our warm compresses of course for the first 24 or 48 hours after an injury cold and then after that hot is fine too or they can alternate whatever makes them comfortable but if this doesn't help they may actually need maybe some steroids some critical steroids to reduce the swelling in the area maybe even stronger narcotic pain medications but they do need to be cautious about introducing these to people and so that they don't become using them in a prolonged period now bed rest briefly a couple of days not prolonged because the back the muscles themselves need to start moving we don't want them to atrophy so after initial periods of rest we want to get them up and moving avoid any extreme activities that will make it worse and a lot of times these resolve within two weeks Typically what I've seen is within the first five to seven days, by the end of that fifth day, a huge increase in the healing process itself.
And then the seventh day, and they're starting to feel much better. And then the healing then continues. So as these patients heal, our goal is to not have them re-injure themselves.
So we need to do a lot of education on body dynamics. and how to keep their back strong. A lot of times these patients go to physical therapy or go to some sort of trainer for strengthening and specific exercises because really our back is only as strong as our abdomen.
So we need to make our core strong so that our lumbar spine is strong also. They call it back school, right? You go and get educated on how to take care of your back. Prevention tip, of course, low heels, flatter shoes, avoid smoking, get your weight under control so you don't have all the pressure.
But then sleeping is really important also. Sleeping on your stomach is really hard on your lower back and your neck is also. So they typically recommend side sleeping or back sleeping.
And then supporting the patient, especially if they're having to change their work or other things financially that may be a challenge for them. but definitely the proper body mechanics to prevent this from happening again. So what if this acute back pain doesn't resolve?
Well if it goes on for more than three months and has repeating episodes and it's incapacitating then this is what they deem as chronic low back pain and it it can be progressive and each time it gets worse and worse and worse so and then we may see other changes actually in the structure of the spine itself like degenerative disc disease or arthritis of the facets, osteoporosis possibly with compression fractures, and then just maybe even some congenital problems if they had some sort of birth defect in the way the bones were formed. All of these can cause chronic low back pain so we're going to have to deal with this in a different way oftentimes. Those degenerative changes like osteoarthritis, rheumatoid arthritis, tumors, Paget's disease, all those can cause that kind of squishing of the spine, the spinal stenosis, right?
The narrowing of that canal and especially in the lumbar area itself. And so we're going to see different symptoms here, pain radiating. Pain gets worse with walking or standing the longer we're in one area at a time.
Numbness and tingling, right, that's that nerve involvement or heaviness. So like I said, as the nerves start getting involved, we start getting concerned because then they won't be able to innervate the legs themselves. Pain tends to get better if they lean forward, but it may even get worse in cold weather. So those are examples of more the chronic degenerative changes that happen.
So care for these patients is very similar to that for acute care, but they may need to be on these for extended periods of time. And then we're going to have to be very concerned about the side effects, especially if they are on NSAIDs in any way. Right. They can cause gastric bleeding and ulcers. So we need to be careful about that.
And they may need to be on some sort of maybe. Antidepressants, the SSRIs and SNRIs, actually do help with the nerve regulation and nerve pain that may be radiating. It also helps with some of the sleeping deficits that they may have. We can use other neurological agents like gabapentin or pre pregabalin.
So Neurontin and Lyrica are ones that also help regulate nerve nerve impulses, so it reduces the neuropathy and nerve pain that the patients may have. But other things too, heat application, weight loss, PT. I can't stress enough how important physical therapy is, not just for these acute episodes, but to really maintain their health throughout their life and making sure that they get on a good regimen. There also are alternative interventions we do. So if these aren't adequate in managing the patient's pain, then we may have to do some sort of surgical procedure.
There are things that are minimally invasive where they can do epidural injections. They can implant devices that actually deliver medication slowly. But if it is really bad, they may have to do surgery itself. And especially if these patients aren't having any support from conservative therapy.
and especially if they have any type of continued neurological problems. We're going to get into a little bit more depth in the intervertebral, the disc diseases, right? Those intervertebral discs contain a very hardened spongy material and in the very center of it, it's more gelatinous and these provide some flexibility in between the discs themselves.
but that can deteriorate, break down, compress, herniate, even rupture themselves. You know, that gelatinous material then ends up spilling out. So lots of different things, and it can be in all different areas.
The cervical, the thoracic, and the lumbar spine can all be affected by these. So looking at this a little deeper too, we can see the large bony vertebral bodies, the big round ones, and then we can see the vertebral prominences that are the posterior spine and the spinal canal goes right in between those two and you can see the the little openings where all of the spinal nerves exit that. Well now if I get degenerative disc disease then this narrows, it decreases in height, the disc itself may bulge out or herniate and so now It's encroaching on the space where those nerves come out. So that's why I'm going to be having things like numbness and tingling and decreased strength and decreased reflexes in my extremities because the nerve impulses can't get there due to the impingement that's happening.
