PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M013/1 Revision: 02 Page: 1 of 229
NATIONAL PHYSIOTHERAPY EXAM PREP GUIDE
NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
PASSAGE TO THE USA, VIA CAPE OF NPTE.
NATIONAL PHYSIOTHERAPY EXAMINATION-PART-1
SPEC. BY: Abdulrehman S. Mulla
DATE: 03/21/2009
REVISION HISTORY
REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT0013 ASM 04/25/2009
02/02 Replace the Front cover poster PT0014 ASM 05/02/2009
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
1

PHYSICAL THERAPY PRINCIPALS & METHODS
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NATIONAL PHYSIOTHERAPY EXAM PREP GUIDE
NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
TABLE OF CONTENTS PAGE
NPTE SYLLABUS:.......................................................................................................................................................................................... 11
1.0 NPTE (NATIONAL PHYSIOTHERAPYEXAMINATION): .............................................................................................................................. 11
1.1 WHY HAVE A LICENSURE EXAM? ...................................................................................................................................................... 12
1.2 NPTE DEVELOPMENT:......................................................................................................................................................................... 12
1.3 PT PASSING STANDARD REVIEW: ..................................................................................................................................................... 13
1.3.1 WHY THE STANDARD REVIEW FOR THE PTA EXAM?..................................................................................................... 13
1.4 LINKING ADMISSIONS CRITERIA TO PERFORMANCE ON NPTE:................................................................................................... 13
1.5 ARE NPTE QUESTIONS GETTING HARDER? .................................................................................................................................... 13
1.6 DO NPTE ITEMS HAVE MORE THAN ONE RIGHT ANSWER? .......................................................................................................... 13
1.5 RECALLED NPTE QUESTIONS:........................................................................................................................................................... 14
1.5.1 A QUESTION FROM A STUDENT: ....................................................................................................................................... 14
1.5.2 CAN I TALK TO MY STUDENTS ABOUT THE NPTE AFTER THEY HAVE TAKEN IT? .................................................... 14
1.6 ENHANCING NPTE TEST ITEMS: ........................................................................................................................................................ 14
1.7 CAN YOU PROVIDE THE BACKGROUND ON THE 20 PT NPTE SCORES THAT WERE INVALIDATED IN 2007? ........................ 15
1.8 SCHOOL PASS RATE REPORTS:........................................................................................................................................................ 16
1.9 WHY DO YOU POST ULTIMATE PASS RATES:.................................................................................................................................. 16
1.10 HOW DO I ORDER SCHOOL REPORTS?............................................................................................................................................ 16
1.11 HOW DO I FIND OUT MY SCHOOL CODE AND PASSWORD IN ORDER TO LOG ON? .................................................................. 16
1.12 WHAT KIND OF REPORTS DO YOU OFFER?..................................................................................................................................... 17
1.13 CAN I PAY WITH A PURCHASE ORDER? ........................................................................................................................................... 17
1.14 WHAT IS THE “MY STUDENTS” LISTING? .......................................................................................................................................... 17
1.15 WHY DO MY REPORTS EXPIRE AFTER 30 DAYS? ........................................................................................................................... 17
1.16 IF MY REPORTS EXPIRE AFTER 30 DAYS, WHY HAVE A SUBSCRIPTION FOR A YEAR? ........................................................... 18
1.17 PRACTICE EXAM AND ASSESSMENT TOOL (PEAT): ....................................................................................................................... 18
1.17.1 DISCOUNTS FOR GROUP PURCHASES OF THE PRACTICE EXAM & ASSESSMENT TOOL (PEAT)?......................... 18
1.18 HINTS: ............................................................................................................................................................................................... 18
1.19 STATE PRACTICE ACTS: ..................................................................................................................................................................... 19
1.20 THE KEYS TO TAKE YOUR TEST ARE: .............................................................................................................................................. 19
1.21 DEVELOPING CONTENT VALIDITY: practice analysis to test content outline: .................................................................................... 19
1.21.1 PURPOSE OF A PRACTICE ANALYSIS:.............................................................................................................................. 19
1.21.2 A STANDARD APPROACH: .................................................................................................................................................. 19
1.21.3 PREVIOUS AND FUTURE PRACTICE ANALYSES: ............................................................................................................ 20
1.21.4 OVERVIEW OF A PRACTICE ANALYSIS:............................................................................................................................ 20
1.21.5 PHASES OF A PRACTICE ANALYSIS:................................................................................................................................. 20
1.21.6 THE OVERSIGHT PANEL AND TASK FORCES: ................................................................................................................. 20
1.21.7 SURVEY DEVELOPMENT: ................................................................................................................................................... 21
A. FREQUENCY OF PERFORMANCE: 21
B. SURVEY PARTICIPATION: 21
C. SURVEY ANALYSIS: 21
1.22 NPTE EXAM INFORMATION:................................................................................................................................................................ 22
1.23 EXAM BREACHES:................................................................................................................................................................................ 23
2.0 MUSCULOSKELETAL PHYSIOTHERAPY:.................................................................................................................................................. 25
2.1 UNDERSTANDING THE MUSKULOSKEELETAL SYSTEM:................................................................................................................ 25
2.1.1 HUMAN SKELETON: ............................................................................................................................................................. 26
A. AXIAL SKELETON: 27
B. APPENDICULAR SKELETON: 28
C. CHARACTERISTICS OF BONE: 29
I. TYPES OF BONE: 29
II. TYPES OF BONE CELLS: 29
1. OSTEOCYTES: 30
2. OSTEOBLASTS: 30
3. OSTEOCLASTS: 30
III. BONE MATRIX: 31
IV. MAJOR TYPES OF HUMAN BONES: 32
V. JOINTS: 33
1. TYPES OF JOINTS: 33
2. ADJACENT BONES: 34
3. ORIENTATION OF FACET JOINTS: 34
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
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PHYSICAL THERAPY PRINCIPALS & METHODS
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NATIONAL PHYSIOTHERAPY EXAM PREP GUIDE
NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
4. BONES OF THE HAND & FOOT: 34
5. HAND ANATOMY: 35
6. ANKLE: 36
7. KNEE JOINT & COMMON KNEE PROBLEMS: 37
VI. COMMON KNEE PROBLEMS: 38
1. ACUTE INJURY: 38
2. MEDIAL KNEE PAIN: 38
3. MCL TEAR: 38
4. MENISCUS TEAR: 39
5. CHONDRAL INJURY: 39
6. LATERAL KNEE PAIN: 39
7. LCL TEAR: 40
8. MENISCUS TEAR: 40
9. CHONDRAL FRACTURE: 41
10. PATELLAR SUBLUXATION / DISLOCATION: 41
11. ACL TEAR: 42
12. CHRONIC PROBLEMS: 43
a. Anterior knee pain, chondromalacia, arthritis of the patella: 43
b. \"Chronic pain leads to poor tracking, poor tracking causes chronic pain.\" 43
c. Treatment: 44
d. Arthritis: 45
e. Surgical treatment: 45
13. JOINT PROTECTION: 46
a. Client in for about joint protection: 46
14. HUMERUS: 48
15. ELBOW AND WRIST: 53
16. THE AXILLA: 53
a. Boundaries: 53
b. Spaces: 54
c. Contents: 54
d. Vasculature: 54
17. THE ARM: 55
18. THE SHOULDER GIRDLE: 56
a. Components of the shoulder girdle: 56
b. Muscles acting on the shoulder girdle: 56
c. Stability of the shoulder girdle: 57
d. Movements of the sternoclavicular joint: 58
e. Movements of the scapula: 59
f. Movements of the glenohumeral joint: 59
g. Clinical anatomy of the shoulder joint: 60
E. LEVERS: 63
I. THE FORCES INVOLVED: 65
II. POSTURE AND BODY MECHANICS: 65
F. MUSCULAR SYSTEM: 66
I. SKELETAL MUSCLES: 67
II. MUSCLE ATTACHMENT AND FUNCTION: 67
III. STRUCTURAL ORGANIZATION OF A MUSCLE FIBER: 68
IV. MYOFILAMENTS: 68
V. SARCOPLASM: 69
VI. EXCITATION: 70
VII. CONTRACTION: 71
VIII. MUSCLE TWITCH: 71
IX. TETANUS: 71
X. ENERGY SOURCES: 71
G. TYPES OF MUSCLE FIBERS: 71
H. CAPSULAR PATTERN: 72
I. PHYSIOTHERAPY SPECIAL TESTS: 74
I. STORK TEST: 75
J. PHYSIOTHERAPY ASSESSMENT: 75
K. TYPES OF FRACTURES: 76
2.1.2 MUSCULOSKELETAL CONDITIONS AND TREATMENTS:................................................................................................. 77
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
A. LEGG-CALVE-PERTHES DISEASE: 78
B. DEVELOPMENTAL DYSPLASIA OF THE HIP: 78
C. SLIPPED CAPITAL FEMORAL EPIPHYSIS: 79
D. POLYMYALGIA RHEUMATICA: 79
E. SYSTEMIC LUPUS SERYTHEMTOSUS: 80
F. SCLERODERMA: 80
G. RHEUMATOID ARTHRITIS: 80
H. JUVENILE RHEUMATOID ARTHRITIS: 81
I. PAGET’S DISEASE: 81
J. OSTEOARTHRITIS: 81
K. GOUT: 81
L. FIBROMYALGIA: 82
M. DUCHENNE MUSCULAR DYSTROPHY: 82
N. ANKYLOSING SPONDYLITIS: 83
O. COMPARTMENT SYNDROME: 83
P. MCMURRAY: 84
Q. COXA VARA/VALGA: 85
R. ROTATOR CUFF REPAIR: 86
2.1.3 GAIT ANATOMY: ..................................................................................................................................................................... 88
A. FUNCTIONS OF THE LOWER EXTREMITY: 88
I. WEIGHT BEARING PROPERTIES: 88
II. CENTER OF GRAVITY: 88
III. STABILITY: 88
B. LOCOMOTION: 89
I. POSITION OF THE LOWER EXTREMITY: 89
II. MOVEMENTS OF THE LOWER EXTREMITY: 89
C. THE GAIT CYCLE: 89
I. DEFINITION: 89
II. PHASES 89
II. ANALYSIS OF THE GAIT CYCLE - JOINT POSITION: 90
III. MUSCLE ACTIVITY (Chart I) 92
D. INITIAL CONTACT: 92
E. LOADING RESPONSE: 92
F. MIDSTANCE: 93
G. TERMINAL STANCE: 93
H. PRESWING: 93
I. TERMINAL CONTACT: 93
J. INITIAL SWING: 93
K. MIDSWING: 93
L. TERMINAL SWING: 94
M. GAIT RLA: 94
2.1.4 ROM OF A PATIENT: .............................................................................................................................................................. 95
A. ROM: 95
B. PAIN: 96
2.1.5 AMBULATING A PATIENT: ..................................................................................................................................................... 97
3.0 NEUROMUSCULAR PHYSICAL THERAPY:.................................................................................................................................................. 98
3.1 PNF (PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION): ........................................................................................................ 101
3.1.1 DEFINITION (S) ..................................................................................................................................................................... 101
3.1.2 PHILOSOPHY: ....................................................................................................................................................................... 101
3.1.3. TREATMENT PURPOSE:...................................................................................................................................................... 102
3.1.4. DEVELOPMENTAL ISSUES:................................................................................................................................................. 102
3.1.5 PATTERNS: ....................................................................................................................................................................... 103
3.1.6 BASIC PNF PRINCIPLES: ..................................................................................................................................................... 103
A. MANUAL CONTACT (MC): 103
I. MOTOR RESPONSES AFFECTED BY MC: 103
1. STRENGTH OR POWER: 103
2. DIRECTION OF MOVEMENT: 104
II. APPLICATION OF APPROPRIATE MC: 104
B. PT BODY POSITION AND MECHANICS: 104
I. BODY POSITION: 104
II. BODY MECHANICS: 104
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
C.
APPROPRIATE RESISTANCE: 105
D.
