Musculoskeletal Disorders Part 3 Muscular Disorders
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Transcript of Musculoskeletal Disorders Part 3 Muscular Disorders
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Maria Carmela L. Domocmat, RN,MSNInstructor, Curative and Rehabilitative Nursing CareManagement II
School of NursingNorthern Luzon Adventist CollegeArtacho, Sison, Pangasinan
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Part 1: Degenerative & Metabolic bonedisorders:
Part 2: Bone infections
Part 3: Muscular disordersPart 3: Muscular disordersPart 3: Muscular disordersPart 3: Muscular disorders
RhabdomyolysisRhabdomyolysisRhabdomyolysisRhabdomyolysis
Part 4: Disorders of the hand
Part 5: Spinal column deformities
Part 6 : Disorders of foot
Part 7: Sports Injuries
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MSN 3
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The word "dystrophy" comes originally from theGreek "dys," which means "difficult" or "faulty,"
and "trophe," meaning "nourishment." This word was chosen many years ago because it
was at first believed that poor nourishment of the
dystrophy. Today we know that muscle wasting in the
disorder is caused by defective genes rather than
poor nutrition.
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MSN 4
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refers to a group of more than 30 inheriteddiseases that cause muscle weakness and muscle
loss. Some forms of MD appear in infancy or
childhood, while others may not appear until.
The different muscular dystrophies vary in whothey affect and the symptoms.
All forms of MD grow worse as the person's
muscles get weaker. Most people with MD eventually lose the ability to
walk.
3/5/2012Maria Carmela L. Domocmat, RN,
MSN 5
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MSN 6
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characterized by progressive weakness anddegeneration
of the skeletal muscles that control movement.
Some forms seen in infancy or childhood-others may not appear until middle a e or later.
differ in terms of the distribution and extent of muscle weakness
(some forms of MD also affect cardiac muscle)
age of onset
rate of progression, and
pattern of inheritance
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MSN 7
http://www.ninds.nih.gov/disorders/md/md.htm
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are a group of inheritedconditions
caused by incorrect ormissing genetic informationthat prevents the body frommaking the proteins needed
healthy muscles. Many cases of MD occur
from spontaneous mutationsthat are not found in thegenes of either parent, andthis defect can be passed tothe next generation.
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MSN 8
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is a general term for a group of inheriteddiseases involving a defective gene.
Each form of muscular dystrophy is caused bya genetic mutation that's particular to that
.
The most common types of musculardystrophy appear to be due to a geneticdeficiency of the muscle protein dystrophin
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MSN 9
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Duchenne's and Becker's musculardystrophies - passed from mother to son
through one of the mother's genes in apattern called X-linked recessive inheritance.
Boys inherit an X chromosome from their
mothers and a Y chromosome from theirfathers. The X-Y combination makes themmale. Girls inherit two X chromosomes, onefrom their mothers and one from their
fathers. The X-X combination determines thatthey are female.
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MSN 10
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The defective gene that causes Duchenne'sand Becker's muscular dystrophies is locatedon the X-chromosome.
Women who have only one X-chromosome
muscular dystrophies are carriers andsometimes develop heart muscle problems(cardiomyopathy) and mild muscle weakness.
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MSN 11
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The disease can skip a generation untilanother son inherits the defective gene onthe X-chromosome.
In some cases of Duchenne's and Becker's,
a new mutation in a gene rather than from aninherited defective gene.
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MSN 12
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Women can pass down X-linked recessive disorderssuch as Duchenne's
muscular dystrophy. A woman who is a carrier
of an X-linked recessivedisorder has a 25 percent
unaffected son, a 25percent chance of havingan affected son, a 25percent chance of havingan unaffected daughter
and a 25 percent chanceof having a daughter whoalso is a carrier.
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MSN 13
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MyotonicMyotonicMyotonicMyotonic dystrophydystrophydystrophydystrophy and most MFMs -passedalong in a pattern called autosomal dominantautosomal dominantautosomal dominantautosomal dominantinheritanceinheritanceinheritanceinheritance.
