Health promotion and disease prevention strategies for a healthy musculoskeletal system need to be appropriate for each specific individual, so you should carefully consider all collected data, both objective and subjective. Subjective data collection involves asking the client about risk factors, social determinants, and other considerations. This kind of inquiry should be integrated throughout the entire assessment. You will ask many probing questions during the subjective assessment, but you should also formulate questions based on critical reflection of the data you have collected during the subjective and objective assessment. Together, the findings will inform your clinical judgement for each specific patient and the health promotion needed.
A sedentary lifestyle with limited activity/exercise is a risk factor that contributes to MSK conditions. Many clients will sit for long periods at work, and then sit at home to relax. Oftentimes, activity is described as one’s general activity in the day (such as the activity they do around the house or at work). Exercise is a form of activity, but is considered intentional and planned physical activity often referred to as “working out.”
Listen to Murat Dalkilinç TED-Ed on Why sitting is bad for you [4:50].
Exercise, including aerobic and strength-training exercise, strengthens the muscles, bones, and joints of the MSK system. Guidelines vary based on age and health, but in general individuals should engage in about 30–60 minutes of aerobic activity, 5–7 times a week. Stretching is also an important element of activity in the workplace or during exercising. Watch the video by Physiopedia called Musculoskeletal Disorders (MSD) & Work Place to learn more about MSD and how stretching can help decrease the risk. Strength training is also important throughout life, and can include weight lifting, resistance bands, and using one’s own body weight for resistance, e.g., squats and push-ups.
Exercise is an important part of life for many clients, and can be part of their self-concept. However, individuals with MSK conditions may not be able to perform activities as they once did. You should assess what an active lifestyle means to the client, learn about their past experiences, and collaboratively design a new exercise program that fits their specific needs and interests.
Probing questions related to activity may include:
- Do you have any concerns about your level of activity or exercise?
- Tell me about your daily pattern of activity? What activities are you involved in?
- What exercise do you engage in? How long do you engage in this type of exercise? How many days of the week do you participate in exercise? (If the client plays sports, ask about their use of protective equipment.)
- What does an active lifestyle mean to you?
Collaborate with the client to create an activity/exercise care plan/program that is specific to their needs and personal goals. For example, low-impact activities such as walking, cycling, and water exercises involve less stress on the joints and muscles, and yoga and tai chi can help release endorphins, control breathing, strengthen balance and posture, and increase flexibility while strengthening muscles. Start at a realistic and attainable level, depending on the client’s physical capabilities and energy level, and slowly start to increase the time and duration of the physical activity. Clients should keep active but maintain pain-free activities and avoid over-strenuous activities when joints and muscles become inflamed or tired. For example, a client with an injury to the back muscles could engage in light activity (such as walking and stretching), but should avoid heavy lifting. Strength training can be resumed when the acuity of the injury subsides.
Many interventions are available to support clients to achieve their activity goals: community walking groups, fitness apps, and joining a local gym or group activity. The participACTION website is a helpful resource related to activity guidelines: https://www.participaction.com/en-ca. Consider activity interventions from a structural health promotion approach, considering the financial costs associated with many of these resources.
Ergonomics and Back Health
Ergonomics is essential to back health and the overall health of the MSK system. Many injuries and chronic health issues are related to inattention to ergonomics science.
Broadly speaking, ergonomics refers to designing a space for the body to move and function based on the needs of the human body. For example, consider body positioning when sitting at a desk, during repetitive actions, or picking up and moving heavy objects. Teach the client about how to maintain proper body alignment by using large muscle groups, keeping the objects close to their centre of gravity, avoiding twisting motions, and instead using pivoting motions or asking for assistance. For example, when picking an object up from the ground, a client should stand directly in front of the object, place their feet hip distance apart to create a supportive centre of gravity, bend down using the knees to engage the large quadricep muscles, keep the object close to the body’s centre of gravity during lifting and standing, engaging their quadriceps and glutes. Maintaining proper body alignment by stabilizing the centre of gravity and core can decrease the risk of injuries. The ultimate aim is to increase comfort and decrease injuries and pain. The workspace is often a focus when considering ergonomics, but it is also important to also consider common spaces in the home.
Listen to Murat Dalkilinç TED-Ed on The benefits of good posture [4:11].
Probing questions related to ergonomics and health may include:
- Tell me about any concerns you have related to ergonomics and your back health at work or at home?