So when we talk about this happening in the cervical discs, we're talking about pain that radiates to the arms and hands. And that's very concerning too. They may drop things or they can't open or go.
grip things like they used to and this can be very very concerning then of course we need to make sure it's not something else and then if it is coming from the spine what are the things we need to do to try and preserve that nerve function Now the lumbar disc here, the low back pain that we've been talking about, so now we've got pressure on those lower nerves, and so the patient will start having like paresthesias or absent reflexes. Now there is a syndrome that's very, very dangerous. They call it cauda equina.
This is a very serious complication about impingement to the lower part of the spine. As we can see in the picture here, the very bottom part of the spine. doesn't stay all together it actually flares out resembling very much like a horse's tail that's why they call it cauda equina horse's tail and so the pressure occurs in this lower spine or this particular part of the spine and then we're going to be seeing problems with the lower extremities we're going to be seeing weakness we're also going to be seeing things in bowel and bladder so they may have incontinence or they may have retention and they don't even feel it. They call it saddle anesthesia. So, you know, when you sit on a saddle, the inside of the legs and the perineum, well, the patients actually lose sensation of all those and that's where all of our urine and bowel control comes from.
So we need to be very careful about this. If it happens suddenly, we need to contact the provider right away because they may end up with permanent paralysis of this, having to be... catheterize the rest of their lives, having to have bowel care for the rest of their lives.
So really be aware of this particular complication to the low back. Our diagnostics are very similar, as mentioned before, starting with x-rays for just basic structural problems, but then going to our CTs and MRIs and maybe even injecting the spinal cord with some dye, myelogram, actually enabling to see the spinal cord much better. They do venograms and discograms and then even the nerve testing to the EMGs to see what the severity of it. So the intervertebral disc disease, conservative therapy, of course, limiting movement, ice or heat, ultrasound massage, even things like this TENS unit. This is a nice example here.
You can actually see the pads and they go around the area of the pain, really focusing on it. And then it actually gives a very small electrical current to the area and to the skin that actually kind of overloads the nervous system within that area so that it doesn't perceive the pain as much. A lot of technology has developed on this particular type of device to really negate the patient's pain that they're having.
And then because of that, they use less medications. So this is really an upcoming. device that's being developed.
So even with disc disease, you know, very similar plan of care. Conservatively, can they manage it? Can they unload the pressure that's on the nerves themselves?
And they'll use the same medications and possibly short-term steroids and things like that. But epidural injections have become one of the main stem pain relieving measures. As you can see here, what they do is they inject medication in the epidermis.
So they're not in the dura they're not in the spinal cord they're around it and they're not in the spinal fluid either that would be a spinal injection so epidura means just outside of it and so it bays all the nerves exiting there with medication to relieve the pain all right similar to our other plans of care with back problems strengthening of course good body mechanics avoiding your extremes And many times these patients are feeling better several months later, but it does take a lot longer than just the acute. It's not just muscles and spasms there. It's a lot more because of the degeneration of the spine itself. Now, if it gets worse and the nerve is starting to break down, conservative therapy fails, they are going to have to do surgery on these patients.
Loss of bowel and bladder, like I mentioned with Cauda equina. the radiculopathy, the nerve pain, persistent neurological deficits. So somebody may actually have one leg or one arm that's actually shrinking and atrophying because the nerve is diseased.
And so now the muscle is starting to atrophy because there's no neurological innervation of it. So always measure your extremities. Do your arms look... the same size, the muscle mass, the legs, are they the same size, is there one that looks smaller, and that's very concerning because that can be permanent loss.
So then they will have to do a surgical procedure. A lot of them are becoming minimally invasive which is nice, it reduces the recovery time, but whenever anybody has anything done with their back we need to be careful in the post-operative period and how to take care of them. So different procedures they can have, they can have a laminectomy where they're taking part of the bony protuberances away.
So it relieves the pressure on the nerve. They can do a discectomy where they actually take that spongy material between the bony vertebrae out. And then oftentimes they end up having to do a fusion where they actually fuse the two discs together.
and create stability there so that the nerves then are preserved. Oftentimes they put bone grafting in there. They can do an autograft where they take it from another part of the body too. Oftentimes they put plates and screws in there so that it's fixated, and then they can do stimulation through the bone stimulators.