If either parent carries the defective gene for',
chance the disorder will be passed along to achild.
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MSN 14
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Some of the less common types of musculardystrophy are passed along in the sameinheritance pattern that marks Duchenne'sand Becker's muscular dystrophies.
passed on from generation to generation andaffect males and females equally. Still othersrequire a defective gene from both parents.
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MSN 15
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In an autosomal dominantdisorder, the mutated gene isa dominant gene located on
one of the nonsexchromosomes (autosomes).You need only one mutatedgene to be affected by thistype of disorder. A person
disorder in this case, thefather has a 50 percentchance of having an affectedchild with one mutated gene(dominant gene) and a 50percent chance of having anunaffected child with twonormal genes (recessivegenes).
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MSN 16
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most common form of MD
primarily affects boys.
caused by the absence of dystrophin, aprotein involved in maintaining the integrity of muscle.
Progresses rapidly. Most boys are unable to walk by age 12, and later need a
respirator to breathe.
Girls in these families have a 50percent chance ofinheriting
and passing the defective gene to their children.
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MSN 17
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a group of genetic disorders that affect the use ofmuscles in the body.
inherited as an X-linked disorder. This is whyDuchenne MD primarily affects boys. Girls can inheritthe gene for DMD but not have any symptoms of thedisease.
,
births. There are thousands of new cases every year. affects children of all ethnic backgrounds. causes an absence of dystrophin, a protein that helps
keep muscle cells intact. This means that muscle cells are easily damaged and
become weak over time.
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MSN 18
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MSN 19
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MSN 20
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similar to Duchenne but the symptoms aremilder and can appear till 25 years of age.
Boys with BeckerBeckerBeckerBecker MD have faulty or not enough dystrophi
life and are also able to walk but they havesome heart problems and is present only inmales.
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MSN 21
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usually begins in the teenage years. causes progressive weakness in muscles of th
eface, arms, legs, and around the shoulders and chest.
affects both males and femalesprogresses slowly and can vary in symptoms from mild to disabling.
about half of the sufferers are able to walkthroughout their life and almost all thepatients live a normal life span.
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MSN 22
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Also known as LandouzyLandouzyLandouzyLandouzy----DejerineDejerineDejerineDejerine dystrophydystrophydystrophydystrophy
involves progressive muscle weaknessinvolving: Face
Abdomen Feet
Upper arms
Pelvic area Lower arms
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MSN 23
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When someone with facioscapulohumeral MDraises his or her arms, the shoulder bladesmay stick out like wings. Progression of thisform is slow, with some spurts of rapidly
.
during the teen to early adult years.
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MSN 24
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Aka: Steinerts disease the disorder's most common adult form
produces stiffness of muscles and an inability torelax muscles at will (myotonia), as well as themuscle weakness of the other forms of musculardystrophy.
typified by prolonged muscle spasms, cataracts,cardiac abnormalities, and endocrine disturbances.
Individuals with myotonic MD have
long, thin faces drooping eyelids a swan-like neck
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MSN 25
http://www.ninds.nih.gov/disorders/md/md.htm
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CauseCauseCauseCause A repeated section of DNA on either chromosome
19 or chromosome 3.
OnsetOnsetOnsetOnset Con enital form a ears at birth.
More common form may begin in teen or adultyears.
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MSN 26
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MSN 27
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dictionary.org/images/wiki/wikipedia/commons/thumb/e/e1/Autodominant.jpg/180px-Autodominant.jpg
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SymptomsSymptomsSymptomsSymptoms Generalized weakness and muscle wasting first
affecting the face, lower legs, forearms, hands andneck, with delayed relaxation of muscles aftercontraction common.
system, vision, heart or respiration. Learning disabilities occur in some cases. Congenital myotonic dystrophy is the more severe
form.
Men with myotonic muscular dystrophy havebaldness on their foreheads.
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MSN 28
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ProgressionProgressionProgressionProgression Progression is slow, sometimes spanning 50 to 60
years.
InheritanceInheritanceInheritanceInheritance Autosomal dominant the disease ma be inherited
through either the father or the mother.