TRACTION AND APPROXIMATION: 105
I. TRACTION: 105
II. APPROXIMATION: 105
E. QUICK STRETCH (QS): 106
F. VERBAL COMMANDS (VC): 106
G. VISUAL STIMULI: 106
H. NORMAL TIMING: 107
I. REPETITION: 107
3.1.7 TECHNIQUES:....................................................................................................................................................................... 107
A. TECHNIQUES(MOTOR CONTROL): 107
B. TECHNIQUES TO PROMOTE MOBILITY: 108
C. CONTRACT RELAX (CR): 109
D. TECHNIQUES TO PROMOTE STABILITY: 109
3.3 HAND MOTOR SEGMENTS:................................................................................................................................................................. 110
3.4 EMG DIAGNOSTIC: ............................................................................................................................................................................... 111
3.4.1 PREPARATION:..................................................................................................................................................................... 111
3.4.2 PROCEDURE: ....................................................................................................................................................................... 111
3.4.3 HOW IT FEELS: ..................................................................................................................................................................... 111
2.2.4 SPINAL SPECIALIZATION: ................................................................................................................................................... 112
3.5 NERVE INJURY: .................................................................................................................................................................................... 113
3.6 PHASES AND SYNNERGY PATTERNS AFTER CVA:......................................................................................................................... 114
3.6.1 LOWER EXTREMITY:............................................................................................................................................................ 114
3.6.2 UPPER EXTREMITY: ............................................................................................................................................................ 114
3.7 BRACHIAL PLEXUS: ............................................................................................................................................................................. 115
3.7.1 BRAIN LOBES: ...................................................................................................................................................................... 116
A. FORMATION OF THE BRACHIAL PLEXUS: 116
I. ROOTS: 116
II. TRUNKS: 116
III. DIVISIONS: 116
a. Cords 116
IV. TERMINAL BRANCHES: 117
V. BRANCHES: 117
VI. DISTRIBUTION OF ROOTS: 118
VII. LESIONS OF THE BRACHIAL PLEXUS: 119
3.8 DERMATOMES AND PEREPHIRAL INNERVATION:........................................................................................................................... 120
3.8.1 DERMATOMES:..................................................................................................................................................................... 120
A. CLINICAL SIGNIFICANCE: 120
B. IMPORTANT DERMATOMES AND ANATOMICAL LANDMARKS: 121
3.8.2 PERIPHERAL NERVE INNERVATION:................................................................................................................................. 123
A. PERIPHERAL NERVE INNERVATION OF LOWER EXTREMITY: 123
II. MOTOR: 124
3.8.3 CNS: ....................................................................................................................................................................... 125
A. THE HUMAN CENTRAL NERVOUS SYSTEM: 126
I. THE SPINAL CORD: 126
1. WHITE MATTER VS. GRAY MATTER: 126
2. THE MENINGES: 126
3. THE EXTRACELLULAR FLUID (ECF) OF THE CENTRAL NERVOUS SYSTEM: 126
4. THE SPINAL CORD: 127
5. CROSSING OVER OF THE SPINAL TRACTS: 127
II. THE BRAIN: 128
1. THE HUMAN BRAIN: 128
2. THE HINDBRAIN: 129
3. PONS: 129
4. CEREBELLUM: 129
5. THE MIDBRAIN: 129
6. THE FOREBRAIN: 130
7. DIENCEPHALON: 130
a. Thalamus: 130
b. Hypothalamus: 130
c. Posterior lobe of the pituitary: 130
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
d. The Cerebral Hemispheres: 130
8. MAPPING THE FUNCTIONS OF THE BRAIN: 131
9. DAMAGE TO THE BRAIN: 132
10. STIMULATING THE EXPOSED BRAIN WITH ELECTRODES: 132
11. CT = X-RAY COMPUTED TOMOGRAPHY: 133
12. PET = POSITRON-EMISSION TOMOGRAPHY: 133
13. MRI = MAGNETIC RESONANCE IMAGING: 134
14. FMRI = FUNCTIONAL MAGNETIC RESONANCE IMAGING: 134
15. THE PROBABLE MECHANISM: 134
16. MAGNETOENCEPHALOGRAPHY (MEG): 134
2.2.11 CRANIAL NERVES: ............................................................................................................................................................... 135
2.2.12 SEGMENTAL TESTING:........................................................................................................................................................ 136
2.3 CARDIOVASCULAR PHYSICAL THERAPY ......................................................................................................................................... 137
2.3.1 SYMPTOMS AFFECTING THE HEART: ............................................................................................................................... 137
A. HEART DEFINITIONS: 137
2.3.2 SYMPTOMS AFFECTING THE BRAIN: ................................................................................................................................ 138
2.3.3 SYMPTOMS OF CARDIOVASCULAR DISEASE IN THE LEGS, PELVIS, OR ARMS: ........................................................ 138
2.3.4 EXERCISE FOR THE PREVENTION AND MANAGEMENT OF CARDIOVASCULAR DISEASE: ...................................... 138
2.3.5 ETT: ....................................................................................................................................................................... 139
2.3.6 CARDIOLOGY: ...................................................................................................................................................................... 140
A. ANGINA: 143
B. SILENT MI OR PAINLESS MI: 143
C. ANSWER THE QUESTIONS: 145
D. ANSWER THE CONDITIONS AS TO METABOLIC/RESPIRATORY, ACIDOSIS /ALKALOTIC. 147
2.4 PULMONARY PHYSICAL THERAPY: ................................................................................................................................................... 149
2.4.1 RESTRICTIVE DISEASES:.................................................................................................................................................... 149
2.4.2 OBSTRUCTIVE DISEASES:.................................................................................................................................................. 149
2.4.3 ABERRANT BREATHING PATTERNS:................................................................................................................................. 149
2.4.4 PHYSICAL THERAPY MANAGEMENT OF THE PATIENT WITH PULMONARY DISEASE:............................................... 150
A. CASE TYPE / DIAGNOSIS: 150
B. INDICATIONS FOR TREATMENT: 150
C. CONTRAINDICATIONS / PRECAUTIONS / CONSIDERATIONS FOR TREATMENT: 150
I. CONTRAINDICATIONS: 150
II. PRECAUTIONS: 151
III. CONSIDERATIONS: 151
IV. DISEASE SPECIFIC CONSIDERATIONS FOR TREATMENT: 151
V. PULMONARY FUNCTION TESTS (PFT): 151
VI. OBSTRUCTIVE SLEEP APNEA: 151
1. SLEEP APNEA CAUSES: 152
2. RISK FACTORS: 152
3. SIGNS AND SYMPTOMS: 153
4. OSA COMPLICATIONS: 154
5. SLEEP APNEA DIAGNOSIS: 154
6. OSA TREATMENT: 156
a. Oral Appliances: 156
b. Positive Pressure Therapy: 157
7. SURGERY: 158
a. Minimally Invasive Treatment: 158
b. Surgical Treatment: 159
VII. MECHANICAL VENTILATION: 160
1. NEGATIVE PRESSURE MACHINES: 160
2. POSITIVE-PRESSURE VENTILATORS: 161
3. INDICATIONS FOR USE: 161
4. TYPES OF VENTILATORS: 162
5. MODES OF VENTILATION: 163
a. Conventional ventilation: 163
b. Breath termination: 163
c. Breath initiation: 163
d. High Frequency Ventilation (HFV) 165
e. Non-invasive ventilation (Non-invasive Positive Pressure Ventilation or NIPPV): 166
f. Proportional Assist Ventilation (PAV): 166
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
g. Adaptive Support Ventilation (ASV) 167
h. Neurally Adjusted Ventilatory Assist (NAVA) 167
6. CHOOSING AMONGST VENTILATOR MODES: 168
7. INITIAL VENTILATOR SETTINGS: 168
a. Tidal volume, rate, and pressures 168
b. Sighs: 169
c. Initial FiO2: 169
d. Positive end-expiratory pressure (PEEP): 169
f. Positioning: 170
g. Sedation and Paralysis: 170
h. Prophylaxis: 171
8. MODIFICATION OF SETTINGS: 171
9. When to withdraw mechanical ventilation: 171
10. Connection to ventilators: 172
11. TERMINOLOGY 173
D. EXAMINATION: 174
I. CHART REVIEW: 174
II. SOCIAL HISTORY: 174
III. PHYSICAL EXAMINATION: 175
IV. COGNITIVE-PERCEPTUAL AND PSYCHOLOGICAL CONSIDERATIONS: 175
E. EVALUATION / ASSESSMENT: 175
F. TREATMENT PLANNING / INTERVENTIONS: 176
I. INTERVENTION: 176
II. PATIENT/FAMILY EDUCATION: 176
III. AVAILABLE HANDOUTS: 177
IV. FREQUENCY OF TREATMENT: 177
V. RECOMMENDED REFERRALS TO OTHER PROVIDERS: 177
G. RE-EVALUATION / ASSESSMENT 177
H. DISCHARGE PLANNING: 178
I. CHEST PHYSIOTHERAPY (CPT): 178
2.4.5 MEDICATIONS: ..................................................................................................................................................................... 178
2.4.6 BENEFITS OF PULMONARY REHABILITATION: ................................................................................................................ 178
2.4.7 LUNG DRAINAGE:................................................................................................................................................................. 179
2.4.5 LUNG VOLUME CAPACITIES:.............................................................................................................................................. 180
2.5 INTEGUMENTARY PHYSICAL THERAPY............................................................................................................................................ 181
2.5.1 DRESSINGS: ....................................................................................................................................................................... 181
2.5.2 SKIN DISORDERS:................................................................................................................................................................ 181
2.5.3 BURNS: ....................................................................................................................................................................... 182
2.6. GI, GU AND METABOLIC/ENDOCRINE AND PSYCHOLOGICAL CONDITIONS: .............................................................................. 183
2.6.1 GASTROINTESTINAL DISEASES: ....................................................................................................................................... 183
A. GI CAN CAUSE: 183
B. GASTROINTESTINAL PHYSIOTHERAPY: 183
C. PHYSIOTHERAPY FOR ACTIVE LIFESTYLE: 184
2.6.2 GU/RENAL (DISEASES OF THE GENITOURINARY (GU) TRACT):................................................................................... 185
A. INCONTINENCE: 186
I. MANAGING INCONTINENCE: 186
II. CATHETER CARE: 187
B. URINARY TRACT INFECTION: 188
C. OBSTRUCTIVE UROPATHY: 189
I. CAUSES OF OBSTRUCTION: 189
II. MANAGING OBSTRUCTIVE UROPATHY: 189
D. BLOOD IN THE URINE (HEMATURIA): 189
E. PELVIC FLOOR MUSCLE TRAINING FOR MEN: 190
F. PELVIC FLOOR MUSCLE TRAINING FOR WOMEN: 191
I. IDENTIFYING THE PELVIC FLOOR MUSCLE: 191
II. FREQUENCY OF PELVIC MUSCLE EXERCISES: 191
2.6.3 RENAL DISEASE:.................................................................................................................................................................. 193
A. ROLE OF PHYSIOTHERAPY IN RENAL REHABILITATION: 193
I. THE NEED FOR EXERCISE: 193
II. PLANNING OF EXERCISE: 195
III. CARDIOVASCULAR EXERCISE TRAINING: 195
MEDICINE: IT’S A NOBLE PROFESSION, IT SERVES HUMANITY.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
IV. ASSESSMENT: 196
VI. EXERCISE APPROACH: 197
2.6.4 PSYCHIATRIC PHYSIOTHERAPY:....................................................................................................................................... 198
A. PSYCHIATRIC AND PSYCHOSOMATIC PHYSIOTHERAPY: 198
B. PHYSIOTHERAPIST’S OFFER: 198
C. PHYSIOTHERAPY TREATMENT: 199
D. METHODS IN THE TREATMENT: 199
E. TREATMENT OF CHILDREN: 199
F. BENEFICIARIES OF THE TREATMENT: 199
2.7 PEDIATRIC PHYSICAL THERAPY:....................................................................................................................................................... 200
2.7.1 BONES, JOINTS AND MUSCLES: ........................................................................................................................................ 201
A. GAIT PROBLEMS: 201
B. MUSCULAR DYSTROPHY (MD): 202
I. WHAT ARE THE FIRST SYMPTOMS OF MUSCULAR DYSTROPHY? 202
II. HOW IS MUSCULAR DYSTROPHY DIAGNOSED? 203
III. TYPES OF MUSCULAR DYSTROPHY: 203
IV. CARING FOR A CHILD WITH MUSCULAR DYSTROPHY: 204
1. PHYSICAL THERAPY AND BRACING: 204
2. PREDNISONE: 204
3. SPINAL FUSION: 205
4. RESPIRATORY CARE: 205
5. ASSISTIVE DEVICES: 205
2.7.2 BRAIN & NERVOUS SYSTEM: ............................................................................................................................................. 207
2.7.3 SYSTEM & LUNG: ................................................................................................................................................................. 208
A. ASTHMA: 208
B. CYSTIC FIBROSIS: 208
2.7.4 EQUIPMENT USED WHILE UNDERGOING PHYSIOTHERAPY: ........................................................................................ 209
2.7.5 ERICKSON STAGES: ............................................................................................................................................................ 209
2.7.6 GRASPS: ....................................................................................................................................................................... 211
2.8 GERIATRIC PHYSICAL THERAPY: ...................................................................................................................................................... 212
2.8.1 PHYSICAL ACTIVITY IN GERIATRICS:................................................................................................................................ 212
A. FUNCTIONAL DIAGNOSIS: 213
B. PROGRAM DEVELOPMENT: 214
C. EXAMPLE OF EXERCISE PROGRAM: 214
D. SELECTION OF THE DIFFERENT EXERCISES: 214
E. MUSCLE STRENGTH: 214
F. AEROBIC EXERCISE: 215
G. FOR ALL TYPES OF EXERCISES: 215
H. THE EXERCISES: 215
I. CONTINUITY IN THE EXERCISE PROGRAM: 215
2.9 THERAPEUTIC EXERCISE FOUNDATIONS:....................................................................................................................................... 216
2.9.1 STRETCHING: ....................................................................................................................................................................... 216
A. PROCEDURE: MUSCLE FLEXIBILITY AND STRETCHING: 216
B. EQUIPMENT / SUPPLIES NEEDED: 217
I. STRETCHING METHODS: 217
II. ADVANTAGES: 217
III. PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF) STRETCHING TECHNIQUES: 217
IV. PATIENT EDUCATION: 218
2.9.2 THERAPEUTIC EXERCISE:.................................................................................................................................................. 218
A. CONTROL INFLAMMATION: 218
B. STRETCHING AND FLEXIBILITY: 219
C. RESTORE RANGE OF MOTION: 220
D. JOINT MOBILIZATION: 221
E. DEVELOPING MUSCULAR STRENGTH, ENDURANCE, AND POWER: 221
F. PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION: 222
G. PLYOMETRICS: 223
H. RETURN TO SPORT ACTIVITY: 224
2.9.3 EFFECTS OF JOINT MOBILIZATION: .................................................................................................................................. 225
A. NEUROPHYSIOLOGICAL EFFECTS: 225
B. NUTRITIONAL EFFECTS: 225
C. MECHANICAL EFFECT: 225
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
D. CRACKING NOISE MAY SOMETIMES OCCUR: 225
I. CONTRAINDICATIONS FOR MOBILIZATION: 225
E. MAITLAND JOINT MOBILIZATION GRADING SCALE: 226
F. ALWAYS EXAMINE PRIOR TO TREATMENT: 227
G. JOINT MOBILIZATION APPLICATION: 227
H. TREATMENT FORCE & DIRECTION OF MOVEMENT: 227
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
PHYSIOTHERAPY:
Now a day, physiotherapy is becoming much popular among the people but still 70 percent of the people in
India including Jammu are unaware of this branch of medical science.
