BODY POSTURE AND MECHANICS

Fatigue, muscle strain and injury can result from improper use or positioning of the body during activity or rest. Good posture is achieved when all parts of the body are in correct body alignment, and is important when sitting, lying, standing or moving. Normal spinal curves should be maintained and the joints should be supported in their normal positions. Good posture (Figure 36.3) and alignment reduces strain on all muscles and joints (Figure 36.4) and enables internal organs to function without interference; for example, full lung expansion is facilitated. Body mechanics is the term used to describe the physical coordination of all parts of the body to promote correct posture and balanced effective movement. The practice of correct body mechanics results in less fatigue and reduces the risk of muscle and joint injury.

Figure 36.3 Body mechanics: correct standing posture

Figure 36.4 Synovial or freely movable joint

ATTITUDES, VALUES AND FEARS TOWARDS EXERCISE

Children learn the value of regular exercise if they are brought up in an environment in which exercise is seen in a positive way and both parents and children discover ways to incorporate exercise into their daily routine. Later on, these children are more likely to continue to exercise into their old age. On the other hand, sedentary parents may send the message to their children that exercise is too much trouble and not worth the effort. Thus early familial attitudes towards exercise can form lifetime patterns of behaviour. Personal values about one’s appearance (e.g. it is better to be slim or build up muscle to produce a ‘good’ body) can motivate both young and older adults to exercise regularly. Nurses need to dispel fears and anxiety about exercise and activity that many people may have because of chronic conditions or lack of information about the benefits of exercise, and respond appropriately to clients’ questions. (See Clinical Interest Boxes 36.2 and 36.3.)

THE OLDER ADULT AND EXERCISE

According to the National Health and Medical Research Council (NHMRC) in Australia, up to half of the functional decline associated with ageing is the result of disuse and can be reversed by exercise. Exercise improves cardiopulmonary fitness, ability to stretch and balance and endurance. Benefits of regular exercise are particularly important for older adults, as being fit makes it easier to perform daily activities and improves recovery after illness as well as minimising the risk of future ill-health. Light exercise is beneficial and, as long as individuals ease into exercise, especially if they have led sedentary lives, there is nothing to stop older adults from starting a regular exercise program. However, it is wise that they consult with their medical officer first. (See Clinical Interest Box 36.4.)

OVERWEIGHT AND OBESITY

In Australia in 2001, 30% of adult males and 36% of adult females aged 45–74 considered themselves to be overweight. The prevalence of obesity (those with a body mass index [BMI] greater than 30) in Australians has risen from one in 14 in 1980, to one in seven in 1989, and one in five by 1995. Based on current trends, by 2025 it could be one in three. It is known that being severely overweight puts a load on the heart and increases the risk of high blood pressure and diabetes, but what was not known until fairly recently is just how many years of life are lost if a person is obese. In the late 1990s American researchers asked that simple question of tens of thousands of Americans and the results were compelling, with reports of females with BMIs over 30 (especially if about 20 years old) losing 5–8 years, and obese men up to 12 years. These data are easily transferable to Australia. (See Chapter 31 for further information on BMI.)

Childhood obesity is of particular concern because the evidence shows that one in three obese children will become obese adults, increasing their vulnerability to weight related diseases. Overweight and obesity in children and adolescents is generally caused by lack of physical activity, unhealthy eating patterns, or a combination of the two, with genetics and lifestyle both important determinants of a child’s weight. Nurses need to be aware that inactivity is a health risk and that obesity is a serious health risk, not just a cosmetic issue, and that obese people risk losing many productive years of their lives. Clinical Interest Box 36.5 provides an outline of some self-care behaviours and exercises.

ISOTONIC, ISOMETRIC AND ISOKINETIC EXERCISE

Isotonic exercise involves muscle shortening and active contraction and relaxation of muscles and occurs with movement, such as carrying out activities of daily living, independent range-of-movement (ROM) exercises, swimming, walking, running, cycling or jogging. Examples of isotonic bed exercises are pushing or pulling against a stationary object, using a trapeze to lift the body off the bed, lifting the buttocks off the bed by pushing with the hands against the mattress and pushing the body to a sitting position (Kozier et al 2000).