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MSN 29
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MSN 30http://blog.thirdeyehealth.com/images/muscular-dystrophy-1.jpg
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The other major types of muscular dystrophyinclude: Limb-girdle muscular dystrophy
Congenital muscular dystrophy
Oculo har n eal muscular d stro h
Distal muscular dystrophy Emery-Dreifuss muscular dystrophy
Myofibrillar myopathies
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MSN 31
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the type which affects from teenage years toadulthood
is present in both males and females.
As the name indicates, in this type the
and then reaches to the shoulders ( pectoralpectoralpectoralpectoralgirdlegirdlegirdlegirdle ) and later legs and arms are alsoaffected,
sufferers are unable to walk and mostpatients live past mid adulthood.
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MSN 32
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the form which is present at the time of birth
rare
cause the loss of muscles
The term "congenital muscular dystrophy"re ers o a group o n er e muscu ardystrophies. Signs of these disorders mayinclude: General muscle weakness
Joint deformities
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MSN 33
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is apparent at birth or becomes evidentbefore age 2.
The course of this disorder variessignificantly depending on the type.
cause only mild disability, while others progressrapidly and cause severe impairment.
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MSN 34
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Signs in infants may include: Severe muscle weakness
Difficulty sucking and swallowing Difficulty breathing
Co nitive im airment
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MSN 35
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affects primarily the muscles of eyes andthroat which occur around 40s to onward
ages symptoms include the weakness of eyes and
dysphagia - predisposes the patients topneumonia and choking.
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MSN 36
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The first sign of this type of musculardystrophy is usually drooping of the eyelids
followed by weakness of the muscles of theeye, face and throat, resulting in difficulty
. .
Signs and symptoms first appear inadulthood, usually in a person's 40s or 50s.
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MSN 37
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very rare
mildest
affects the muscles of fore arms to hands andmuscles of lower legs to feet
very s ow y progress ng
not very severe
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MSN 38
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This group involves the muscles farthest awayfrom the center of the body (distal muscles)
those of the hands, forearms, feet andlower legs. The severity is generally less than
,
progress slowly. Distal MD generally begins inadulthood between the ages of 40 and 60.
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MSN 39
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the type which affects from childhood to teenyears
present only in the males
affects the muscles of pectoral region to
with that patients have extreme heartextreme heartextreme heartextreme heartproblemsproblemsproblemsproblems that are usually fatal.
This is the type which also affects the carriers
(females) but the symptoms are not verysevere.
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MSN 40
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This form of muscular dystrophy usuallybegins in the muscles of the: Shoulders Upper arms
Shins
Cardiac arrhythmias, stiffness of the spineand muscle contractures are other features ofEmery-Dreifuss MD. Emery-Dreifuss MD
usually begins in the childhood to early teenyears and progresses slowly.
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MSN 41
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Though in some cases the MFMs affect onlythe muscles closest to the center of the body
(proximal muscles) such as the shoulderand hip muscles the distal muscles also are
.
disorders also is commonly associated with: Stiffness of the spine
Muscle contractures
Nerve damage (peripheral neuropathy) Thickening and stiffening of the heart muscle
(cardiomyopathy)
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MSN 42
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MSN 43
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Progressive muscular weakness
Delayed meeting of motor milestones
Waddling gait Walking on toes
Frequent falls
Gowers signGowers signGowers signGowers sign Hyperthrophied calf muscles
Poor balance
Scoliosis of the spine
Fracture of long bones Inability to walk (late stages)
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MSN 44
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Waddling gait, a distinctive ducklike walk, is animportant sign of muscular dystrophy, spinal
muscle atrophy or, rarely, congenital hipdisplacement.
The ait results from deterioration of the pelvic
girdle musclesprimarily the gluteus medius, hipflexors, and hip extensors. Weakness in thesemuscles hinders stabilization of the weight-bearing hip during walking, causing the opposite
hip to drop and the trunk to lean toward that sidein an attempt to maintain balance.