- What physical position are you typically in at work (e.g., sitting, standing)?
- Are you engaged in any repetitive motions at home or at work (e.g., typing at a computer, lifting heavy objects, or other activities such as dishes/sewing)?
- Additional probing questions may be required based on the client’s answers:
- Tell me more?
- How does it affect your back or body?
- Do you experience any pain?
When considering interventions for a client, think about activities the client is concerned about, for example those that cause pain or other issues. Always consider health promotion from a preventative perspective, based on cues that are suggestive of potential issues.
Use relational and structural health promotion perspectives to further assess a client’s ergonomics and back health. Health is affected by relationships with others in the workplace and at home, and broader structural influences may require discussions and advocacy, especially with regard to the work space.
A healthy diet is important for musculoskeletal health because nutrients and hydration are important for the bones, joints, and muscles to grow and function. A healthy diet is also essential to help maintain an ideal body weight: when a person is overweight, the MSK system has to work harder to move the body because of the excess weight on the joints.
A well-balanced diet includes protein, calcium, vitamins D and K, magnesium, and zinc, which help with muscle and bone growth, repair, and maintenance, and adequate water intake helps with hydration and joint fluid. Inadequate nutrition can increase the risk of injury and negatively affects muscle, bone, and joint repair. Clients should avoid foods that cause inflammation such as refined carbohydrates (e.g., white bread), fried foods, processed meats, sugar, and trans and saturated fats.
Probing questions related to diet may include:
- Tell me about your usual diet?
- What have you eaten in the last 24 hours? Is that your usual diet?
- How much fluids do you typically drink in a day? What fluids do you drink (e.g., water, caffeinated beverages, alcohol)?
- Have you had any recent changes in your life that have affected your diet?
- With rising food costs, purchasing food can be difficult. Do you have enough money to buy healthy food?
Assess the client’s familiarity with Health Canada’s Food Guide (Government of Canada 2021) and discuss how they might use it to guide their food choices: https://food-guide.canada.ca/en/. Be aware that this new guide still has a Eurocentric element to it, so you should collaborate with the client about its relevance in the context of their cultural food practices. A snapshot of the guide is now available in dozens of languages: https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/snapshot/languages.html. Many resources have also been developed related to healthy eating and food safety for Indigenous individuals: https://www.sac-isc.gc.ca/eng/1581522106156/1581522147811
Based on the food guide, some key elements to consider are:
- Water should be the drink of choice: hydration can help keep muscles and joints lubricated.
- A meal/dinner plate should have half vegetables/fruit, one-quarter protein, and one-quarter whole grains.
- Cook whenever possible, as opposed to eating processed meals and purchasing fast foods.
Assess each client’s situational environment to understand how it affects their diet. For example, people with arthritis may have difficulty opening certain food items; you can help the client find adaptive tools that help with their grip. Nurses can collaborate with occupational therapists and physiotherapists to help clients create an accessible living environment that meets their specific needs.
From a structural health promotion approach, consider a client’s geographical access and financial ability to purchase healthy food. These are elements of food security, and the rising cost of food globally has made it difficult to ensure everyone is food secure. This is especially true in many remote regions of Canada’s North, where access to nutritious food is limited in terms of availability, and even when available, the costs are excessive. There may be times when you should refer the client to a dietician with certain and more severe musculoskeletal conditions.
Stress is a risk factor for MSK-related conditions as it can have physical, social, mental and emotional effects. Talking about stress factors can be triggering, so always use a trauma-informed approach to support the client during this type of conversation.
- Change and disrupt sleep patterns.
- Cause tooth-grinding, which can affect the temporomandibular joint.
- Lead to feelings of self-consciousness and subsequent self-isolation.
- Increase muscular tension in the trapezius muscles, causing neck or lower back pain.
- Affect breathing, thereby decreasing oxygen to muscles.
- Release hormones that increase inflammation in the body.
- Lead to injury due to distractions caused by a trigger.
Stress is usually a combination of multiple stressors. You should pay attention to how clients perceive or talk about themselves, their life, and their current situation, as these can indicate potential concerns and areas that need further assessment.
Probing questions related to stress may include:
- Tell me about stressors in your life?
- Have you experienced stress recently? Physically? Socially? Emotionally?
- Have you had any recent changes in your life? Tell me more?
- How does stress affect you?