Isometric exercise involves muscle contraction without shortening, so that there is minimum movement, for example, asking an immobilised client to contract and relax their quadriceps or gastrocnemius (calf) muscle without moving the leg. Nurses encourage both types when caring for clients. Two examples of isometric exercise are:

When isotonic exercises are not possible, isometric exercises are encouraged. Clients are taught to contract the muscle for the count of 10, then relax it. This exercise should be repeated about 10 times every 3–4 hours while awake. Benefits of isotonic and isometric exercise include increase in muscle tone, mass and strength, improved joint mobility, increased circulation and osteoblastic activity. However, when a nurse performs passive range-of-movement (ROM) exercises, in which the client’s muscles do not exert effort, some of the potential benefits are reduced in favour of improved joint mobility and circulation. Isokinetic exercise involves muscle contraction with resistance; for example, rehabilitative exercises for knee and elbow injuries. In this case, isokinetic devices are used to take muscles and joints through a complete ROM without stopping, with resistance at each point.

Mechanical devices are available for specific joints, which place these joints through continuous passive ROM (CPM). These CPM machines are used postoperatively to place joints through a selective repetitive ROM. The CPM can be set to certain degrees of joint mobility, with increasing joint mobility or flexion as the required outcome (Crisp & Taylor 2005).

RANGE-OF-MOVEMENT (ROM) EXERCISES

Joints are capable of a wide range of movement (Table 36.1). ROM or motion exercises are either active, when the clients are able to move the joints themselves, or passive, when the nurse moves clients’ joints within the normal ROM, noting joint flexibility and/or limitations of movement. ROM exercises are illustrated in Figure 36.5. Joints that are not moved regularly can develop contractures (shortening of a muscle and eventually ligaments and tendons and eventual loss of function). The following 11 terms are associated with joint movement:

TABLE 36.1 JOINT MOVEMENTS

Figure 36.5 Range-of-movement joint movements

The frequency with which ROM exercises are performed depends on the client’s condition and medical and nursing management, but they are commonly performed at least twice daily. However, it is important not to overtire the client. ROM exercises may be performed independently or with assistance. Using appropriate movements, all joints are exercised in a logical sequence. Exercise routines are normally individually designed and the intensity and frequency depend upon the client’s general condition, level of fitness and capabilities.

GAIT

Gait is the term used to describe the manner of walking and, while varying from one person to another, there is normally a certain rhythm to a person’s walk. Gait abnormalities may occur when there is a disorder of the musculoskeletal or nervous system; for example, unilateral hip dislocation produces a distinct ‘waddle’ with each step. A staggering, or ataxic, gait may be caused by a lesion in the brain or spinal cord, and a ‘scissors’ gait is one in which the legs cross each other in progression. An abnormal gait may also result from pain or discomfort due to a lesion on the foot, such as a corn, or from ill-fitting and uncomfortable shoes.

MYASTHENIA GRAVIS

This condition affects females more than males, usually occurs between age 20 and 40, and is an autoimmune disease of unknown origin. Defective muscle stimulation is caused by the development of antibodies that damage receptors in the neuromuscular junction, blocking impulses to muscle fibres. Progressive and extensive muscle weakness occurs, with the eyelids affected first by drooping (ptosis), and clients sometimes complaining of diplopia or double vision, owing to extraocular muscle weakness. The neck and limb muscles are affected next, with remissions and relapses precipitated by extreme exercise, infections, emotional disturbances and pregnancy.

MYOPATHIES AND PROGRESSIVE MUSCULAR DYSTROPHIES

Progressive muscular dystrophies are an inherited group of diseases in which there is progressive degeneration of groups of muscles. The major differences between these types of conditions are age of onset, rate of progression and groups of muscles involved. For example, the Duchenne type is gender-linked and presents at about age 5, while myotonic dystrophy usually begins in adulthood. Both progress without remission, and death occurs from respiratory failure or cardiac disease.

CRUSH SYNDROME

Sustained pressure on limbs causes ischaemia resulting in muscle necrosis or death. When pressure is released and circulation restored, necrotic products enter the blood and the filtration system of the renal system. Death may result from acute renal failure. Infection is a common complication and may cause gas gangrene (necrosis of soft tissue accompanied by gas bubbles; it can occur after surgery or trauma and is caused by infection with anaerobic organisms).