3/5/2012Maria Carmela L. Domocmat, RN,
MSN 45
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Typically, the legs assume a wide stance andthe trunk is thrown back to further improve
stability, exaggerating lordosis andabdominal protrusion. In severe cases, leg
equinovarus deformity of the foot combinedwith circumduction or bowing of the legs.
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MSN 46
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With Duchenne's musculardystrophy, waddling gait becomes clinically
evident between ages 3 and 5. The gaitworsens as the disease progresses, until the
use of a wheelchair, usually between ages 10and 12. Early signs are usually subtle: a delayin learning to walk, frequent falls, gait or
posture abnormalities, and intermittent calfpain
3/5/2012Maria Carmela L. Domocmat, RN,
MSN 47
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With Becker's muscular dystrophy, waddlinggait typically becomes apparent in late
adolescence, slowly worsens during the thirddecade, and culminates in total loss ofambulation. Muscle weakness first appears int e pe v c an upper arm musc es.Progressive wasting with selected musclehypertrophy produces lordosis withabdominal protrusion, poor balance, a
positive Gowers'sign and, possibly, mentalretardation.
3/5/2012Maria Carmela L. Domocmat, RN,
MSN 48
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With facioscapulohumeral musculardystrophy, which usually occurs late in
childhood and during adolescence, waddlinggait appears after muscle wasting has spread
to the pelvic girdle and legs. Earlier effectsinclude progressive weakness and atrophy offacial, shoulder, and arm muscles; slight
lordosis; and pelvic instability.
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MSN 49
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to stand, affected children press their handsagainst their ankles, knees and thighs
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MSN 50
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MSN 51
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Morbidity and mortality rates depend on thetype of congenital muscular dystrophy.
Its incidence varies, as some forms are morecommon than others.
3300 live male births.
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Myotonic muscular dystrophy is the mostfrequent form of muscular dystrophy among
adults. Its prevalence is estimated at one casefor every 10,000 people in most countries.
,
the Charlevoix and Saguenay-Lac-St-Jeanregions, where one person out of 500 isestimated to carry the disease.
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MSN 53
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Careful review of family's history of muscledisease
medical history review and physical examination Blood testsBlood testsBlood testsBlood tests
Dama ed muscles release enz mes such as creatinekinase (CK), into blood. High blood levels of CK suggesta muscle disease, such as muscular dystrophy.
ElectromyographyElectromyographyElectromyographyElectromyography
UltrasonographyUltrasonographyUltrasonographyUltrasonography
Muscle biopsyMuscle biopsyMuscle biopsyMuscle biopsy
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MSN 54
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Genetic testing.Genetic testing.Genetic testing.Genetic testing. Blood samples are examined for mutations in some of
the genes that cause different types of muscular
dystrophy. For Duchenne's and Becker's muscular dystrophies,
standard tests examine just the portions of thedystrophindystrophindystrophindystrophin genegenegenegene responsible for most cases of thesetypes of MD. These tests identify deletions or
duplications on the dystrophin gene in more than two-thirds of people with Duchenne's and Becker's MDs. The genetic defects responsible for Duchenne's and
Becker's muscular dystrophies are harder to identify inother cases of those affected, but new tests that
examine the entire dystrophin gene are making itpossible to pinpoint tiny, less common mutations.
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MSN 55
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There is no cure for muscular dystrophyno cure for muscular dystrophyno cure for muscular dystrophyno cure for muscular dystrophy.
Current treatment is designed to help prevent
or reduce deformities in the joints and thespine and to allow people with MD to remain
.
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MSN 56
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Treatments include Physical and speech therapy
Orthopedic devices Surgery Medications
ome peop e w muscu ar ys rop y ave
mild cases that worsen slowly. Other casesare disabling and severe.
Research into gene therapy may eventually
provide treatment to stop the progression ofsome types of muscular dystrophy.