Now, let us understand what the physiotherapy is, well, it is a branch of medical science, which employs
treatment by including the use of electro medical equipments and various physical and remedial exercises. i.e. the
treatment by this branch of medical science is applied by means of electrotherapy and exercise therapy.
Electrotherapy includes the use of light rays like infrared UV rays, short wave, long waves, medium frequency
currents and many more. Whereas exercise therapy includes manipulation, mobilization of the joints and many
exercises which helps and benefits the patient in his recovery from various ailments.
It is the most beneficial treatment in bringing a person in his normal functioning after fractures, in the early
management of various deformities like deformities of the back scoliosis, khyposis, lordosis etc. deformities of
knee, hip, foot, shoulder, elbow, wrist etc. It helps in increasing the muscle power of the muscles by various
exercises and modalities.
Physiotherapy helps in aiding the body of the person to develop, improve, restore, prevent and maintain: -
 Strength
 Endurance and cardiovascular fitness.
 Mobility and flexibility
 Stability
 Relaxation
 Co-ordination, balance and functional skill.
A physiotherapist plans and implements the treatment of the patient, depending upon the muscle power and
according to degree of dysfunction. Physiotherapy is helpful and result oriented in different orthopedical and
neurological conditions like Ankylosing spondylitis, poliomyelitis, Arthritis, shoulder syndromes, cervical
syndromes, low back ache, paralysis, CP neuropathies etc.
People suffering from such problems should go for physiotherapeutic treatment for proper relief. There are so
many other therapies which are related with the physiotherapy like occupational therapy (include any physical or
mental occupation given to the patient as an aid to recovery from an illness.
Occupations can be like
 Knitting,
 Pottery,
 Playing with toys for cerebral palsy children etc)
Occupational therapy is almost confined to make a disabled person to do his occupation i.e. to make him
independent for his ADL’s (Activities of daily living). Occupational therapy is the most beneficial therapy.
Physiotherapy is also related to speech therapy, vocational therapy, orthotics, prosthetist etc.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
NPTE SYLLABUS:
1. NPTE POLICIES, PROCEDURES & FREQUENTLY ASKED QUESTIONS
2. MUSCULOSKELETAL PHYSICAL THERAPY
3. NEUROMUSCULAR PHYSICAL THERAPY
4. CARDIOVASCULAR PHYSICAL THERAPY
5. PULMONARY PHYSICAL THERAPY
6. INTEGUMENTARY PHYSICAL THERAPY
7. OTHER SYSTEMS INCLUDING GI, GU AND METABOLIC/ENDOCRINE AND PSYCHOLOGICAL
CONDITIONS
8. PEDIATRIC PHYSICAL THERAPY
9. GERIATRIC PHYSICAL THERAPY
10. THERAPEUTIC EXERCISE FOUNDATIONS
11. PHYSICAL AGENTS AND MODALITIES
12. FUNCTIONAL TRAINING AND ORTHOTIC, PROSTHETIC AND SUPPORTIVE DEVICES
13. PROFESSIONAL ROLES AND MANAGEMENT
14. EDUCATION & CONSULTATION
15. RESEARCH AND EVIDENCE-BASED PRACTICE
16. PATHOLOGICAL
1.0 NPTE (NATIONAL PHYSIOTHERAPYEXAMINATION):
In order to be certified or licensed as a physiotherapist or physiotherapist assistant, individuals must
pass the National Physiotherapy Examination (NPTE) or the National Physiotherapy Assistant Examination
(NPTAE). These exams were developed by the Federation of State Boards of Physiotherapy to establish a
minimum level of competency for physiotherapist and physiotherapist assistants. The exam for
physiotherapists consists of 250 multiple-choice questions, and must be completed within 5 hours. The
major content areas covered by the exam for physiotherapists are as follows: Patient Examination (52
questions); Evaluation, Diagnosis, Prognosis, and Outcomes (45 questions); Intervention (83 questions);
and Standards of Care (20 questions). The exam for physiotherapist assistants consists of 200 multiple-
choice questions, and must be completed within 4 hours. The major content areas covered by the exam for
physiotherapist assistants are as follows: Tests and Measures (32 questions); Intervention (90 questions);
and Standards of Care (28 questions).
Each of the exams contains pre testing questions that are not scored and are used to develop future
versions of the exam. The number of questions answered correctly determines exam scores. This raw
score is converted into a score on a scale of 200 to 800. There is no deduction for incorrect answers, so
candidates should guess at those questions they do not know. The examination is scored by the FSBPT
and this body to the relevant licensing authority gives results. The passing score is typically a 600. The
NPTE is a computerized exam. Thomson Prometric administers it throughout the year at locations around
the country. To register, visit the FSBPT website.(FSBPT candidate handbook)
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.1 WHY HAVE A LICENSURE EXAM?
Why do licensing boards require passing the NPTE for licensure? Why isn’t graduation from a
CAPTE-accredited program sufficient?
There are a few points that need to be considered when answering this question.
The purpose of the NPTE is different from the purpose of PT or PTA programs. The programs’
primary purpose is to educate PTs and PTAs. The educational component provides a broad range of
knowledge, education and skills, including a clinical component, so that PTs and PTAs understand
the role of physiotherapists and physiotherapist assistants in providing healthcare to patients.
Programs teach skills and knowledge that might not be used by entry-level practitioners, but will be
used as individual becomes more experienced. The NPTE ‘s specific purpose is to protect the public
by testing candidates on the minimum knowledge and education necessary for safe and competent
entry-level work; it does not include a clinical component.
Programs can be subject to many different pressures – the pressure to graduate a certain number of
students or to maintain a certain passing rate on the NPTE are two that come to mind. Development
of the NPTE is subject to a different requirement – the Federation must be able to provide evidence to
licensing boards that the NPTE is a valid and reliable tool for measuring entry-level competence of
PTs and PTAs.
Even though all programs are accredited by CAPTE, there is a variation in programs. This includes
coursework and grading standards. The NPTE provides licensing boards with one standard to which
everyone is held accountable.
Completion of a broad educational program and passing a specific exam that measures entry-level
competence provides licensing board members with the assurance that they are licensing or
certifying competent entry-level practitioners who will be able to grow and mature in their profession.
1.2 NPTE DEVELOPMENT:
I have heard that the questions on the NPTE take a long time to develop and validate. Since the
profession of Physiotherapy is rapidly changing and is becoming much more evidence based, how do
you assure that the questions on the exam are current?
It is critical that a high stakes licensing examination covers current practice. While it is a challenge to
maintain this currency, the item writers and exam committees work very hard to assure the exam
reflects current practice. Currency is maintained via the following steps:
The exam blueprint or content outline is revised at a minimum of every five years. The exam blueprint
determines the content of the exam and assures that the content is relevant to current practice.
Currency is stressed at item-writer workshops; item writers are required to reference questions to
recognized authoritative texts that have been published within the past five years.
Items are not used where there may be conflicting references or viewpoints in the literature
An item goes through committee review multiple times and each time, it is reviewed for currency.
The item goes through a final review for currency (among other things) prior to each and every time it
is being released as an operational question.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.3 PT PASSING STANDARD REVIEW:
In 2005, the Federation conducted a Standard Review for the PT exam with a resulting adjustment in
the passing standard (passing score).
1.3.1 WHY THE STANDARD REVIEW FOR THE PTA EXAM?
It is the Federation of State Board of Physiotherapy Board of Director’s responsibility to
assure that the quality and integrity of the NPTE is always maintained. In doing this, there are
many quality assurance processes and procedures that are continually being conducted. In
reviewing some of the outcomes of the quality assurance procedures, there were several
things that pointed to the need for a standard review for the PT exam. These included
variable pass rates from 1996 through 2004 and significant stakeholder feedback from PT
program faculty and employers. Neither of these sources was observed for the PTA exam.
1.4 LINKING ADMISSIONS CRITERIA TO PERFORMANCE ON NPTE:
As a PTA program, we maintain very high admissions criteria for our students. However, with the
increased pressure to admit diverse populations as well as the pressure to admit most anyone at the
community college level, we are having a hard time justifying this standard. Have there been studies
linking admission criteria to performance on the PTA exam?
Most of the studies looking at admission criteria and pass/fail performance on the NPTE have been
focused on physiotherapist programs. However, several researchers are beginning to look at this
topic related to PTA programs. You may want to contact your colleagues to see what efforts are being
conducted related to NPTE performance of PTA programs.
1.5 ARE NPTE QUESTIONS GETTING HARDER?
The pass rate for the NPTE for physiotherapists dropped in 2003. Many stakeholders have asked if
more difficult questions are being included on the NPTE, which in turn has made the examination
more difficult to pass. Individuals have speculated that as FSBPT improves the quality of items written
for the NPTE, the reliability of these items improves, and it becomes more and more difficult for
candidates to determine the correct answer through the powers of deduction and logic.
High quality items are more difficult to answer correctly for students who do not know the material.
However, test questions on the NPTE are not becoming more difficult. The FSBPT monitors item- and
form-level difficulty as a standard part of its psychometric procedures. Test forms are assembled to
be as similar as possible with respect to content and difficulty. Forms administered from 2001 through
2005 vary slightly in average item difficulty but do not show a consistent trend toward increasing
difficulty. It is important to note that even if the average item-level difficulty across forms had
increased, this should not influence the pass rate because all test forms are equated so that a form
with more difficult items will have a lower passing score than a form with easier items.
1.6 DO NPTE ITEMS HAVE MORE THAN ONE RIGHT ANSWER?
I have been told that the exam is structured in such a way that there are two \"right\" answers, but that
one is a better choice. Is the exam scored using a partial credit model to account for an individual
who might select the less favorable of the correct choices? Or is it an all-or-none credit system?
There is only one correct answer for each question. The item writers and exam committees go
through great lengths assuring that there is one correct answer and three incorrect answers. Each
option must be backed up with a rationale and reference as to why it is either correct or incorrect.
Beyond this, statistics are collected on the item that also helps support the one correct answer. There
is no “partial credit” for an answer. It is either correct or incorrect.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.5 RECALLED NPTE QUESTIONS:
1.5.1 A QUESTION FROM A STUDENT:
As an exam candidate who just completed my examination, i recall several questions on
the exam where i was not sure of the answer. Is it ok for me to discuss the questions with my
instructor?
On the surface, it may seem natural for you to go to a faculty member to discuss specific
questions on your licensing examination. You may want to be assured that you answered the
item correctly. You may also be motivated to “learn from mistakes” and a discussion of the
question could be a productive learning experience. This is particularly true if you find you
have failed the exam. You certainly want to pass the next time! However, by doing this you
are putting yourself and your instructor in jeopardy.
Every item on the exam is copyright protected. When a candidate takes the exam, the
candidate agrees not to share any question or part of a question with anyone else. Good
intentions do not nullify this agreement or the copyright protection of the exam. The bottom
line is that it is illegal for a candidate to share a test question with an instructor or anyone
else. You might say: “Ok, so it is technically illegal, but what is the harm if I discuss the item
with my instructor? I can trust her. She would not share the information. So, no harm no foul.”