OSTEOPOROSIS

Osteoporosis is a condition in which the amount of bone tissue is reduced because the rate of bone deposition lags behind the rate of resorption. It may be progressive, temporary or permanent. Cancellous bone is usually affected before compact bone. Osteoporosis may be localised or occur throughout the skeleton. Bones are brittle and susceptible to fracture. The factors that contribute to excessive bone loss include diminished oestrogen levels, immobility, lack of exercise, nutritional deficiencies and certain endocrine disorders. Manifestations include low back pain, kyphosis (rounded back) and spontaneous or pathological fractures resulting from minor injury.

RICKETS

Rickets occurs in children, and osteomalacia in adults after ossification is complete, and both are caused by vitamin D deficiencies. Vitamin D is formed in the skin by the action of sunlight. In vitamin D deficiency, bones become soft, bowed and prone to fractures. Paget’s disease is found in people over age 40, is of unknown origin and characterised by hyperactivity of osteoblasts and osteoclasts; that is, rapid turnover of bone tissue. Bones are soft, thick and enlarged and may ‘bow’. Usually the pelvis, long bones, lumbar vertebrae and skull are affected.

TUMOURS OF BONE

Tumours of the bone may be benign, primary malignant or metastatic. Benign tumours may be single or multiple, or of several types. The most common benign form is giant-cell tumour, which is composed of multinucleate giant cells or osteoclasts. Clients complain of pain and tenderness, with localised swelling. Osteogenic sarcoma is the most common primary malignant bone tumour. The areas most often affected are the ends of long bones, especially the distal femur or proximal tibia, and metastases may occur, commonly in the lungs. Bone tumours are characterised by the gradual onset of pain in a limb, or the sudden onset of pain after a minor injury to the limb, where a localised mass or swelling develops, as well as a limp. Fatigue is a common symptom. Metastatic bone tumours occur when cells of a malignant primary tumour in another part of the body enter the blood or lymph and are spread to the bone.

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is a systemic disease characterised by chronic inflammation of the synovial joint linings, with periods of remission and exacerbation. Joints most commonly affected are those of the wrists, hands and feet. Rheumatoid arthritis results in muscle atrophy, osteoporosis and anaemia, as well as cardiovascular and pulmonary symptoms. The cause is unknown but the disease involves release of antigen–antibody (rheumatoid factor) complexes into the joints. More common in females, signs and symptoms include swelling and stiffness of the joints, followed by marked deformities resulting from soft tissue weakness and joint destruction. Rheumatoid nodules may be present over the extensor surfaces of the elbows or Achilles tendons.

Juvenile rheumatoid arthritis affects children under the age of 16. As for adult rheumatoid arthritis, the cause is unknown and, when acute, is characterised by pyrexia and arthralgia. Arthritis can be self-managed with the correct diagnosis by professionals, regular and appropriate exercise, pain relief and a well-balanced diet to maintain an ideal body weight. Infectious arthritis is inflammation of a joint that results from microorganisms that invade the synovial membrane. Symptoms include severe pain, inflammation and swelling of the affected joint, accompanied by systemic signs and symptoms of infection.

ANKYLOSING SPONDYLITIS

Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the axial skeleton (spine and adjacent soft tissue) and has characteristics similar to those of rheumatoid arthritis, but the rheumatoid factor is absent. The cause is unknown but heredity, immune responses and infection are suspected. Signs and symptoms include gradual onset of back pain, decreased spinal mobility, peripheral arthritis and, in advanced stages, kyphosis (hunched back).

OSTEOARTHRITIS AND GOUT

Osteoarthritis is a degenerative non-infectious disease that causes pain and restricted movement of affected joints. Cartilage in the joints becomes thinner and eventually the two bones come into contact and begin to degenerate, followed by inflammation and effusion. Thought to be caused by excessive use, it usually develops in late middle age and affects large weight-bearing joints (hips, knees and cervical and lower lumbar spine).