But yeah, so different things need to be done depending on how much damage and what area is damaged. If they have to do a fusion, the patient then loses the mobility of those vertebrae twisting and moving on themselves and it actually puts more stress on the vertebrae above and below. So there is a lot more research going into artificial disc replacements too where it still allows that movement so that it doesn't put as much strain on the other ones above and below.
So how do we take care of these patients, especially after they've had surgery? We've discussed the conservative therapy and the medications, but now if they have surgery themselves, we're going to have to maintain proper alignment of the spine itself. So we log roll these patients.
We're going to have to assess them neurologically. We're going to have to assess their bowel and bladder function also. We always put pillows under their knees or thighs when they're laying on their back. If they do turn on their side, we make sure that we put a pillow between their knees also to keep their spine in alignment.
But like I said, we always log roll them. We want to keep the spine as one unit. And then teaching the patient on how to move this way is very helpful too.
But do assure them that this is just a postoperative healing period. As they get stronger after the surgery itself, then their mobility and their flexibility will improve too. Now postoperatively we will have to work on pain management. So they'll get opiates for the first 24 to 48 hours, maybe even a PCA where they're able to control it themselves and hit the button. But really these patients didn't have surgery on their gut so their GI tract should wake up quite quickly after surgery.
So we're always assessing their bowel sounds, we're asking them about passing any gas, any nausea would be a signal that maybe they're not, their bowels aren't awake. We will be giving them muscle relaxants. And always remember, muscle relaxants have a similar side effect to opiates.
So if I'm taking an opiate painkiller and a muscle relaxant, it amplifies respiratory depression, constipation, sedation, respiratory. So really be careful when we give these patients some medications. We also need to assess their pain. Is it getting worse? Maybe they have bleeding or bruising into the area.
Assess for any clear fluid leaks because they are doing surgery around the spinal area. Maybe some spinal fluid is starting to leak out and it would be clear. It looked very watery and we can test it for glucose and also to check it for the halo sign also.
So when we do our assessment, make sure you focus on movement, sensation, um Ask them, are you having any pins or needles, you know, the paresthesias that can occur? And this needs to be done quite frequently after surgery. And then repeatedly assess their vital signs to temperature, any signs of infection, especially since they are working around the spinal cord.
You know, bacteria can get into the spinal fluid too. Check their circulation, cap refill, and their peripheral pulses. But assess their bowel function.
Besides the pain medication themselves, if they have any complications or swelling, like I mentioned, cauda equina, they could get an ileus from that. We want to make sure we give them stool softeners and laxatives early on from day one because they don't want to strain. We don't want them to push.
It'll actually put more pressure on their back, which can actually cause damage. So monitoring their bladder, too. If there is any dysfunction with their bladder, it may indicate nerve damage and they may have retention of urine, so we may have to catheterize them. So look for retention, but also look for incontinence too, because all of those can be a sign of complications. A lot of these patients will take a little bit longer to heal too, and they may have activity limitations.
So what type of work they do can be greatly affected by having back surgery, and they may be out. Can they change what they're doing? Now some of these patients also have to have a TLSO, a lumbosacral orthotic, some sort of a brace that goes around the core itself around the back.
And so this will help to support them as they're actually healing. We'll have to support them in trying to apply it. We may actually work with the orthotists who are applying it.
Now, if they have cervical spine problems, what we need to do is observe for any swelling that occurs in the cervical spine. Now, if it's that high, then it can actually cause weakness and paralysis of the respiratory muscles, swallowing. And so, and the upper extremities, how are their grips? Their grips and their pushers should be equal and strong, just like they were before surgery, along with their pushes too.
Now, these patients typically have some sort of a mobilizing device on their neck, either a hard collar initially, and then they move to a soft collar, but definitely assess their neurological status, but also, like I said, airway and breathing. That can be a very dangerous complication for these patients. So when we're assessing the surgical site, of course, looking for any bleeding or swelling in the area. If they have a donor site, maybe they had to take bone from the iliac crest or the fibula to donate to a fusion.
Those sites also have to be assessed. If it is on the leg, watch for compartment syndrome. right if it's on the the hip itself make sure that you're not pulling or stressing that incision too but oftentimes those those can be quite painful but these patients as we try and transition them home post-operatively really teaching them how to get out of bed avoiding sitting or standing for long periods shifting their weight you know what are their lifting restrictions initially they are not allowed to lift anything more than five pounds but then as they heal they'll be able to lift more and more as they progress and as the provider determines use your legs and to lift and also trying to absorb shock when you're walking right we don't want to jar the back itself make sure they have a good body mechanics even with sleeping too having that firm mattress so all right this concludes our musculoskeletal for the acute back