- How often do you experience stress?
- How do you handle this stress?
- Tell me about the coping strategies you use?
When considering interventions for a client, consider their daily patterns of living and potential stressors that may be disrupting these patterns.
Stress management and coping strategies may include:
- Engaging in regular physical activity.
- Spending time with family and friends.
- Practicing relaxation techniques such as yoga, deep breathing exercises, and tai chi.
- Taking time for oneself and personal interests.
- Getting adequate sleep (usually 7–9 hours). (Wang et al., 2022).
Use a relational and structural health promotion approach to further assess the client’s situation in relation to stress and potential strategies/resources. Once you understand how the client experiences, perceives, and manages stress in relation to themself and their relationships, you can start to create a collaborative plan of action.
All clients experience stress at some point in their lives, but structural factors influence whether they are more at risk for stress or are better able to manage stress. For example, ableism is a determinant that can lead to highly stressful experiences, such as not being able to access community services due to lack of wheelchair/walker accessibility. In this case, use a trauma-informed approach to stress and stress management to understand how the client is being influenced by ableism and how best to support them. Socioeconomic status can also influence a person’s access to resources to cope with stress; when collaborating with clients to develop stress management techniques, you must be aware of these structural influences.
Arthritis is a common condition affecting many older people. However, about 25,000 Canadians under the age of 18 live with arthritis (Arthritis Society, 2022); a pediatric client can be diagnosed with arthritis as early as 12 months. A client-centred approach is essential for these cases, as the disease affects each individual differently. Arthritis affects the joints in fingers, hands, hips, knees, ankles and toes, which affect daily activities such as writing school assignments, participating in school activities, playing sports, and eating lunch with friends. Inflamed joints can cause pain, stiffness, and limitations in mobility, which can affect the physical, emotional, and social health of a young person, who may feel embarrassed or self-conscious or isolated because of their limitations. You can help the client adapt by using open supportive dialogue for them to share their feelings (verbally and nonverbally), and discuss strategies on how to adapt to specific situations so they can still participate. Use an interprofessional team approach, which can include nurses, doctors, occupational therapists, pharmacists, physiotherapist, school counsellors, teachers, care partners, and sometimes peers. A strong community network can help the client build meaningful relationships and decrease their risk of isolation.
Gillian Taylor, a Clinical Nurse Specialist in Rheumatology, from Montreal Children’s Hospital, highlights experiences of individuals living with juvenile arthritis in the video Juvenile Arthritis – Kids Get it Too What Educators Need to Know About Juvenile Arthritis [9:01].
To learn more about arthritis go to www.arthritis.ca
Falls are a common cause of injury at any age, but they are the leading cause of injury among older adults in Canada, affecting 30% of the population each year (Public Health Agency of Canada, 2014). Falls can result in hospitalization due to head injuries or hip fractures, and can have a psychological impact on an individual’s self-concept. Completing a fall assessment and implementing prevention strategies can help decrease the risk.
One preventative strategy is wearing proper footwear. Shoes that do not properly fit or support the foot during an activity (e.g., walking or running) can lead to knee, hip, and lower back pain, as well as skin integrity and foot issues (e.g., nail damage). Outdoor and indoor shoes should have an intact non-slip sole, laces or Velcro to increase ankle support and maintain a snug fit around the foot, and an appropriate length with no extra space for the foot to slide. Walking in socks or bare feet can increase the risk of falling.
Other strategies to help prevent falls include regular medical checkups (e.g., eye and hearing exams), creating a safe home environment (e.g., grab bars, lighting, non-slip carpets, mobility aids), eating nutritious meals (e.g., protein, calcium, water), exercising (e.g., walking, yoga, swimming), monitoring alcohol intake, and managing medications (e.g., side effects). Clients begin to lose muscle mass after about age 30, so it is important to engage in exercise as a preventative strategy.
Activity: Check Your Understanding
Public Health Agency of Canada. (2014). Senior’s falls in Canada: Second report. https://www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/seniors-falls-canada-second-report.html
Wang, C., Colley, R.C., Roberts, K.C., Chaput, J-P., & Thompson, W. (2022). Sleep behaviours among Canadian adults: Findings from the 2020 Canadian Community Health Survey healthy living rapid response module. Statistic Canada Health Reports, 33(3), 3-14. https://www.doi.org/10.25318/82‐003‐x202200300001‐eng