Basically, it is not for you to decide when you can break the law or when you can’t. The law is
the law.
1.5.2 A PARALLEL QUESTION FROM AN INSTRUCTOR: CAN I TALK TO MY
STUDENTS ABOUT THE NPTE AFTER THEY HAVE TAKEN IT?
Certainly general comments about the exam are not a violation of copyright law.
However, if your students discuss specific items or specific characteristics of the exam with
you, they are in violation of the confidentiality terms that they agree to when they take the
exam. Included in these terms is not disclosing the content of examination items. Legal action
could be taken against candidates who violate these terms including criminal prosecution.
Ultimately the student may risk being able to ever obtain a license.
Educators may unwittingly cross the line by asking students questions about the exam or
by listening to a student share a question from the exam. It is important that educators defend
the integrity of the licensure process by making students and colleagues aware of these
critical issues and reporting violations when they occur. You can also report any violations to
security@fsbpt.org.
Educators can find accurate information regarding the exam in the “For
Candidates/Licensees” section of the website. The entire candidate Handbook is found at
“For Candidates/Licensees”/ “NPTE.” The test content outline can be found at “For
Candidates/Licensees”/ “NPTE” / “Exam Development.” More detailed information on the
NPTE can be obtained by attending a NPTE Workshop for Faculty. Information on upcoming
workshops can be found in the “News and Events” section.
1.6 ENHANCING NPTE TEST ITEMS:
Currently, the NPTE contains questions that include graphics. Does the Federation have plans to add
other testing technologies such as “hot spots” or video?
The Federation has been exploring other testing formats for some time. While we have the technical
capabilities of utilizing these formats, we are not planning on adding these types of test questions in
the immediate future. These types of questions create a host of additional issues and complexities.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
For example, a question that requires the examinee to review to a video clip of a gait pattern and
determine the dysfunction may seem like the perfect question for a Physiotherapy licensing
examination. However, before such a question can be used, several issues have to be addressed.
How much time needs to be allowed for a question that requires the viewing of a video as compared
to a standard multiple choice question? How many times should the candidate be allowed to re-run
the video? Is the video clip clear enough that all candidates are able to see the action taking place
clearly? How does one account for the psychometric differences between the video question and
other questions?
Another reason we are waiting prior to implementing additional test question formats is to continue to
allow our tests to remain stable for a period of time before implementing any significant test format
changes.
In spite of these factors, we do believe there may be some advantages to utilizing different test
formats at some point in the future and will continue to review the literature and address the questions
mentioned above. Ultimately, it is critical to determine whether or not these additional test formats
provide us with better information related to the competency of the entry-level physiotherapist.
1.7 CAN YOU PROVIDE THE BACKGROUND ON THE 20 PT NPTE SCORES THAT WERE
INVALIDATED IN 2007?
The following information was taken from the “news and events” section.
Forensic Analysis Conducted to Investigate Effect of Trafficking in Recalled Test Items Leads to
Invalidation of 20 Candidate Test Scores
On Friday, August 17, 2007, the Board of Directors of the Federation of State Boards of
Physiotherapy approved the invalidation of 20 candidates’ National Physiotherapy Exam (“NPTE”)
test results. This decision resulted from an extensive forensic analysis of the test performances of all
candidates who sat for the NPTE between March 1, 2005 and June 5, 2007.
The forensic analysis, conducted by Caveon, a test security company, was commissioned in
response to the unlawful trafficking of NPTE questions by Philippines-based exam prep centers.
Through its own private investigation efforts, as well as Philippines government surveillance and raids
of two Manila test centers in January 2007, FSBPT has confirmed that the centers have distributed to
customers compilations of actual NPTE test questions memorized and shared by prior test takers
(“recalled items”). In an effort to assess the potential effects of this practice of using recalled test
items, Caveon analyzed approximately 23,512 test performances of all NPTE candidates, regardless
of place of education.
Caveon’s analysis conclusively establishes that at least twenty individuals benefited unfairly from
advance access to recalled test items. All twenty candidates are Philippines-educated, some but not
all of whom are already licensed to practice physical therapy. FSBPT’s assessment and review of the
Caveon forensic analysis is continuing, so as to determine whether additional candidate score
invalidation is appropriate.
In identifying these twenty candidates, the forensic analysis used three statistical indices to identify
aberrant candidate performances. First, performance on compromised test questions (those known to
be compromised by distribution at Philippines-based test prep centers) was compared to performance
on non-compromised test items. Second, the similarity among candidate response choices was
examined, with higher degrees of similarity suggesting the possibility of prior knowledge of test
content. Third, the analysis computed the probability that each test taker had attended a course at
which recalled items were used. In each case, the percentage of candidates flagged as aberrant was
highest for Philippines-educated test takers.
FSBPT limited the universe of “aberrant” test performances under each of the three indices to those
test results whose likelihood of occurring by chance was at least 1 in 10,000 (one in ten thousand).
The twenty invalidated candidate scores are those that appeared aberrant based on all three
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
statistical indices. The likelihood of aberrant performance on all three statistical indices is extremely
unlikely and at least less than 1 in one million.
“As with every decision we’ve made in addressing the troubling use of recalled items, the FSBPT
Board did not take this action lightly,” stated E. Dargan Ervin, Jr., FSBPT President. “We made the
decision only after careful consideration of the issues and in light of the overwhelming statistical data
that calls into question the legitimacy of these scores.”
1.8 SCHOOL PASS RATE REPORTS:
Please explain the timing and rationale for posting pass rates.
When are pass rate data updated on FSBPT’s websites?
Pass rate data are updated quarterly on the following schedule:
 February 1
 May 1
 August 1
 November 1
When will the 2005-2007 ultimate pass rates be posted?
The 2005-2007 ultimate pass rates will be posted on May 1, 2009. The reason for this is that ultimate
pass rates do not become stable until 15 months after graduation. This delay in reporting ensures that
the Federation publishes stable data for all PT and PTA programs, including those with late
graduation dates.
When will the 2008 pass rates (exam year, graduation year, rank order) be posted?
The 2008 pass rates will also be posted on May 1, 2009. This allows time for students of programs
graduating late in the year to have taken the NPTE before the pass rates are posted.
When are exam year pass rates posted?
Exam years end on February 28th. Since updates are posted quarterly (see above), the first quarter
the exam year pass rate can be published is May 1st.
1.9 WHY DO YOU POST ULTIMATE PASS RATES:
FOR INDIVIDUAL PROGRAMS AND NOT FIRST TIME PASS RATES ON THE PUBLIC SITE?
The intent of the FSBPT Board of Directors is to post first time pass rates as well as ultimate pass
rates. However due to some of the historical fluctuations in pass rates, the Board decided to hold off
on posting first-time pass rates until they became more stable. The Board will revisit the posting of
first -time pass rates in two to three years.
1.10 HOW DO I ORDER SCHOOL REPORTS?
School administrators will need to go back to “For Faculty” and click on “School Reports” to order
school report subscriptions.
1.11 HOW DO I FIND OUT MY SCHOOL CODE AND PASSWORD IN ORDER TO LOG ON?
If you have not yet subscribed or don’t know/don’t remember your school code and password, please
send an email to schoolreports@fsbpt.org. From there, go to “For Faculty”/ “School Reports” on
www.fsbpt.org and log in to either request a free subscription (reports are mailed twice a year at
specific intervals determined by the Federation) or purchase an online subscription.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.12 WHAT KIND OF REPORTS DO YOU OFFER?
We offer four types of reports. Before you order any subscription, it is a good idea to review the
sample reports first. That way you can be sure you’re ordering the report that provides the information
you really want. Go to “For Faculty”/ “School Reports” on www.fsbpt.org. Look to the right of the
SCHOOL ADMINISTRATOR LOGIN box. You will find report descriptions and links to sample reports.
1. Basic Mail Subscription (Free): Includes two \"Basic Reports\" that are sent via mail at specific
intervals determined by the Federation. If you would like to receive the free basic mail
subscription, you must subscribe to it through this online website. This report is available for the
current year and it will include information for two prior years.
2. Basic Online Subscription ($100): Includes two \"Basic Reports\" that are accessible via the
Schools Home website. Basic reports show pass rates for most current graduating classes and
two prior years. They include names of student in those graduating classes, although they do not
include individual student’s scores on the NPTE.
3. Enhanced Subscription ($200): Includes two \"Enhanced Reports\" that are accessible via the
Schools Home website. The format of the enhanced report is the same as the Basic Reports but
in addition, Enhanced Reports provide individual students’ scores on each attempt to pass the
exam.
4. Content Area Subscription ($200): Includes two \"Content Breakdown Reports\" that are accessible
via the Schools Home website. This report is available for graduating classes of 2003 until
present. It compares your first time test takers to first time test takers from all U.S. CAPTE
accredited schools during the same period on each area of the examination.
1.13 CAN I PAY WITH A PURCHASE ORDER?
The online system has two payment options; credit card or invoice. If you pay by credit card, your
reports are available to be run the same day. If you prefer to have your institution send a check, you
can choose to pay by invoice. When you choose to pay by invoice, the last screen of the purchase
process is the official invoice. The invoice can be printed and submitted to your accounts payable
department so that a check can be issued and mailed to the Federation with the invoice. Please do
not send a purchase order - use the invoice you printed at the time you registered online for your
subscription.
1.14 WHAT IS THE “MY STUDENTS” LISTING?
The “My Students” listing is a critical component of the school report process. Immediately prior to
running each report you should review “My Students” to verify that all the students on the listing did
indeed graduate from your institution. If you find a student listed that did not graduate from your
program, there is a link to “Request a Correction” for each graduating class on the My Students page.
Remember to review the “My Students” listing prior to running every report.
Additionally, you can view the “My Students” listing to see how many candidates have tested (and
when they tested) so that you can decide when the best time is to run your report. For instance, you
probably would not want to run a report that includes candidates for 2007 if only a small portion of
those candidates have tested.
1.15 WHY DO MY REPORTS EXPIRE AFTER 30 DAYS?
The Federation simply does not have the “storage space” to maintain all school reports for an
unlimited period of time. Instead, you should print the reports or to save them as Excel files on your
own computers so that you have a permanent record.
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NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.16 IF MY REPORTS EXPIRE AFTER 30 DAYS, WHY HAVE A SUBSCRIPTION FOR A
YEAR?
The first reason is so that you can choose when you would like to run your reports during the year.
You may choose to run one report mid-year and another report at the end of the year. The second
reason is that by having a subscription, you can request additional reports at a discounted rate of only
$50.
1.17 PRACTICE EXAM AND ASSESSMENT TOOL (PEAT):
1.17.1 DO YOU OFFER DISCOUNTS FOR GROUP PURCHASES OF THE PRACTICE
EXAM & ASSESSMENT TOOL (PEAT)?
 Yes. In order to qualify for a group PEAT discount, 15 or more students must be
registered. If the group pays by check, the cost will be $72 per PEAT ($74 per PEAT if
paid by credit card).
 To purchase PEAT as a group, you’ll need to send an email to peat@fsbpt.org. Please
request a registration form and instruction sheet. Each student will need to register as
individuals, indicating “pay later by Visa or MasterCard” for the method of payment. The
students will each need to provide the school with a social security and transaction
number (obtained once the student has signed up for PEAT).
 Once the students have signed up (everyone must be registered in order to process the
payment), a confirmation email will be sent to each individual with his/her product key.
The school will also receive the returned registration list with each student’s product key
and transaction code.
1.18 HINTS:
1. Many times, students will see the following message when they log on to PEAT. “Thank you for
visiting FSBPT. PEAT is now running in another browser window.” In this case, the student will
need to disable their pop-up blocker in order to see PEAT. They should allow pop-ups for the
duration of the PEAT.
2. PEAT can only be accessed through Microsoft’s Internet Explorer browser – no other browser will
work.
3. PEAT expires 30 days after the first practice exam has been accessed. However, students can
download and print the supplemental materials and this won’t count toward the 30 days.
4. After taking the first exam and reviewing their performance report as well as the references and
rationales for each question, students can move to the second practice exam. The performance
reports and study material for both PEAT exams will be available for the duration of the student’s
access period.
5. An extension is available for 15 days if the student has not completed both practice exams. The
extension fee is $45 and can be purchased by going to “Home” and selecting the “Purchase
PEAT” shortcut.
6. Confirmation emails for PEAT purchases are generally received within 2-3 hours. The exception
is YAHOO accounts (they seem to be sent to junk mail or filtered as spam). If the student hasn’t
received the confirmation email, they can call or email FSBPT and receive the product key and
confirmation email.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.19 STATE PRACTICE ACTS:
We’d like to be able to see what our state’s practice act allows, such as whether it allows temporary
licensure or direct access to Physiotherapy services. Does the Federation maintain that kind of
regulatory information?