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MSN 57
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As muscular dystrophy progresses and musclesweaken, fixations (contractures) can develop in
joints. Tendons can shorten, restricting the flexibility
and mobility of joints. Contractures are uncomfortable and may affect
the joints of your hands, feet, elbows, knees and
hips. One goal of physical therapy is to provide regular
range-of-motion exercises to keep joints asflexible as possible, delaying the progression of
contractures, and reducing or delaying curvatureof your spine. Using hot baths (hydrotherapy)also can help maintain range of motion in joints.
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In some cases, doctors may prescribemedications to slow the progression and
manage signs and symptoms of musculardystrophy: ,,,,
((((myotoniamyotoniamyotoniamyotonia).).).).Medications that may be used to helpmanage myotonia associated with MD includemexiletine (Mexitil), phenytoin (Dilantin, Phenytek),baclofen (Lioresal), dantrolene (Dantrium) and
carbamazepine (Tegretol, Carbatrol).
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Muscle deterioration.Muscle deterioration.Muscle deterioration.Muscle deterioration. The anti-inflammatorycorticosteroid medication prednisone may help
improve muscle strength and delay the progressionof Duchenne's MD. The immunosuppressive drugscyclosporin and azathioprine also are sometimes
cells.
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Assistive devicesAssistive devicesAssistive devicesAssistive devicesBraces can both provide support for
weakened muscles of your hands and lowerlegs and help keep muscles and tendons
,
progression of contractures. Other devices,such as canes, walkers and wheelchairs, canhelp maintain mobility and independence. If
respiratory muscles become weakened, usinga ventilator may become necessary.
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SurgerySurgerySurgerySurgeryTo release the contractures that may develop
and that can position joints in painful ways,doctors can perform a tendon release
.
of your hip and knee and on the Achillestendon at the back of your foot. Surgery mayalso be needed to correct curvature of the
spine.
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Other treatmentsOther treatmentsOther treatmentsOther treatmentsBecause respiratory infections may become a
problem in later stages of musculardystrophy, it's important to be vaccinated for
influenza shots.
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Perform passive and active muscle-stretchingexercises to the arms and legs.
Encourage the patient to walk at least 3 hourseach day (with leg braces, if necessary) to
,
contractures, and delay further gaitdeterioration, if possible.
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Stay near the patient during ambulation, toprovide support if necessary.
Provide a balanced diet to maintain energylevels and prevent obesity.
with muscular dystrophy and spinal muscleatrophy, provide emotional support for thepatient and his family.
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Caution the patient about long, unbrokenperiods of bed rest, which accelerate muscle
deterioration. Refer the patient to a local Muscular
, .
Suggest genetic counseling for parents, ifthey're considering having more children.
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On the cover: AndyVladimir, of CoconutGrove, Fla., had MMDand used a wheelchair,but that barely slowed
businessman, textbookauthor, world travelerand travel writer,including for MDA's
Quest magazine, Andylived to age 76.
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http://www.mdausa.org/
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-dystrophy/DS00200/DSECTION=treatments-
-
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a condition that may occur when muscletissue is damaged due to an injury in which
muscle in the body is damaged rhabdomyo=skeletal muscle + lysis= rapid
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There are a three of types of muscle in thebody, including:
skeletal muscles that move the body; cardiac muscle located in the heart; and
smooth muscle that lines blood vesselsgastrointestinal tract, bronchi in the lung, and thebladder and uterus. This type of muscle is notunder conscious control.
Rhabdomyolysis occurs when there is damage
to the skeletal muscle.
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is the breakdown of muscle fibers withleakage of potentially toxic cellular contents
into the systemic circulation. The final common pathway of rhabdomyolysis
homeostasis
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The injured muscle cell leaks myoglobin (aprotein) into the blood stream.
Myoglobin can be directly toxic to kidneycells, and it can impair and clog the filtration
.
Both mechanisms can lead to kidneyfailure (the major complication ofrhabdomyolysis).
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Significant muscle injury can cause fluidand electrolyte shifts from the bloodstream
into the damaged muscle cells, and in theother direction (from the damaged musclecells into the bloodstream).
As a result, dehydration may occur. Elevated
levels of potassium in the bloodstream(hyperkalemia) may be associated with heartrhythm disturbances and sudden cardiac
death due to ventriculartachycardia and ventricular fibrillation.
