This topic groups systemic connective tissue diseases, chronic musculoskeletal pain syndromes, and structural spine problems.

Systemic lupus erythematosus (SLE)

• Chronic autoimmune disease in which autoantibodies and immune complexes deposit in tissues and cause inflammation of skin, joints, kidneys, serous membranes, blood cells, brain, and vessels
• Most common in women of childbearing age; course alternates between flares and remission
• Triggers of flares: ultraviolet (sun) exposure, infection, stress, pregnancy and postpartum period, stopping medications, certain drugs (e.g., hydralazine and procainamide cause drug-induced lupus)

Other connective tissue and muscle disorders

• Systemic sclerosis (scleroderma): fibrosis of skin and organs; Raynaud phenomenon, tight skin, esophageal dysmotility, lung fibrosis, and scleroderma renal crisis (sudden severe hypertension, kidney failure — treated urgently with an ACE inhibitor such as captopril)
• Polymyalgia rheumatica: older adults with shoulder and hip-girdle aching and stiffness; linked with giant cell arteritis (new headache, scalp tenderness, jaw pain with chewing, visual loss — an emergency)
• Fibromyalgia: widespread chronic pain with fatigue, poor sleep, and cognitive complaints from altered central pain processing; no inflammation or joint damage
• Carpal tunnel syndrome: median nerve compression at the wrist; numbness of thumb, index, and middle fingers, worse at night

Low back pain and herniated disc

• Most acute low back pain is nonspecific (mechanical) and improves within weeks
• Herniated intervertebral disc: the nucleus pulposus bulges through a weakened annulus and compresses a nerve root. Most common at L4–L5 and L5–S1 (causing sciatica — pain radiating down the leg) and C5–C6, C6–C7 (pain radiating down the arm)
• Lumbar spinal stenosis: narrowing of the spinal canal from degenerative changes in older adults. Causes neurogenic claudication: leg pain, numbness, and weakness when walking or standing upright, relieved by sitting or bending forward (flexion opens the canal; extension narrows it)

Scoliosis

• Lateral curvature of the spine with vertebral rotation; adolescent idiopathic scoliosis is most common and often progresses during growth spurts, especially in girls
• Severity is measured by the Cobb angle on standing X-ray

SLE

• Fatigue, fever, weight loss
• Malar ("butterfly") rash sparing the nasolabial folds, discoid rash, photosensitivity, hair loss
• Oral or nasal ulcers (often painless) — a new ulcer can signal disease activity
• Symmetric arthralgia or non-erosive arthritis
• Pleuritic chest pain (pleuritis), pericarditis
• Lupus nephritis: edema, foamy urine (proteinuria), hematuria, hypertension
• Seizures, psychosis, cognitive changes; Raynaud phenomenon

Back and neck disorders

• Pain location, radiation, onset, aggravating and relieving positions
• Lumbar disc: pain worse with sitting, bending, coughing, or straining; positive straight-leg raise; dermatomal numbness; weak ankle or toe dorsiflexion; reduced ankle or knee reflex
• Cervical disc: neck pain radiating to the shoulder and arm, hand numbness, weak grip
• Spinal stenosis: leg symptoms with walking, relieved by leaning forward (e.g., on a shopping cart)
• Red flags: saddle anesthesia, urinary retention or incontinence, bowel incontinence, progressive leg weakness (cauda equina syndrome); fever, IV drug use, or immunosuppression (infection); history of cancer, unexplained weight loss, night pain (malignancy); major trauma or osteoporosis (fracture)

Scoliosis

• Uneven shoulders, scapulae, or waist; one hip higher; rib hump on the Adams forward-bend test

Carpal tunnel — positive Phalen test (wrists flexed back-to-back for 60 seconds reproduces tingling) and Tinel sign (tapping over the median nerve produces tingling); thenar atrophy in advanced cases.

SLE

• Hydroxychloroquine for all clients unless contraindicated — reduces flares and improves survival. Risk: retinal toxicity — baseline eye exam, then yearly screening after 5 years (sooner with risk factors); dose not above 5 mg/kg actual body weight per day
• Glucocorticoids for flares at the lowest dose and shortest time; maintenance 5 mg/day prednisone-equivalent or less, and withdraw when possible. Adverse effects: hyperglycemia, infection, osteoporosis, weight gain, mood change, cataracts; do not stop abruptly (adrenal insufficiency)
• Immunosuppressants and biologics when hydroxychloroquine is not enough or steroids cannot be reduced: azathioprine, methotrexate, mycophenolate (teratogenic — contraception required), belimumab, anifrolumab; cyclophosphamide for severe organ disease (bone marrow suppression, hemorrhagic cystitis — hydrate; infertility; teratogenic). Screen for infection risk; avoid live vaccines on strong immunosuppression
• NSAIDs short-term for musculoskeletal pain; caution with nephritis
• Anticoagulation for antiphospholipid syndrome: warfarin is preferred; direct oral anticoagulants are avoided, especially in triple-positive disease, because of excess thrombosis

Polymyalgia rheumatica / giant cell arteritis — glucocorticoids. Start high-dose glucocorticoids immediately whenever giant cell arteritis is suspected — do not wait for temporal artery biopsy; visual symptoms call for urgent (often IV) treatment to prevent blindness.