Yes, you can find all kinds of regulatory information in the Jurisdiction Licensure Reference Guide on
the Federation’s public website. This guide compares some of the major similarities and differences
among the jurisdictions’ practice acts. It may be used as a reference for educational programs,
students, licensing boards, professional associations, and others. Information is listed in aggregate
and by individual jurisdiction. To review the information, go to “Regulatory Tools” and click on
“Licensure Reference Guide.”
1.20 THE KEYS TO TAKE YOUR TEST ARE:
 Don't stress out about the exam.
 Referred to other medical professionals if you don't know the answer to a patient's problem.
 Do No Harm- with patient care.
 Set-up a dedicated study plan.
 Understand the content before you start taking practice tests.
Be familiar with format of the exam prior to test day.
1.21 DEVELOPING CONTENT VALIDITY: practice analysis to test content outline:
What types of knowledge need to be covered on the National Physical Therapy Examination (NPTE)
in order to determine if an individual is minimally competent to work as an entry-level PT or PTA? It's
a key question that ultimately is answered through a process referred to as a practice analysis. A
practice analysis is a study that systematically determines these responsibilities or \"activities,\" and
the knowledge and skill requirements (KSRs) for performing the activities. The results of a practice
analysis are useful for informing decisions about the test content outline and for providing evidence of
content validity.
1.21.1 PURPOSE OF A PRACTICE ANALYSIS:
FSBPT uses practice analysis to:
Verify current entry-level practice in the physical therapy profession;
Determine the knowledge and skill requirements (KSRs) required to perform at an entry level;
and maintain the content validity of the NPTE by ensuring that the test content outline
continues to measure entry-level knowledge and skills important for public protection.
The practice analysis conducted by the FSBPT is not intended to encompass the entire
physical therapy profession or what it “should be.” It also is not intended to be a curriculum
outline or synopsis of physical therapy education, an evaluation of advanced knowledge and
skills for physical therapy, or to express an opinion or a position on physical therapy.
1.21.2 A STANDARD APPROACH:
The practice analyses conducted by the Federation reflect best practices and meet criteria
set forth in the Standards for Education and Psychological Testing developed by the
American Education Research Association, the American Psychological Association and the
National Council on Measurement in Education for defensible methods of establishing
content validity in licensure and certification testing. The frequency with which a practice
analysis should be conducted depends on how rapidly job requirements change; for the
physical therapy profession, practice analyses are typically conducted every five years.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.21.3 PREVIOUS AND FUTURE PRACTICE ANALYSES:
The Federation conducted a study in the United States and Canada in 1995-1996, with
individual content outlines for PTs and PTAs in each country. The last study in the United
States was completed in 2002. The Federation has just begun its 2006 Analysis of Practice of
physical therapists and physical therapists assistants.
1.21.4 OVERVIEW OF A PRACTICE ANALYSIS:
Job responsibilities differ for PTs and PTAs. As a result, a different examination is developed
for each occupation. The practice analyses for physical therapist and physical therapist
assistant NPTEs also are parallel but separate processes. The Federation first develops and
pilots surveys to obtain information on activities of entry-level PTs and PTAs and the
knowledge and skill requirements (KSRs) for these activities. The pilot surveys are then
revised and distributed to a nationally representative sample of PTs and PTAs. To the
Federation, that means sending surveys to physical therapists and physical therapist
assistants in all 53 licensure jurisdictions.
The survey data are analyzed to determine the set of activities and KSRs critical for entry-
level practice. The results are used to update the PT and PTA NPTE test content outlines,
which ensures that the tests continue to measure important information in the right
proportions.
1.21.5 PHASES OF A PRACTICE ANALYSIS:
 Conduct a literature review of current physical therapy practice documents to develop a
list of potential activities and KSRs for the surveys
 Develop and pilot surveys for entry-level PT and entry-level PTA activities and KSRs
(knowledge and skill requirements)
 Develop final surveys based on data from pilot surveys
 Distribute final surveys to a nationally representative sample of PTs and PTAs
 Analyze survey data to determine critical activities
 Link critical activities to KSRs
 Use the findings to update the content outlines for the PT and PTA NPTE
1.21.6 THE OVERSIGHT PANEL AND TASK FORCES:
The Federation solicits nominations from member jurisdictions and professional physical
therapy groups and sections in order to ensure the oversight panel and task forces represent
the profession in terms of physical therapy practice settings, ethnicities, ages, lengths of
practice and regions of the United States.
The Practice Analysis Oversight Panel is appointed to oversee the practice analysis process
and task forces. Members of the panel are familiar with the NPTE development process, its
content outlines and current practice issues in physical therapy. The panel reviews the pilot
surveys, activity lists and KSRs, providing advice and guidance to the task forces and staff
throughout the process.
Two task forces are appointed, one for the PT practice analysis and one for the PTA practice
analysis. They produce the pilot and final surveys and use the survey results to build new
content outlines for the PT and PTA examinations. The task forces participate in two
assignments: (1) developing lists of job activities and knowledge and skill requirements; and
(2) reviewing preliminary survey and linkage results. The results of those assignments are
used to update the PT and PTA test content outlines.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.21.7 SURVEY DEVELOPMENT:
Both pilot and final surveys ask for demographic and professional background information
from the individual taking the survey. They include lists of activities and KRS, which will be
rated on scales to assess their importance to entry-level practice. Typical scales include: 1)
acquisition level, 2) consequence of incorrect performance, and 3) frequency of performance.
The pilot survey also asks general questions about the survey itself such as \"Did we forget an
activity that was essential?\" and \"Was some activity not physical therapy?\"
Acquisition Level: At what level of practice are the knowledge requirements and skills
necessary to independently perform this activity typically required?
Consequence of Incorrect Performance: When considering the risk of unnecessary
complications, impairment of function or serious distress to patients, how much physical or
psychological harm will the incorrect performance of this activity most likely cause the
patient?
A. FREQUENCY OF PERFORMANCE:
Task force members review the pilot survey findings and revise the survey as suggested
by the respondents. Revisions included clarifying confusing areas, condensing the survey
and including the amount of time needed to complete the survey in the request to
participate.
B. SURVEY PARTICIPATION:
The survey of activities is representative, meaning that the number of pilot and final
survey participants are based on the total number of PTs and PTAs in jurisdictions. The
ideal survey subjects have up to five years of experience so they are not too far from
entry-level practice. They represent the same diversity as the profession in key areas
such as gender, age, ethnicity, region and various clinical settings. All have passed the
exam and are licensed or certified.
A sophisticated distribution plan is used to elicit as many responses as possible. For
instance, an alert letter may be offered the survey on a web link. Non-respondents
receive a follow-up letter with a paper survey. This communication may be followed up
with a postcard, then a second follow-up letter with another paper survey.
The typical respondent to the last practice analysis survey (done in 2000) was female,
white, licensed or certified between 1996 and 2000, full-time/salaried, working in direct
patient care (especially ambulatory/outpatient and acute care) and more likely to report
obtaining an MPT or MSPT credential.
C. SURVEY ANALYSIS:
Ratings from the activity survey are combined into a single index of criticality, with the
entry-level activities having consequence for public protection receiving the most weight.
Knowledge and skills required to perform these important entry-level activities are linked
to the critical activities and then structured into a preliminary content outline for each
exam. The task forces are reconvened to review and finalize the test content outlines. It
should be noted that activities may be dropped from a content outline if they are part of
advanced practice or too infrequently performed to warrant inclusion. Once the test
content outline is finalized, new forms of the NPTE are assembled to meet the updated
test content outlines.
A Status Report on the 2006 Practice Analysis To date, the Practice Analysis Oversight
Panel and task forces have been appointed. They have generated a list of activities and
KSRs, which are currently being used to develop the pilot surveys. The pilot surveys will
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
be sent in late spring this year and the national survey will be sent this summer. We
expect to finalize test content outlines by early fall.
1.22 NPTE EXAM INFORMATION:
In order to become certified as a physical therapist or a physical therapist assistant, individuals need
to pass the National Physical Therapy Examination. This exam has been developed by the
Federation of State Boards of Physical Therapy to maintain high standards in the practice of physical
therapy, and to ensure that professional standards are consistent from jurisdiction to jurisdiction. The
NPTE exam is required for licensure or certification in all fifty states.
The NPTE exam for physical therapists is divided into the following four sections:
Examination (26% of the exam);
Evaluation, Diagnosis, Prognosis, and Outcomes (22.5%);
Intervention (41.5%);
Standards of Care (10%).
The NPTE exam for physical therapist assistants is divided into the following three sections:
Tests and Measures (21.3%);
Intervention (60%);
Standards of Care (18.7%).
On both exams, the systems of the body are covered in the following approximate proportions:
Musculoskeletal (24%);
Neuromuscular (24%);
Cardiovascular/pulmonary (13%);
Integumentary (7%);
Non-system (32%).
 The physical therapist examination consists of 250 questions and must be completed within 5
hours;
 The physical therapist assistant examination consists of 200 questions and must be completed
within 4 hours. There is a fifteen-minute break scheduled for the middle of the exam.
 Fifty of the exam questions are pre-test questions, which do not count towards a grade but are
used to develop future versions of the exam. It will not be possible to tell which questions are pre-
test questions.
 Scoring is based on the number of correct answers, so candidates should select the best answer
when they are unsure.
 The raw score (number of questions answered correctly) will be converted into a score on a scale
of 200 to 800; the scaled score takes into account differences in difficulty between versions of the
exam. The minimum passing score is a 600.
 The test administrator to the relevant licensing jurisdiction will deliver exam results; Candidates
will obtain their scores from their licensing authority. The NPTE exam is administered by
Thomson Prometric throughout the year at locations around the country; prospective test-takers
can register at the Prometric website. Test-takers must arrive at the testing location at least thirty
minutes before the examination with two forms of identification: one government-issued photo ID
and one ID with the name pre-printed and a signature (a credit card, for instance).
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1.23 EXAM BREACHES:
IMPACT ON BOARDS AND CANDIDATES NEWPORT BEACH, CA:
September 20, 2008
Exam Breaches: A Problem for Everyone
Test Developers and Administrators
Licensed Professionals
General Public
Licensing Boards
Candidates
Innocent Bystanders
Immigration Authorities
Vendors
Universities/Programs
Governments
Employers
Test Prep Companies
Recruiters
BUT ANYTIME SOMEONE KNOWINGLY OBTAINS AN UNFAIR ADVANTAGE . . .
THE FREE QUESTIONS ON THIS SITE ARE PRIMARILY FOR PHYSIOTHERAPISTS.
The FSBPT hosts the NPTE exam for physiotherapists and assistants. FSBPT stands for The Federation of
State Boards of Physical Therapy. NPTE stands for the National Physiotherapy Examination.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
Note:
The topics covered herein are to give you an idea and it is a fraction of what will be asked for in the NPTE
test. Hence the best practice is revising the 1st, 2nd, 3rd and 4th year syllabus. Many a physiotherapists have
passed the exams in their first attempts, yet others have made several attempts. (Remember the king and the
ant story “try try till you succeed)
“Success comes to those who seek it”
Good Luck
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.0 MUSCULOSKELETAL PHYSIOTHERAPY:
Musculoskeletal Physiotherapy is the term used to describe the field of physiotherapy, which relates to
disorders of the musculoskeletal system. The term musculoskeletal refers to muscles, bones, joints, nerves,
tendons, ligaments, cartilage, and spinal discs. Musculoskeletal Physiotherapy utilizes the basic sciences of
anatomy, physiology and biomechanics as background theory in the assessment and management of
patients. Approaches to management in the field of musculoskeletal physiotherapy involve ‘manipulation’, but
also manual assessment and treatment techniques, specific therapeutic exercise, electrotherapy and advice
on posture and movement disorders.
2.1 UNDERSTANDING THE MUSKULOSKEELETAL SYSTEM:
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
 The human musculoskeletal system (also known as the locomotor system) is an organ
system that gives humans the ability to move using the muscular and skeletal systems. The
musculoskeletal system provides form, stability, and movement to the human body.
 It is made up of the body's bones (the skeleton), muscles, cartilage, tendons, ligaments,
joints, and other connective tissue (the tissue that supports and binds tissues and organs
together). The musculoskeletal system's primary functions include supporting the body,
allowing motion, and protecting vital organs. The skeletal portion of the system serves as the
main storage system for calcium and phosphorus and contains critical components of the
hematopoietic system.
 There are, however, diseases and disorders that may adversely affect the function and
overall effectiveness of the system. These diseases can be difficult to diagnose due to the
close relation of the musculoskeletal system to other internal systems. The musculoskeletal
system refers to the system having its muscles attached to an internal skeletal system and is
necessary for humans to move to a more favorable position.
 The musculoskeletal system describes how bones are connected to other bones and muscle
fibers via connective tissue such as tendons and ligaments. The bones provide the stability to
a body in analogy to iron rods in concrete construction. Muscles keep bones in place and
also play a role in movement of the bones. To allow motion joints connect different bones.