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When muscles are damaged, especially due toa crush injury, swelling within the muscle can
occur, causing compartment syndrome. If this occurs in an area where the muscle is
membrane), the pressure inside the musclecompartment can increase to the point atwhich blood supply to the muscle is
compromised and muscle cells begin to die.
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Rhabdomyolysis was first appreciated as asignificant complication from crush and blast
injuries sustained in a volcano eruption inItaly, in 1908.
and second World Wars help furtherunderstand the relationship between massivemuscle damage and kidney failure.
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United StatesUnited StatesUnited StatesUnited States Rhabdomyolysis accounts for an estimated 8-15%
of cases of acute renal failure.
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When muscle is damaged myoglobin (protein pigment) - released into the
bloodstream and filtered out of the body by thekidneys.
Myoglobin breaks down into potentially harmfulcompounds.
It may block the structures of the kidney, causingdamage such as acute tubular necrosis or kidneyfailure.
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Dead muscle tissue may cause a largeamount of fluid to move from the blood into
the muscle, reducing the fluid volume of thebody and leading to shock and reduced blood
.
The disorder may be caused by any conditionthat results in damage to skeletal muscle,especially trauma.
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The etiologies may be subdivided into Traumatic
exercise induced toxicologic
Environmental
Metabolic
Infectious
Immunologic
inherited classifications
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Major blunt trauma and crush injury
Electrocution
Lightening strikes Major burns
Excessive exercise, or examp e, running a
marathon or excessive weight lifting Patients in status epilepticus, in which
the seizure lasts for a prolonged period of
time and muscles involuntarily contract
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Prolonged immobilization patients who have been lying in one position for a
prolonged period of time due to adebilitating stroke, alcohol or drug overdose,
or those who have remained unconscious for aprolonged period of time for other reasons
The weight of the body is enough to crush themuscles that are pushed up against a hard surfacesuch as the floor.
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Dystonic reactions cause muscles to spasm,and if left untreated can damage muscle
Cholesterol lowering medications [forexample, statins prescribed to treat highcholesterol (particularly when combined withother cholesterol lowering medications such
as fibrates) Antidepressant medications
[for example selective serotonin reuptake inhibitors(SSRIs) antidepressants may cause a serotoninsyndrome characterized by agitation, fever, andmuscle spasm]
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Some anesthetics can cause malignanthyperthermia syndrome with high fever and
muscle rigidity A variety of drugs of abuse [for
, , ,
(PCP), and amphetamines] Hyperthermia and hypothermia (high and low
body temperature, respectively)
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Complications from a variety of infectionscaused by bacteria, viruses, and fungi
Association with other diseases such as sicklecell disease, polymyositis,
Complications from the venom from snakebites and black widow spider bites
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Alcoholism (with subsequent muscle tremors)
Certain inherited or genetic syndromes
Crush Injuries Heat intolerance
Heatstro e
Ischemia or necrosis of the muscles (as mayoccur with arterial occlusion, deep venousthrombosis, or other conditions)
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Low phosphate levels
Seizures
Severe exertion such as marathon running orcalisthenics
a ng c s
Trauma Use or overdose of drugs, especially cocaine,
amphetamines, statins, heroin, or PCP
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Melli et al reviewed 475 patients withrhabdomyolysis hospitalized at Johns
Hopkins Hospital and found that the mostcommon risk factors were exogenous toxinsexogenous toxinsexogenous toxinsexogenous toxins,
illicit drugs, alcohol, and prescription medicationsresponsible in 46% of patients.
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Abnormal urine color (dark, red, or colacolored)
General weakness Muscle stiffness or aching (myalgia)
usc e en erness
Weakness of the affected muscles
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Additional symptoms that may be associatedwith this disease include the following:
Fatigue Joint pain
Seizures
Weight gain (unintentional)
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An examination reveals tender or damagedskeletal muscles.
CPK is very high. Serum myoglobin test is positive.
Serum otassium ma be ver hi h
Urinalysis may reveal casts and be positivefor hemoglobin without evidence of red blood cellson microscopic examination.