Fibromyalgia — graded aerobic exercise first, sleep hygiene, cognitive behavioral therapy; duloxetine, milnacipran, pregabalin (sedation, dizziness) if needed. Opioids are not recommended.

Acute low back pain

• Stay active; bed rest delays recovery
• Superficial heat, massage, spinal manipulation, acupuncture first; then NSAIDs or skeletal muscle relaxants (e.g., cyclobenzaprine — drowsiness, anticholinergic effects, fall risk in older adults) for short periods
• Chronic back pain: exercise therapy, physical therapy, weight loss, psychological therapies

Herniated disc and stenosis

• Conservative care for 6 weeks for most: activity modification, physical therapy, NSAIDs, epidural steroid injection
• Surgery (discectomy/microdiscectomy, laminectomy, spinal fusion) for progressive neurologic deficit, persistent disabling pain, or cauda equina syndrome (emergency surgery)

Scoliosis

• Observation for small curves; bracing for growing adolescents with moderate curves (roughly 25–40°), worn many hours daily
• Spinal fusion with instrumentation for severe or progressive curves (generally above 45–50°)

Carpal tunnel — wrist splint in neutral position (especially at night), activity modification, corticosteroid injection, surgical release.

Listed in priority order.

1. Neurologic and airway safety
   • After cervical spine surgery: monitor airway, swallowing, voice, and neck swelling (hematoma can compress the airway)
   • Perform neurovascular checks of all extremities (movement, sensation, strength) after spine surgery; report new weakness, numbness, or urinary retention immediately
   • Clear drainage from the incision, or a headache that worsens when sitting up, may be a cerebrospinal fluid leak — report
2. SLE priorities
   • Assess for flare and organ involvement: new oral ulcers (size, appearance, pain), rash, joint pain, edema, blood pressure, urine protein, chest pain, neurologic change — report findings
   • Infection surveillance in immunosuppressed clients
3. Post-spinal surgery positioning and mobility
   • Log-roll with a pillow between the legs to keep shoulders and hips aligned; avoid twisting
   • Head of bed as prescribed; firm mattress
   • Early ambulation as ordered to promote lung expansion and venous return (prevents atelectasis, pneumonia, DVT)
   • Brace application as ordered before getting up
4. Pain management — scheduled analgesia after surgery; assess for new or worsening radicular pain
5. Bladder and bowel — monitor voiding after spine surgery; prevent constipation from opioids and immobility
6. Skin care under braces; check pressure points daily
7. Psychosocial support — chronic illness, body image (rash, hair loss, brace), adolescent self-esteem

SLE

• Sun protection: broad-spectrum sunscreen (SPF 30 or higher), protective clothing, avoid midday sun
• Take hydroxychloroquine daily even when well; attend eye exams
• Never stop steroids abruptly
• Report fever, new rash, mouth ulcers, joint swelling, edema, foamy urine, chest pain
• Plan pregnancy with the care team: conceive when disease has been inactive for at least 6 months; continue hydroxychloroquine during pregnancy (stopping it provokes flares); stop mycophenolate at least 6 weeks before conception and switch other teratogenic drugs
• Stay current on non-live vaccines; balance activity and rest to manage fatigue

Back health (herniated disc, low back pain)

• Lift with the knees bent and back straight, keep loads close to the body, avoid twisting
• Sit in a chair with back support, feet flat, knees level with or slightly above hips; change position every 30–60 minutes
• Lie on the side with knees bent, or on the back with a pillow under the knees
• When standing for long periods, rest one foot on a low stool
• Continue normal activity within tolerance — prolonged bed rest is not recommended
• Core-strengthening exercise, weight control, smoking cessation

Spinal stenosis — flexion-based positions relieve symptoms: rest by sitting or leaning forward; walking with a walker or cycling is better tolerated; avoid back-extension exercises that narrow the canal.

After spinal fusion (including scoliosis surgery)

• No bending, lifting, or twisting for the period the surgeon specifies (often several months); avoid heavy backpacks
• Walking is encouraged; contact sports and heavy lifting are restricted until fusion is confirmed
• Keep the incision clean and dry; report fever, drainage, or new numbness

Scoliosis bracing — wear the brace for the prescribed hours; wear a thin cotton shirt underneath; inspect skin daily.

• SLE: women of childbearing age; malar rash, photosensitivity, oral ulcers, arthritis, nephritis; ANA, anti-dsDNA, low complement
• A new oral ulcer in SLE may signal a flare — assess and report
• Hydroxychloroquine for all SLE clients; yearly eye screening; steroids tapered to 5 mg/day or less
• Sun protection is essential in SLE
• Herniated lumbar disc: L4–L5, L5–S1, sciatica, positive straight-leg raise
• Spinal stenosis: symptoms relieved by bending forward or sitting
• Acute low back pain: stay active, heat, NSAIDs; no routine imaging without red flags
• Cauda equina syndrome is a surgical emergency
• After spine surgery: log-roll, neurovascular checks, early ambulation, watch for CSF leak
• Scoliosis: Adams forward-bend test, Cobb angle; brace in growing teens, fusion for large curves; no heavy backpacks after fusion
• Carpal tunnel: Phalen and Tinel signs; night splint in neutral