Cartilage prevents the bone ends from rubbing directly on to each other. Muscles contract
(bunch up) and extend (stretch) to move the bone attached at the joint.
2.1.1 HUMAN SKELETON:
THE HUMAN SKELETAL SYSTEM
NUMBER OF
PART OF THE SKELETON BONES
Axial Skeleton 80
Skull 22
Ossicles (malleus, incus and stapes) 6
Vertebral column 26
Ribs 24
Sternum 1
Hyoid 1
Appendicular Skeleton 126
Upper extremities 64
Lower extremities 62
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
A. AXIAL SKELETON:
The axial skeleton consists of 80 bones forming the trunk (spine and thorax) and skull.
 Vertebral Column: The main trunk of the body is supported by the spine, or
vertebral column, which is composed of 26 bones, some of which are formed by the
fusion of a few bones. The vertebral column from superior to inferior consists of 7
cervical (neck), 12 thoracic and 5 lumbar vertebrae, as well as a sacrum, formed by
fusion of 5 sacral vertebrae, and a coccyx, formed by fusion of 4 coccygeal
vertebrae.
 Ribs and Sternum: The axial skeleton also contains 12 pairs of ribs attached
posteriorly to the thoracic vertebrae and anteriorly either directly or via cartilage to the
sternum (breastbone). The ribs and sternum form the thoracic cage, which protects
the heart and lungs. Seven pairs of ribs articulate with the sternum (fixed ribs)
directly, and three do so via cartilage; the two most inferior pairs do not attach
anteriorly and are referred to as floating ribs.
 Skull: The skull consists of 22 bones fused together to form a rigid structure which
houses and protects organs such as the brain, auditory apparatus and eyes. The
bones of the skull form the face and cranium (brain case) and consist of 6 single
bones (occipital, frontal, ethmoid, sphenoid, vomer and mandible) and 8 paired
bones (parietal, temporal, maxillary, palatine, zygomatic, lacrimal, inferior concha and
nasal). The lower jaw or mandible is the only movable bone of the skull (head); it
articulates with the temporal bones.
 Other Parts: Other bones considered part of the axial skeleton are the middle ear
bones (ossicles) and the small U-shaped hyoid bone that is suspended in a portion of
the neck by muscles and ligaments.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
B. APPENDICULAR SKELETON:
The appendicular skeleton forms the major internal support of the appendages—the
upper and lower extremities (limbs).
 Pectoral Girdle and Upper Extremities: The arms are attached to and suspended
from the axial skeleton via the shoulder (pectoral) girdle. The latter is composed of
two clavicles (collarbones) and two scapulae (shoulder blades). The clavicles
articulate with the sternum; the two sternoclavicular joints are the only sites of
articulation between the trunk and upper extremity.
 Each upper limb from distal to proximal (closest to the body) consists of hand, wrist,
forearm and arm (upper arm). The hand consists of 5 digits (fingers) and 5
metacarpalbones. Each digit is composed of three bones called phalanges, except
the thumb, which has only two bones.
 Pelvic Girdle and Lower Extremities: The lower extremities, or legs, are attached
to the axial skeleton via the pelvic or hip girdle. Each of the two coxal, or hip bones
comprising the pelvic girdle is formed by the fusion of three bones—illium, pubis, and
ischium. The coxal bones attach the lower limbs to the trunk by articulating with the
sacrum.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
C. CHARACTERISTICS OF BONE:
Bone is a specialized type of connective tissue consisting of cells (osteocytes) embedded
in a calcified matrix that gives bone its characteristic hard and rigid nature. Bones are
encased by a periosteum, a connective tissue sheath. All bone has a central marrow
cavity. Bone marrow fills the marrow cavity or smaller marrow spaces, depending on the
type of bone.
I. TYPES OF BONE:
There are two types of bone in the skeleton:
 Compact bone
 Spongy (cancellous) bone.
1. Compact Bone: Compact bone lies within the periosteum, forms the outer
region of bones, and appears dense due to its compact organization. The living
osteocytes and calcified matrix are arranged in layers, or lamellae. Lamellae may
be circularly arranged surrounding a central canal, the Haversian canal, which
contains small blood vessels.
2. Spongy Bone: Spongy bone consists of bars, spicules or trabeculae, which
forms a lattice meshwork. Spongy bone is found at the ends of long bones and
the inner layer of flat, irregular and short bones. The trabeculae consist of
osteocytes embedded in calcified matrix, which in definitive bone has a lamellar
nature. The spaces between the trabeculae contain bone marrow.
II. TYPES OF BONE CELLS:
The cells of bone are
 Osteocytes,
 Osteoblasts,
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
 Osteoclasts.
1. OSTEOCYTES:
Osteocytes are found singly in lacunae (spaces) within the calcified matrix and
communicate with each other via small canals in the bone known as canaliculi.
The latter contain osteocyte cell processes. The osteocytes in compact and
spongy bone are similar in structure and function.
2. OSTEOBLASTS:
Osteoblasts are cells which form bone matrix, surrounding themselves with it,
and thus are transformed into osteocytes. They arise from undifferentiated cells,
such as mesenchymal cells. They are cuboidal cells that line the trabeculae of
immature or developing spongy bone.
3. OSTEOCLASTS:
Osteoclasts are cells found during bone development and remodeling. They are
multinucleated cells lying in cavities, Howship’s lacunae, on the surface of the
bone tissue being resorbed. Osteoclasts remove the existing calcified matrix
releasing the inorganic or organic components.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
III. BONE MATRIX:
Matrix of compact and spongy bone consists of collagenous fibers and ground
substance that constitute the organic component of bone. Matrix also consists of
inorganic material that is about 65% of the dry weight of bone. Approximately 85% of
the inorganic component consists of calcium phosphate in a crystalline form
(hydroxyapatite crystals). Glycoproteins are the main components of the ground
substance.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
IV. MAJOR TYPES OF HUMAN BONES:
Type of Bone Characteristics Examples
Humerus, radius, ulna, femur,
Long bones Width less than length tibia
Length and width close to
Short bones equal in size Carpal and tarsal bones
Scapulae, ribs, sternum, bones
of cranium (occipital, frontal,
Flat bones Thin flat shape parietal)
Irregular bones Multifaceted shape Vertebrae, sphenoid, ethmoid
Small bones located in
Sesamoid tendons of muscles ---------
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
V. JOINTS:
The bones of the skeleton articulate with each other at joints, which are variable in
structure and function. Some joints are immovable, such as the sutures between the
bones of the cranium. Others are slightly movable joints; examples are the
intervertebral joints and the pubic Symphysis (joint between the two pubic bones of
the coxal bones).
1. TYPES OF JOINTS:
Joint Type Characteristic Example
Permits all types of
movement (abduction,
adduction, flexion, extension,
circumduction); it is
Ball and socket considered a universal joint. Hips and shoulder joints
Permits motion in one plane Elbow and knee, interphalangeal
Hinge (ginglymus) only joints
Rotation is only motion Radius and ulna, atlas and axis (first
Rotating or pivot permitted and second cervical vertebrae)
Between tarsal bones and carpal
Plane or gliding Permits sliding motion bones
Permits motion in two planes
which are at right angles to
each other (rotation is not
Condylar (condyloid) possible) Metacarop-phalangeal joints,v
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2. ADJACENT BONES:
At a joint are connected by fibrous connective tissue bands known as ligaments.
They are strong bands, which support the joint and may also act to limit the degree
of motion occurring at a joint.
3. ORIENTATION OF FACET JOINTS:
4. BONES OF THE HAND & FOOT:
Medial View
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
5. HAND ANATOMY:
The important structures of the hand can be divided into several categories. These
include
 Bones and joints
 Ligaments and tendons
 Muscles
 Nerves
 Blood vessels
The front, or palm-side, of the hand is referred to as the palmar side. The back of
the hand is called the dorsal side.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
6. ANKLE:
Ankle joint. Point to and name the locations of the ligaments
1. Piriformis
2. Gemellus Superior
3. Obturator Internus
4. Gemellus Inferior
5. Obturator Externus
6. Quadratus Femoris
External rotators and adductors hip
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
7. KNEE JOINT & COMMON KNEE PROBLEMS:
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
VI. COMMON KNEE PROBLEMS:
1. ACUTE INJURY:
First Aid: Here are some general rules for treatment.
 If you heard a pop - something is usually torn. Likely culprits are menisci,
medial collateral ligament, and anterior cruciate ligament.
 If your knee swells right away, something is bleeding inside. Most likely
injuries are meniscal tears and anterior cruciate tears.
 Use ice, and wrap you knee with an ace wrap.
 If you can't walk - don't! Get crutches
 It's pretty bad - very swollen, can't walk, painful. Get some help. Call primary
care MD, go to an ER or walk-in clinic
 It's not too bad. Tolerable , stiff, sore. Start rehabilitation.
 Contusion usually a blunt injury to the knee. May be very painful. Use
standard approach - Ice, Ace, NSAI Medication, weight bearing as tolerated,
early motion. Improvement should be dramatic in 2 - 5 days. If not see MD.
Achiness is typical. \"Locking\" or severe pain is not.
2. MEDIAL KNEE PAIN:
Medial knee pain generally comes on suddenly(acute) or slowly over
time(chronic). Acute trauma usually causes meniscus tears, collateral ligament
tears. Both may cause a \"pop\". Both may cause swelling. In fact, they may be
difficult to tell apart - and may occur together. Ligament injuries often have a
story of \" the knee bent to the side\". These knees feel unstable or \"give way\".
Typical example: My ski tips went apart and I fell\". \"I got clipped by another
player.\" Be aware that other ligaments may be injured. Meniscus tears usually
have a twisting mechanism. You may hear a pop. These injuries usually swell
within hours of injury. Sometimes the torn piece of cartilage jams in the joint and
causes \"locking\". Chronic problems are usually the late result of old trauma or
related to abnormal posture or mechanics. These problems may appear slowly -
and without apparent cause. Sharp pain along the inner knee with twisting or
squatting is most usually a meniscus tear. The pain may be caused by a joint
surface roughness - a sort of pre arthritis.
3. MCL TEAR:
A common injury. Usually the foot is bent outward, away from the midline and a
pop or tearing sensation is felt on the inner side of the knee. The injury is graded
or rated 1, 2, or 3.
 Grade I is bruised ligament with no instability. These injuries are painful but
not unstable. Grade II injuries have mild to moderate instability. These
injuries represent partial or incomplete tears.
 Treatment on grade I and Grade II injuries are the same ice, ace, anti
inflammatory medication, early motion - especially stationary cycling. Many
people use an immobilizer brace for 1 - 2 weeks for walking. Flexibility is
usually normal in 2-4 weeks. Full return to vigorous pursuits in 3 - 6 weeks.
Return to normal in 10-12 weeks.
 Grade III injuries are very unstable and are often associated with other
injuries. These should be evaluated by an MD.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
4. MENISCUS TEAR:
 Meniscus tears are common and come in several varieties. A tear usually
occurs when the joint is compressed and twisted - pinching the meniscus and
ripping it. Some tears are large, painful and lock the knee up entirely. Others
are relatively small and minor.
 Symptoms include pain at the joint line, fluid on the knee, stiffness, catching
and locking. In some cases, the diagnosis is confirmed with an MRI.
 Meniscus tissue is valuable. The meniscus cushions and improves the fit of
the femur to the tibia. Removal of large amounts of meniscus causes
increased stress and wear - and - tear within the joint. Thus, treatments are
based on maintaining as much meniscal tissue as possible.
 A meniscus tear can often be \"calmed down\". Standard treatment is ice,
wrap, motion, and anti-inflammatory medication. Surgical treatment is
needed if the knee will not get better or if the motion is limited. Surgical
treatment involves using a small microscope to look at and treat the tear.
After anesthesia is established, the arthoscope is inserted into the knee and
the meniscus tear is examined. If the tear involves the vascular portion of the
meniscus, it can be repaired. Repairs are done with the arthroscope -
passing sutures across the tear. If the meniscus is not repairable, then a
microscopic shaver is used to remove the torn portion. The goal is to leave
the joint surfaces smooth.
 Most meniscal tears do not need immediate surgery. However, surgery is
often required to eliminate the symptoms. Occasionally, a part of a torn
meniscus becomes wedged into the front of the knee. The knee becomes
stuck or locked. Arthroscopic surgery is usually done within a few days in
order to relieve pain and prevent long term stiffness.
5. CHONDRAL INJURY:
Each of the bony surfaces within the knee is covered with articular cartilage.
This surface may be injured in sport, a trauma or with overuse - especially with a
malalignment. Injury may include bruising or a break / fracture of the surface.
Symptoms include joint line pain, swelling catching or locking. The diagnosis
might be confirmed with an MRI or with arthroscopy. Treatment varies with the
extent of the injury. Bruising often responds to non-impact conditioning for 2 - 3
weeks. Broken surfaces often require arthroscopy to smooth the edges and
remove broken fragments. Treatment may include stimulating a biologic repair
(drilling or micro fracture). Cartilage culturing with replantation or cartilage
transplant procedures are also useful for select cases.
