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Impaired Joint Mobility

BPHTI: PTH5201 Jul 2015

Learning outcomes:
At the end of this unit the student will be able to:
Explain the current evidence of age-associated changes
in joint mobility
Analyze the implications of impaired joint mobility for
clinical management of older adult patients/ clients.

BPHTI: PTH5201 Jul 2015

JOINT MOBILITY WITH AGING


Operationally defined, joint mobility is the capacity of
a joint to move passively, taking into account the joint
surfaces and surrounding tissue.
Interactions between muscle, tendon, ligament,
synovium, capsule, cartilage, and bone at a joint create
the unique aspects of joint mobility.
The result of the structural changes can include joint
impairment, activity limitation, and participation
restriction.

BPHTI: PTH5201 Jul 2015

BPHTI: PTH5201 Jul 2015

BPHTI: PTH5201 Jul 2015

Change in Joint Structures


Joint structures can be categorized as chondroid,
fibrous, and bony.
Chondroid structures are of cartilaginous make-up and
include articular cartilage, menisci, labra, and
fibrocartilaginous discs.
Fibrous structures include the ligaments and tendons
that surround the joint (i.e., extraarticular) as well as
ligaments within the joint boundaries (i.e.,
intraarticular). The other primary fibrous structure is
the joint capsule of diarthroses.
Bone creates the structural segments that move relative
to one another at the articulations.

BPHTI: PTH5201 Jul 2015

Chondroid Structures
As with all joint structures, there is no clear distinction
between typical aging and pathology of chondroid
structures.
One factor complicating this delineation is the
influence of loading history.
The incidence of osteoarthritis (OA) in individuals
involved in sports and occupations with high levels of
traumatic and static joint loading.
Once articular cartilage becomes damaged, the capacity
to heal is limited and initial injury may progress to the
development of cartilage lesions (i.e., cartilage
fibrillation)

BPHTI: PTH5201 Jul 2015

A histologic change specific to articular cartilage is


increased calcification over time.
Decreased hydration compromises the viscoelastic
properties and load-absorbing capacity of the cartilage.
Distinct changes specific to the intervertebral disc also
occur over time.
The nucleus becomes more fibrous and less gel-like
and the annulus becomes less organized.
Cracks may also develop in the annulus and nucleus.

BPHTI: PTH5201 Jul 2015

Decreased water content is also noted in the


intervertebral discs and is associated with shorter disc
heights.
The loss of disc height can lead to the chronic
pathological condition referred to as spinal stenosis, a
major cause of pain and disability for older adults.
Change of the intervertebral disc also alters
surrounding structures. For example, the diarthrodial
facet joints may experience greater loads, and elasticity
of the ligamentum flavum may decrease because of
decreasing tensile forces over time.

BPHTI: PTH5201 Jul 2015

Fibrous Structures
In typical function, fibrous structures absorb and
transfer some level of tensile load, based on collagen
content.
Although orientation and composition of tissue
components vary between fibrous structures and
between joints, the overarching similarities in response
to aging are increased stiffness and reduced elasticity.
In addition, there is evidence in animal models that
cross-sectional area and tensile strength of fibrous
structures decrease with age.

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Bone
Bony change is both directly and indirectly related to
joint mobility.
Directly, changes in bone can influence the joint
surfaces to alter joint mechanics.
Indirectly, fractures and other bony structural change
can alter joint alignment and function with possible
secondary influences on joint mobility.
The thickness and density of subchondral bone tends to
decrease with advancing age, although this is not
uniform at all joint surfaces.

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It is well established that osteopenia is prevalent with


aging, because of increased osteoclast and decreased
osteoblast activity, leading to increased risk of
osteoporosis.
The combination of lowered threshold for loading and
increased load demand results in an increased risk of
bone fracture with aging.
Fractures can alter joint mobility in a variety of ways,
such as disrupting circulation to joint structures,
altering loading patterns, and decreasing available
range of motion.
In addition, pain associated with fractures can be a
major problem, interfering significantly with an
individuals activity and participation.

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Whole Joint Changes


At the level of the whole joint, changes include
decreased joint space, increased laxity, altered
dispersion of loads, and altered joint moments of force.
Over time, the unloading of surrounding tissues and
joint structures that provide tensile support, because of
decreased joint space, may predispose the joint to
decreased range of motion.
Functionally, joint changes are reflected by age
associated changes seen in kinematics at both the
segmental level (i.e., osteokinematics) and between
joint surfaces (i.e., arthrokinematics).

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Range of Motion
Joint range of motion (ROM) decreases with increasing
age, although nonuniformly among joints, and is often
direction-specific within a given joint.
Generally, active and passive motion both decrease,
with active ROM tending to decline more than passive.
For the cervical spine, gradual decline in ROM is seen
beyond the age of with extension and lateral flexion
demonstrating the greatest decline.
Examinations of thoracic and lumbar motion reveal
extension to be most limited in older adults, with
minimal or no age-dependent decline in rotation.