Urine myoglobin test is positive.
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This disease may also alter the results of thefollowing tests:
CPK isoenzymes Urine creatinine
Serum creatinine
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Vigorous hydration with isotonic crystalloidVigorous hydration with isotonic crystalloidVigorous hydration with isotonic crystalloidVigorous hydration with isotonic crystalloid the cornerstone of therapy for rhabdomyolysis.
Support of the intravascular volume increases theglomerular filtration rate (GFR) and oxygen deliveryand dilutes myoglobin and other renal tubulartoxins.
Immediately obtain intravenous access with a large-bore catheter.
Administer isotonic crystalloid 500 mL/h and thentitrate to maintain a urine output of 200-300 mL/h.
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Because injured myocytes can sequester largevolumes of extracellular fluid, crystalloid
requirements may be surprisingly large.
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Assess ABCs and support as needed.
Treat any underlying conditions, such as
trauma, infection, or toxins. General recommendations for the treatment
fluid resuscitation prevention of end-organ complications
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Patients with CK elevation in excess of 2-3 timesthe reference range, appropriate clinical history,and risk factors should be suspected of having
rhabdomyolysis. Administer isotonic crystalloid 500 mL/h and
titrate to maintain a urine output of 200-300m .
Consider central venous pressures or Swan-Ganzcatheterization in patients with cardiac or renaldisease. These invasive studies can assist in the assessment of
the intravascular volume.
Repeat CK assay every 6-12 hours in order todetermine peak CK level.
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Acute renal failureAcute renal failureAcute renal failureAcute renal failure develops in 30-40% ofpatients with rhabdomyolysis.
Suggested mechanisms include precipitation of myoglobin and uric acid crystals
decreased glomerular perfusion, and
the nephrotoxic effect of ferrihemate (formed upondissociation of myoglobin in the acidic environmentof the renal parenchyma). I
To prevent renal failure, many authorities advocateurine alkalinizationalkalinizationalkalinizationalkalinization, mannitol, and loop diuretics, mannitol, and loop diuretics, mannitol, and loop diuretics, mannitol, and loop diuretics.
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UrinaryUrinaryUrinaryUrinary alkalinizationalkalinizationalkalinizationalkalinization recommended for patients with rhabdomyolysis and
CK levels in excess of 6000 IU/L. should be considered earlier in patients with
acidemia, dehydration, or underlying renal disease..
ampule of sodium bicarbonate administered at 100
mL/h and titrated to a urine pH higher than 7. After establishing an adequate intravascular
volume, mannitol may be administered to enhancerenal perfusion. Loop diuretics may be used to
enhance urinary output in oliguric patients, despiteadequate intravascular volume.
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Treatment of hyperkalemiahyperkalemiahyperkalemiahyperkalemia consists of intravenous sodium bicarbonate, glucose, and
insulin; oral or rectal sodium polystyrene sulfonate
(Kayexalate); and
hemodialysis.
Administer intravenous calcium chloride forpatients who are hemodynamically compromisedand hyperkalemic.
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HypocalcemiaHypocalcemiaHypocalcemiaHypocalcemia is noted early in the course ofrhabdomyolysis and generally is not of clinicalsignificance. Calcium supplementation is not recommended.
Compartment syndromeCompartment syndromeCompartment syndromeCompartment syndrome
fasciotomy.
DICDICDICDIC fresh frozen plasma, cryoprecipitate, and platelet
transfusions.
Hyperuricemia and hyperphosphatemiaHyperuricemia and hyperphosphatemiaHyperuricemia and hyperphosphatemiaHyperuricemia and hyperphosphatemia rarely are of clinical significance and rarely require
treatment.
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Medical therapy for rhabdomyolysis focuseson
restoring adequate intravascular volume usingisotonic crystalloid.
Adjunctive measures that may decrease theincidence of acute myoglobinuric renal failure
include urinary alkalinization and osmotic and loopdiuresis.