6. LATERAL KNEE PAIN:
Lateral knee pain generally comes on suddenly(acute) or slowly over
time(chronic). Acute trauma usually causes meniscus tears, collateral ligament
tears or a dislocating patella. Each may cause a \"pop\". Each may cause
swelling. Also, tendinitis along the outer side of the knee is common -
specifically involving the ileotibial band (ITB).
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
7. LCL TEAR:
A common injury. Usually the foot is bent outward, away from the midline and a
pop or tearing sensation is felt on the inner side of the knee. The injury is graded
or rated 1, 2, or 3. Grade I is bruised ligament with no instability. These injuries
are painful but not unstable. Grade II injuries have mild to moderate instability.
These injuries represent partial or incomplete tears. Treatment on grade I and
Grade II injuries are the same ice, ace, anti inflammatory medication, early
motion - especially stationary cycling. Many people use an immobilizer brace for
1 - 2 weeks for walking. Flexibility is usually normal in 2-4 weeks. Full return to
vigorous pursuits in 3 - 6 weeks. Return to normal in 10-12 weeks. Grade III
injuries are very unstable and are often associated with other injuries. These
should be evaluated by an MD.
8. MENISCUS TEAR:
 Meniscus tears are common and come in several varieties. A tear usually
occurs when the joint is compressed and twisted - pinching the meniscus and
ripping it. Some tears are large, painful and lock the knee up entirely. Others
are relatively small and minor.
 Symptoms include pain at the joint line, fluid on the knee, stiffness, catching
and locking. In some cases, the diagnosis is confirmed with an MRI
(magnetic resonance image).
 Meniscus tissue is valuable. The meniscus cushions and improves the fit of
the femur to the tibia. Removal of large amounts of meniscus causes
increased stress and wear - and - tear within the joint. Thus, treatments are
based on maintaining as much meniscal tissue as possible.
 A meniscus tear can often be \"calmed down\". Standard treatment is ice,
wrap, motion, and anti-inflammatory medication. Surgical treatment is
needed if the knee will not get better or if the motion is limited. Surgical
treatment involves using a small microscope to look at and treat the tear.
After anesthesia is established, the arthoscope is inserted into the knee and
the meniscus tear is examined. If the tear involves the vascular portion of the
meniscus, it can be repaired. Repairs are done with the arthoscope - passing
sutures across the tear. If the meniscus is not repairable, the a microscopic
shaver is used to remove the torn portion. The goal is to leave the joint
surfaces smooth.
 Most meniscal tears do not need immediate surgery. However, surgery is
often required to eliminate the symptoms. Occasionally, a part of a torn
meniscus becomes wedged into the front of the knee. The knee becomes
stuck or locked. Arthroscopic surgery is usually done within a few days in
order to relieve pain and prevent long term stiffness.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
9. CHONDRAL FRACTURE:
 Each of the bony surfaces within the knee is covered with articular cartilage.
This surface may be injured in sport, a trauma or with overuse - especially
with a malalignment.
 Symptoms include joint line pain, swelling catching or locking.
 The diagnosis might be confirmed with an MRI of with arthroscopy. While
MRI is an extremely useful tool, and very accurate for meniscus tears (95 -
98%), it is only 50% - 70% accurate for chondral pathology. Arthroscopy is
the gold standard.
 Treatment includes cleaning the roughened surface (debridement) and or
stimulating a biologic repair (drilling or micro fracture). Cartilage culturing with
replantation or cartilage transplant procedures are also useful for select
cases.
10. PATELLAR SUBLUXATION / DISLOCATION:
 Patellar subluxation occurs when the patella slips away from the front of the
knee - almost always to the outer side. The slip may be minor (subluxation)
or major (dislocation). The patella may return by itself - or be stuck. Often
the under surface of the patella is injured during a sublux or dislocation. The
patella is scraped against the outer rim of the femur. Either or both surfaces
may be bruised, abraded or fractured. Loose chips of cartilage or bone within
the knee are common after a dislocation. As the patella slides laterally the
ligaments and muscle are often torn free from the inner portion of the patella.
This muscle injury is a common reason for difficult rehabilitation, quadriceps
atrophy and poor patellar tracking afterward.
 Risk factors include a person with generalized ligamentous laxity, prior
dislocations, a long patellar tendon (high riding patella - \"alta\"), knocked knee
posture, externally rotated tibias (duck footed), and flat or pronated feet.
 The diagnosis is usually made by the patient;\"my knee cap went out\".
Tenderness may occur on both the inner and outer side of the patella.
Usually the knee develops a large amount of fluid (effusion). X-rays are
usually negative but may show a subluxation or loose body.
 Early treatment involves bracing and early range of motion. Strengthening
should also start within a week - consisting of quadriceps tensing, straight leg
raising, and advancing to cycling and closed chain strengthening.
 Some catching or a mild sense of grinding is common after any knee injury.
Severe or persistent catching, locking or grinding may indicate a damaged
joint surface. Further diagnostic tools such as an MRI or arthroscopy may be
necessary.
 McConnell Taping or knee cap taping may be extremely useful to allow
earlier return to aggressive training and earlier return to sport.
 Patellar bracing is also very helpful as a protective tool during the first few
weeks and during early return to sports.
 Multiple dislocations may require surgical stabilization. (Extensor mechanism
reconstruction).
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
11. ACL TEAR:
 Anterior cruciate ligament tears occur with a twist, clip or hyperextension
mechanism. The athlete often feels a tear or hears a \"pop\". The knee usually
swells within 4 hours. Sometimes the knee feels better after a few minutes
and the athlete attempts to return to play. Often, knee then \"gives out\" - with
great pain. The knee with a isolated ACL injury will begin to feel much better
within a week. Linear activities such as walking, cycling, etc. become easy.
Accelerated moves:jumping, cutting will cause the knee to give way ( and
reinjure). Often the injury involves more than just the ACL. Small fractures or
bone bruises of the top surface of the tibia are common. The meniscus or
other ligaments are often injured during the initial accident - or in subsequent
give way episodes. Risk factors include fatigue and poor strength, a narrow
notch (space between femoral condyles), hyperlax joints, knees which
hyperextend, and bad luck (most are in this category). The diagnosis is by
history and physical exam. Torn ligaments allow too much motion when the
knee is stressed. The physical exam can usually determine the magnitude of
the injury. X-ray or MRI may be needed - especially for additional injuries to
cartilages, other ligaments, and bones.
 Early treatment involves icing, wrapping and working towards full flexibility.
Difficulty with weight bearing usually indicated other injuries. An isolated ACL
may cause very little pain.
 Cycling is encouraged as soon as possible. The first sessions are on a
stationary bike. The knee should be iced for 10 - 20 minutes prior to exercise.
Gentle stretching should follow for 2 - 3 minutes. Next, get onto the cycle and
\"play\" with the pedals. The injured knee will often not be capable of
completing a revolution. So, start by rocking back and forth. Gradually
increase the range until revolutions are possible. This process may take 2 -3
days. Try to maintain a level pelvis while riding. This \"warm up\" may be
required at the beginning of each session for a week. Cycle for 30 min per
day . Several shorter sessions may be easier.
 Strengthening should be started within a week. Exercises should be \" closed
chain \". This means that forces should be applied through the foot into the
floor or pedal. Examples: step ups, leg press, lunges, and calf raises.
Quadriceps extensions should be avoided.
 Return to vigorous sport requires the ability to run without a limp, and
stability. Stability may be a sports brace or surgical reconstruction. The right
choice of treatment is base on many factors including overall stability of the
knee, associated injuries, age, activity level and motivation. Example : 40 yr
old accountant who enjoys cycling and occasional soccer, ACL exam shows
only moderate instability. Treatment: closed chain strengthening for 3 - 6
weeks, brace for high velocity sports. Example : 16 yr old female athlete with
chronic patellar pain. Treatment: ACL reconstruction with a hamstring graft.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
12. CHRONIC PROBLEMS:
Chronic problems are usually the late result of old trauma or related to abnormal
posture or mechanics.
a. Anterior knee pain, chondromalacia, arthritis of the patella:
Anterior knee pain refers to pain coming from the patella or surrounding
structures - patellar tendon , or quadriceps. Often the patella does not track
properly in the groove on the front of the femur. Usually a painful patella
drifts to the outer side(lateral) of the knee. Fluid within the knee(water on the
knee), causes the patella to track poorly. A painful patella causes a reflex
atrophy in the quadriceps. The quadriceps helps to maintain correct patellar
alignment. Thus, chronic pain leads to poor tracking, poor tracking causes
chronic pain.
b. \"Chronic pain leads to poor tracking, poor tracking causes chronic
pain.\"
 How do you break the cycle?
 Hold the patella \"on track\", strengthen the quadriceps, \"stroke\" the joint
surfaces.
 Motion clears fluid and \"pumps\" joint fluid into the joint surfaces (articular
cartilage).
Examples:
 Tape the patella into its proper position(McConnell taping) and start non-
impact conditioning i.e. cycling, elliptical trainer, stair climber.
 Anterior knee pain is common and very treatable. First, let's define terms.
 The kneecap or patella is a bone in the front of the knee. The patella
connects the quadriceps muscle with the tibia. The quad, patella and
patella function together to extend the knee (straighten the knee).
Problems with the patella or surrounding structures are referred to as
anterior knee pain. (Anterior referrer to front side of the knee).
 The joint surface of the patella is covered with articular cartilage. This
surface is normally very slippery and smooth. If the patella is injured, the
joint surface often becomes roughened. This roughening of the cartilage
is called chondromalacia - literally \"sick cartilage\". The patella can easily
start to ride \"off center\" - nearly always toward the outside. This poor
alignment is called maltracking . This process is worsened by knock
kneed posture, hyperpronating feet, poor muscle tone, high body weight,
high impact activity, inadequate shoes, and fluid in the knee (effusions).
Maltracking tends to worsen chondromalacia and visa versa.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
c. Treatment:
 Based on reducing swelling and inflammation, restoring a normal tracking
pattern, and restoring quadriceps tone.
 Non impact Conditioning
 Non impact conditioning 30 min per day
 Walking / jogging /treadmill is too stressful for an acute knee injury,
 Start with a stationary bike. Set the seat high, low resistance. Start by
rocking you feet \"to and fro\". Eventually, work up to spinning.
 Swimming is another good choice. Swim laps, walk or \"run\" in chest high
water. Avoid breaststroke or whip kicking at first.
 Anti-inflammatory Medication
 Anti-inflammatory medication reduces pain and swelling. These medicines
are all quite similar. Use the one with a cost and dosage schedule that
suits you.
 Avoid these medications if you have a history of stomach problems or
ulcers, kidney problems, allergy to aspirin, or take the medication
coumadin.
 Return to High Velocity Sport
 Run full speed without a limp
 McConnell Taping
 Physical therapy for a home program.
 McConnell taping is a biofeedback technique. The tape pulls the knee cap
outward - helping to reestablish normal tracking. Normally, taping will
cause in immediate improvement. The program involves taping every day,
prior to 30 minutes of non-impact exercise.
 Arch Supports
 Off-the-shelve arch supports
 Spencoe
 Superfeet
 Weight Loss
 If appropriate - usual goal 10%
 Good shoes: Must absorb impact - no thin soles, no high or wooden heals
\"air\" soles, crepe, rubber Examples: athletic cross trainers Dress:
Easyspirit, Rockport, Bass
 Glucosamine Sulfate
 1500 mg per day Builds joint lubrication.
 Custom molded arch supports
 Gait analysis and orthotic fabrication
 Designed to \"center\" biomechanic forces and reduce pronation 80 % of
patients with knee pain respond.
 Hyaluronic Acid Injections
 Series of three weekly injections Hyaluronic acid is a natural lubricant
within joints. Injections help arthritic surfaces to glide more smoothly.
Studies suggest that 80% of patient will experience reduced pain for 6
months.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
d. Arthritis:
Others start slowly and progressively worsen. Risk factors include ligament
injury, high body weight, a hyperpronating foot (flat foot), deep squatting or
kneeling, \"bow legged\" or \"knock kneed\" posture.
e. Surgical treatment:
 ACL reconstruction involves replacing the torn ligament with another
tissue - a graft. The graft may be taken from the patellar tendon,
hamstring tendon or a cadaver (allograft). Each method has advantages
& disadvantages. Surgery is performed Arthroscopic ally, as a outpatient.
Crutch walking is required for about 3 weeks.
 Return to sedentary work takes about a week. Moderate activities i.e.
stand, walk all day 4 - 8 weeks. Return to full velocity sports takes 5
months. [Post op instructions and rehabilitation]
 Arthroscopic debridement:
Outpatient procedure, approximately 1 hr, no crutches, ice and rest for 2
days, then progressive rehabilitation. Debridements smoothes the joint
surface - relieves pain and \"grinding\" - allows rehabilitation.