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Declines in joint motion occur at the hip and foot/ankle


joint complexes, whereas knee motion, in the absence
of pathology, remains relatively consistent across the
life span.
It has been postulated that reduced hip extension seen
with aging may directly relate to decreased walking
speed in older adults, especially those with sedentary
lifestyles.
Decreased ankle sagittal plane motion is also seen with
aging, particularly in the direction of dorsiflexion.
The shoulder complex is most influenced, with flexion
and external rotation being the primary motions
affected.
At the elbow and wrist, no age-associated declines in
motion have been noted in absence of disease.

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Arthrokinematics
The connective tissue changes previously described can
potentially alter arthrokinematics through such
mechanisms as increased fibrous structure stiffness,
decreased chondroid structure volume and
viscoelasticity, and altered bone structure.
Although isolated arthrokinematic motions cannot be
performed volitionally, limitations can have a direct
influence on joint mobility.

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Force Transmission
It has already been noted that connective tissue
structures demonstrate altered capacity to transmit
tensile and compressive loads in older adults.
These alterations can result in increased demands on
specific regions within joints, possibly leading to
disease.
The changes in posture relate to alterations in joint
alignment and mobility. As a consequence of alignment
change, static and dynamic demands on joints are
altered.

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Influence on Activity and Participation


Postural control during activities such as walking,
position transfers, and reaching are known to decline
with age.
Age-associated activity limitation often culminates in
decreased participation in life events.
The relationship also works in the opposite direction,
with changes in activity and participation leading to
more sedentary lifestyles and secondary changes to
joint structure and function.

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Joint Examination
History
Activity and participation
Symptoms
Occupation/Activity
Health condition/Surgery
Family history
Living Environment
Systems Review

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Four Major Types of Tests and Measure Categories


to Consider When Assessing Joint Mobility
Observational task analysis
Self-report measures of activity and participation
Performance-based measures of activity
Joint-specific mobility testing

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Evaluation and Diagnosis


For example, consider an older adult presenting with
impaired hip mobility that limits walking.
If this individual seeks intervention after a proximal
femur fracture, Impaired joint mobility, muscle
performance, and range of motion associated with
fracture is an appropriate diagnostic classification.
In contrast, consider the patient who presents with hip
mobility impairment in addition to several other
ipsilateral symptom manifestations from a cerebral
vascular accident.
In this case, the musculoskeletal diagnostic
classification of the hip is secondary to a primary
neuromuscular diagnosis.
Goals

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Intervention
Remediation- Education, therapeutic exercise, and
manual therapy techniques
Compensation- use of assistive devices
Prevention-prevent onset or progression of problems.

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Patient education
Education on activity modification
Use of assistive devices

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Therapeutic exercise
Stretching-the longer the hold of stretch, up to 60
seconds, the greater the ROM benefit.
Strengthening- joint mobility improvement can be
achieved partly as a result of improved muscle
function. Strengthening also influences joint mobility
by loading the joint structures.
Endurance training, and
Balance training-stabilization exercises, Tai Chi, yoga

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Manual Intervention Techniques


Age is not a contraindication to joint mobilization and
manipulation.
In relation to older adults with osteoporosis, the use of
manual intervention techniques is controversial.
For individuals with spinal osteoporosis, grade V
mobilization (i.e., manipulation) has been
contraindicated based on concerns for fracture risk.

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Assistive/Adaptive Devices and Equipment


Assistive and adaptive devices can be used as
compensatory or preventive approaches to protect joint
structure and assist with load transfer across joints.
Devices such as canes and walkers are useful
components to physical therapy intervention for
individuals with joint mobility impairment.
Braces designed to alter joint alignment have also been
used with older adults. Findings indicate that alignment
can be altered and joint loading decreased across
painful areas of osteoarthritic joints during gait
function.

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Selection of appropriate footwear, designed to


strategically cushion and support, may be a simple way
to provide immediate relief of symptoms by decreasing
loads across lower extremity joints.
Additionally, shoe orthotics may improve lower
extremity alignment and bring about changes in joint
loading

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Outcomes
Self-Report Outcome Instruments Neck Disability Index (NDI)
Neck Pain and Disability Scale (NPAD)
The Roland-Morris Disability Questionnaire (RMDQ)
Oswestry Disability Index (ODI)
Western Ontario Osteoarthritis of the Shoulder Index
(WOOS),
The Western Ontario Rotator Cuff Index (WORC)
The Rotator Cuff Quality of Life Questionnaire (RCQOL),
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Australian/Canadian Osteoarthritis Hand Index


(AUSCAN)
The Disabilities of the Arm, Shoulder, and Hand
Questionnaire (DASH).
Lower Limb Core Score
Functional Ankle Disability Index (FADI)
Functional Ankle Ability Measure (FAAM)
Knee Injury and Osteoarthritis Outcome Score (KOOS)
Oxford Knee Score
Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC)

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Performance-Based Outcome Instruments


The functional reach test
Timed up and go test
Five times sit-to-stand test
Six-minute walk test
Stair climb test
Gait speed

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References:
Andrew A. Guccione, Rira A. Wong, Dale Avers, 2012
Geriatric Physical Therapy, 3rd ed, Elsevie
Timothy L. Kauffman, John O. Barr, Michael L. Moran
2007 Geriatric Rehabilitation Manual, 2 nd ed, Churchill
Livingstone
ACSMs guidelines for exercise testing and
prescription.9th edition.

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Thank you

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