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Class SummaryClass SummaryClass SummaryClass Summary Sodium bicarbonate is administered IV to alkalinize
urine in patients with rhabdomyolysis. This mayprevent toxicity caused by the presence ofmyoglobin in acidic urine and crystallization of uricaci .
Sodium bicarbonate (Sodium bicarbonate (Sodium bicarbonate (Sodium bicarbonate (NeutNeutNeutNeut)))) Useful in alkalization of urine to prevent acute
myoglobinuric renal failure. Titrate dose to increasepH to >7.
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Class SummaryClass SummaryClass SummaryClass Summary These agents increase osmolarity of glomerular filtrate
and induce diuresis. They hinder tubular reabsorption ofwater, causing sodium and chloride excretion toincrease.
Mannitol (Mannitol (Mannitol (Mannitol (OsmitrolOsmitrolOsmitrolOsmitrol))))
inadequate despite aggressive fluid therapy.
Initially assess for adequate renal function in adults byadministering a test dose of 200 mg/kg IV over 3-5 min.Should produce a urine flow of at least 30-50 mL/h over2-3 h.
In children, assess for adequate renal function by
administering a test dose of 200 mg/kg IV over 3-5 min.It should produce a urine flow of at least 1 mL/h over 1-3 h.
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Class S mmarCl SCl SClass S mmar
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Class SummaryClass SummaryClass SummaryClass Summary These agents elicit a loss of free water, increasing
diuresis.
Furosemide (Lasix)Furosemide (Lasix)Furosemide (Lasix)Furosemide (Lasix) Increases water excretion by interfering with the
- ,inhibition of sodium and chloride reabsorption inthe ascending loop of Henle and distal renal tubule.
Individualize doses. Depending on response,administer at increments of 20-40 mg q6-8h untildesired diuresis occurs. When treating infants,titrate with 1-mg/kg/dose increments until asatisfactory effect is achieved
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continued volume support and urinarycontinued volume support and urinarycontinued volume support and urinarycontinued volume support and urinary
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continued volume support and urinarycontinued volume support and urinarycontinued volume support and urinarycontinued volume support and urinaryalkalinizationalkalinizationalkalinizationalkalinization
Obtain serial CK measurementsCK measurementsCK measurementsCK measurements to verify thatvalues have peaked and are returning toreference range.
Serial physical examinations and laboratory
studies are indicated to monitor for compartment syndrome Hyperkalemia acute oliguric or nonoliguric renal failure DIC
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In patients with no apparent precipitating
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In patients with no apparent precipitatingfactors for rhabdomyolysis
consider inherited disorders of carbohydrate orlipid metabolism and myopathies.
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Death from hyperkalemia or renal failure
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Death from hyperkalemia or renal failure
Compartment syndrome
Disseminated intravascular coagulation (DIC) Hepatic insufficiency
Hypovo emia sequestration o p asma water
within injured myocytes)
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Hyperkalemia (release of cellular potassium
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Hyperkalemia (release of cellular potassiuminto the systemic circulation)
Metabolic acidosis (release of cellularphosphate and sulfate)
Acute renal failure (nephrotoxic effects ofliberated myocyte components)
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The prognosis depends on the underlying
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The prognosis depends on the underlyingetiology and any existing comorbidities.
Acute kidney failure occurs in many patients.
rea men soon a er r a omyo ys s eg ns
will reduce the risk of chronic kidney damage. People with milder cases may return to
normal activity within a few weeks to a month
or more. However, some continue to haveproblems with fatigue and muscle pain.
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Advise patients with rhabdomyolysis caused
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Advise patients with rhabdomyolysis causedby hyperthermia and/or inordinate exertion
to exercise in moderation with carefulattention to hydration and external methods.
Advise patients with rhabdomyolysis relatedto ethanol, recreational drugs, or prescriptionmedications to discontinue use of theoffending agent and refer them to a
rehabilitation program.
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Drink plenty of fluids after strenuous exercise
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Drink plenty of fluids after strenuous exerciseto dilute the urine and flush the myoglobin
out of the kidney. Proper hydration is also necessary after any
to skeletal muscle.
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