Gout is a condition characterised by joint inflammation due to deposits of sodium urate crystals in joints and tendons. Causes include a metabolic defect responsible for increased serum uric acid production and impaired excretion of uric acid by kidneys. Use of alcohol and diuretics may precipitate attacks. The large toe is commonly affected and becomes tender, inflamed and very painful. It occurs in males more often than females.

MUSCULOSKELETAL INFECTIONS AND INFLAMMATORY DISORDERS

Tendinitis is painful inflammation of tendons and of tendon–muscle attachments to bone, which commonly affects the shoulder rotator cuff, hip, Achilles tendon or hamstring muscle. Bursitis is inflammation of the synovial membrane lining a bursa, and usually occurs in the sub-deltoid, olecranon, trochanteric, calcaneal or prepatellar bursae. The cause of tendinitis and bursitis is overuse of a particular muscle group, which can eventually damage a tendon or bursa. Tendinitis can also result from other musculoskeletal disorders such as rheumatoid arthritis, whereas bursitis can result from calcium deposits in bursae, or infection. Signs and symptoms include pain, swelling and limited movement.

Occupational overuse syndrome (also known as repetitive strain injury [RSI]) is a collective term for a range of conditions that are mainly work related and characterised by discomfort or persistent pain in muscles and tendons. The syndrome results when activities performed on a repetitive basis cause gradual injury to specific muscles and tendons.

Osteomyelitis is a pyogenic (pus-forming) infection involving bone, bone marrow, and surrounding soft tissues, and may be acute or chronic, with resultant bone destruction. Acute osteomyelitis is characterised by rapid onset of severe pain in the involved bone, with local heat, swelling and inflammation as well as pyrexia, tachycardia, nausea and malaise. Chronic osteomyelitis is characterised by slight pyrexia, pain and persistent drainage of purulent material from a sinus tract.

COMMON SIGNS AND SYMPTOMS OF MUSCULOSKELETAL DISORDERS

Sprains, strains and fractures

A sprain is an injury to a ligament, caused when a joint is forced beyond its normal ROM. A ligament may be stretched or torn and local bleeding and bruising present with restricted movement. A strain is an injury to a muscle and/or a tendon, resulting from excessive physical effort. Both sprains and strains cause pain and swelling, but strains may cause muscle spasm as well. A fracture is a broken bone, often with nearby soft tissue, blood vessel and nerve damage, and is most commonly caused by injury to the bone. A stress fracture occurs when a bone is subjected to repeated or prolonged stress such as jogging. A pathological fracture may occur in weakened bone as a result of osteoporosis. Fractures are classified as open or closed, simple or complicated. Open (or compound) fractures are those in which the bone breaks through the skin, while closed fractures are those where the skin is intact. In a simple fracture only the bone is involved, while in complicated fractures nearby blood vessels, nerves or organs are affected.

Table 36.2 lists the various types of fractures, according to the way in which the bone has broken. Signs and symptoms vary but mostly there is pain, swelling, involuntary and painful muscle spasm, bruising, obvious deformity, abnormal mobility and loss of function. Crepitus (grating caused by bone fragments rubbing together) may be heard or felt. Shock may occur as a result of haemorrhage or extensive damage.

TABLE 36.2 TYPES OF FRACTURES

Type	Description
Greenstick	The fracture is incomplete and does not extend through the bone. The bone bends, and splits or cracks on one side
Transverse	The fracture line is straight across the bone
Oblique	The fracture line is at an angle across the bone
Spiral	The fracture line coils around the bone. This type of fracture generally results from twisting of the limb
Impacted	The fragments of broken bone are pushed (telescoped) into each other
Comminuted	The bone is broken into a number of fragments
Depressed	The broken edges are pushed below the level of the rest of the bone. This type of injury may occur when the skull is fractured
Avulsion	A fragment of bone, connected to a ligament, breaks off from the rest of the bone
Intracapsular	The fracture is within the joint capsule
Extracapsular	The fracture is close to a joint, but is outside the joint capsule

A neurovascular assessment is performed for every client who has experienced a fracture, whether treated with a cast or traction. It should be performed every hour for the first 24 hours and, if the cast is dry, then every 4–8 hours. Check the health facility’s protocol. The assessment includes inspection of:

• Skin: inspect area distal to the injury; palpate skin temperature with the back of the hand and compare with the opposite extremity or site

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