 Biologic resurfacing:
Outpatient procedure, approximately 1 hr, crutches or brace for one
month, early swim / cycle Several techniques, all stimulate new cartilage
to form in region of damage or disease.
 Arthroscopic lateral release:
Outpatient procedure, approximately 1 hr, crutches or brace for 10 days,
early swim / cycle Ideal for knees with tight lateral ligaments, lateral side
pain - and otherwise normal alignment
 Extensor mechanism realignment:
Outpatient procedure, approximately 1 hr, crutches or brace for 10 days,
early swim / cycle Ideal for knees with significant lateral patella alignment
/ forces.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
13. JOINT PROTECTION:
a. Client in for about joint protection:
o Be kind to your body. After doing heavy work, or doing the same task over
and over, stop. Slow down by doing an easy task, or by taking a rest.
o Use your back, arms and legs in safe ways to avoid putting stress on joints.
For example, carry a heavy load close to your body.
o Use helpful devices such as a cart to carry your grocery bags, or an enlarged
handle that fits over a knife handle so you can hold it easily. A cart will help
you to walk more safely. A grab bar, which attaches to a shower, will help you
to get in and out of the tub more easily.
o Consider getting a splint to hold your joints in a comfortable position at night
or while you work. A splint can help decrease pain, swelling and stiffness.
o Protecting your joints means using them in ways that avoid excess stress.
Benefits include less pain and greater ease in doing tasks. Three main
techniques to protect your joints are:
i. Pacing, by alternating heavy or repeated tasks with easier tasks or
breaks, reduces the stress on painful joints and allows weakened muscles
to rest.
ii. Positioning joints wisely helps you use them in ways that avoid extra
stress. Use larger, stronger joints to carry loads. For example, use a
shoulder bag instead of a hand-held one. Also, avoid keeping the same
position for a long period of time.
iii. Using helpful devices, such as canes, luggage carts, grocery carts and
reaching aids, can help make daily tasks easier. Small appliances such
as microwaves, food processors and bread makers can be useful in the
kitchen. Using grab bars and shower seats in the bathroom can help you
to conserve energy and avoid falls. Splints may be useful if you have joint
inflammation, or problems with joint alignment or stability. They can help
rest your joints at night, or hold the joints in a comfortable position while
working. This, in turn, helps decrease joint pain, swelling and stiffness.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
14. HUMERUS:
The humerus is the longest and largest bone of the upper extremity; it is divisible
into a body and two extremities.
 Upper Extremity: The upper extremity consists of a large rounded head
joined to the body by a constricted portion called the neck, and two
eminences, the greater and lesser tubercles.
 The Head (caput humeri): The head, nearly hemispherical in form, (*54 is
directed upward, medialward, and a little backward, and articulates with the
glenoid cavity of the scapula. The circumference of its articular surface is
slightly constricted and is termed the anatomical neck, in contradistinction to
a constriction below the tubercles called the surgical neck, which is
frequently the seat of fracture. Fracture of the anatomical neck rarely occurs.
The anatomical Neck (collum anatomicum) is obliquely directed, forming an
obtuse angle with the body. It is best marked in the lower half of its
circumference; in the upper half it is represented by a narrow groove
separating the head from the tubercles. It affords attachment to the articular
capsule of the shoulder-joint, and is perforated by numerous vascular
foramina.
 The Greater Tubercle: (tuberculum majus; greater tuberosity): The greater
tubercle is situated lateral to the head and lesser tubercle. Its upper surface
is rounded and marked by three flat impressions: the highest of these gives
insertion to the Supraspinatus; the middle to the Infraspinatus; the lowest
one, and the body of the bone for about 2.5 cm. below it, to the Teres minor.
The lateral surface of the greater tubercle is convex, rough, and continuous
with the lateral surface of the body.
Left humerus. Posterior view.
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to recall by Mullsons Health & Wellness at any time.
 The Lesser Tubercle: (tuberculum minus; lesser tuberosity):
o The lesser tubercle, although smaller, is more prominent than the
greater: it is situated in front, and is directed medialward and forward.
Above and in front it presents an impression for the insertion of the
tendon of the Subscapularis.
o The tubercles are separated from each other by a deep groove, the
intertubercular groove (bicipital groove), which lodges the long tendon of
the Biceps brachii and transmits a branch of the anterior humeral
circumflex artery to the shoulder-joint. It runs obliquely downward, and
ends near the junction of the upper with the middle third of the bone. In
the fresh state its upper part is covered with a thin layer of cartilage, lined
by a prolongation of the synovial membrane of the shoulder-joint; its
lower portion gives insertion to the tendon of the Latissimus dorsi. It is
deep and narrow above, and becomes shallow and a little broader as it
descends. Its lips are called, respectively, the crests of the greater and
lesser tubercles (bicipital ridges), and form the upper parts of the anterior
and medial borders of the body of the bone. The Body or Shaft (corpus
humeri):The body is almost cylindrical in the upper half of its extent,
prismatic and flattened below, and has three borders and three surfaces.
 Borders:
o The anterior border runs from the front of the greater tubercle above to
Longitudinal section of head
the coronoid fossa below, separating the antero-medial from the antero-
of left humerus.
lateral surface. Its upper part is a prominent ridge, the crest of the
greater tubercle; it serves for the insertion of the tendon of the Pectoralis
major. About its center it forms the anterior boundary of the deltoid
tuberosity; below, it is smooth and rounded, affording attachment to the
Brachialis. The lateral border runs from the back part of the greater
tubercle to the lateral epicondyle, and separates the anterolateral from
the posterior surface. Its upper half is rounded and indistinctly marked,
serving for the attachment of the lower part of the insertion of the Teres
minor, and below this giving origin to the lateral head of the Triceps
brachii; its center is traversed by a broad but shallow oblique depression,
the radial sulcus (musculospiral groove). Its lower part forms a
prominent, rough margin, a little curved from behind forward, the lateral
supracondylar ridge, which presents an anterior lip for the origin of the
Brachioradialis above, and Extensor carpi radialis longus below, a
posterior lip for the Triceps brachii, and an intermediate ridge for the
attachment of the lateral intermuscular septum.
o The medial border extends from the lesser tubercle to the medial
epicondyle. Its upper third consists of a prominent ridge, the crest of the
lesser tubercle, which gives insertion to the tendon of the Teres major.
About its center is a slight impression for the insertion of the
Coracobrachialis, and just below this is the entrance of the nutrient
canal, directed downward; sometimes there is a second nutrient canal at
the commencement of the radial sulcus. The inferior third of this border is
Plan of ossification of the
raised into a slight ridge, the medial supracondylar ridge, which becomes
humerus.
very prominent below; it presents an anterior lip for the origins of the
Brachialis and Pronator teres, a posterior lip for the medial head of the
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Triceps brachii, and an intermediate ridge for the attachment of the
medial intermuscular septum.
 Surfaces:
The antero-lateral surface is directed lateralward above, where it is smooth,
rounded, and covered by the Deltoideus; forward and lateralward below,
where it is slightly concave from above downward, and gives origin to part of
the Brachialis. About the middle of this surface is a rough, triangular
elevation, the deltoid tuberosity for the insertion of the Deltoideus; below this
is the radial sulcus, directed obliquely from behind, forward, and downward,
and transmitting the radial nerve and profunda artery.
 Left Humerus:
Posterior view. The antero-medial surface, less extensive than the antero-
lateral, is directed medialward above, forward and medialward below; its
upper part is narrow, and forms the floor of the intertubercular groove which
gives insertion to the tendon of the Latissimus dorsi; its middle part is slightly
rough for the attachment of some of the fibers of the tendon of insertion of
the Coracobrachialis; its lower part is smooth, concave from above
downward, and gives origin to the Brachialis. The posterior surface appears
somewhat twisted, so that its upper part is directed a little medialward, its
lower part backward and a little lateralward. Nearly the whole of this surface
is covered by the lateral and medial heads of the Triceps brachii, the former
arising above, the latter below the radial sulcus.
 The Lower Extremity:
The lower extremity is flattened from before backward, and curved slightly
Epiphysial lines of humerus
forward; it ends below in a broad, articular surface, which is divided into two
in a young adult. Anterior
parts by a slight ridge. Projecting on either side are the lateral and medial
aspect. The lines of
epicondyles. The articular surface extends a little lower than the epicondyles,
attachment of the articular
and is curved slightly forward; its medial extremity occupies a lower level
capsules are in blue.
than the lateral. The lateral portion of this surface consists of a smooth,
rounded eminence, named the capitulum of the humerus; it articulates with
the cup shaped depression on the head of the radius, and is limited to the
front and lower part of the bone. On the medial side of this eminence is a
shallow groove, in which is received the medial margin of the head of the
radius. Above the front part of the capitulum is a slight depression, the radial
fossa, which receives the anterior border of the head of the radius, when the
forearm is flexed. The medial portion of the articular surface is named the
trochlea, and presents a deep depression between two well-marked borders;
it is convex from before backward, concave from side to side, and occupies
the anterior, lower, and posterior parts of the extremity. The lateral border
separates it from the groove, which articulates with the margin of the head of
the radius. The medial border is thicker, of greater length, and consequently
more prominent, than the lateral. The grooved portion of the articular surface
fits accurately within the semilunar notch of the ulna; it is broader and deeper
on the posterior than on the anterior aspect of the bone, and is inclined
obliquely downward and forward toward the medial side. Above the front part
of the trochlea is a small depression, the coronoid fossa, which receives the
coronoid process of the ulna during flexion of the forearm. Above the back
part of the trochlea is a deep triangular depression, the olecranon fossa, in
which the summit of the olecranon is received in extension of the forearm.
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to recall by Mullsons Health & Wellness at any time.
These fossæ are separated from one another by a thin, transparent lamina of
bone, which is sometimes perforated by a supratrochlear foramen; they are
lined in the fresh state by the synovial membrane of the elbow-joint, and their
margins afford attachment to the anterior and posterior ligaments of this
articulation. The lateral epicondyle is a small, tuberculated eminence, curved
a little forward, and giving attachment to the radial collateral ligament of the
elbow-joint, and to a tendon common to the origin of the Supinator and some
of the Extensor muscles. The medial epicondyle, larger and more prominent
than the lateral, is directed a little backward; it gives attachment to the ulnar
collateral ligament of the elbow-joint, to the Pronator teres, and to a common
tendon of origin of some of the Flexor muscles of the forearm; the ulnar
nerve runs in a groove on the back of this epicondyle. The epicondyles are
continuous above with the supracondylar ridges.
 Structure:
The extremities consist of cancellous tissue, covered with a thin, compact
layer the body is composed of a cylinder of compact tissue, thicker at the
center than toward the extremities, and contains a large medullary canal,
which extends along its whole length.
 Ossification:
The humerus is ossified from eight centers, one for each of the following
parts: the body, the head, the greater tubercle, the lesser tubercle, the
capitulum, the trochlea, and one for each epicondyle. The center for the body
appears near the middle of the bone in the eighth week of fetal life, and soon
extends toward the extremities. At birth the humerus is ossified in nearly its
whole length, only the extremities remaining cartilaginous. During the first
year, sometimes before birth, ossification commences in the head of the
bone, and during the third year the center for the greater tubercle, and during
the fifth that for the lesser tubercle, make their appearance. By the sixth year
the centers for the head and tubercles have joined, so as to form a single
large epiphysis, which fuses with the body about the twentieth year. The
lower end of the humerus is ossified as follows. At the end of the second
year ossification begins in the capitulum, and extends medialward, to form
the chief part of the articular end of the bone; the center for the medial part of
the trochlea appears about the age of twelve. Ossification begins in the
medial epicondyle about the fifth year, and in the lateral about the thirteenth
or fourteenth year. About the sixteenth or seventeenth year, the lateral
epicondyle and both portions of the articulating surface, having already
joined, unite with the body, and at the eighteenth year the medial epicondyle
becomes joined to it.
Note: Though the head is nearly hemispherical in form, its margin, as
Humphry has shown, is by no means a true circle. Its greatest diameter is,
from the top of the intertubercular groove in a direction downward,
medialward, and backward. Hence it follows that the greatest elevation of the
arm can be obtained by rolling the articular surface in this direction—that is to
say, obliquely upward, lateralward, and forward. [back]
Note: A small, hook-shaped process of bone, the supracondylar process,
varying from 2 to 20 mm. in length, is not infrequently found projecting from
the antero-medial surface of the body of the humerus 5 cm. above the medial
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epicondyle. It is curved downward and forward, and its pointed end is
connected to the medial border, just above the medial epicondyle, by a
fibrous band, which gives origin to a portion of the Pronator teres; through
the arch completed by this fibrous band the median nerve and brachial artery
pass, when these structures deviate from their usual course. Sometimes the
nerve alone is transmitted through it, or the nerve may be accompanied by
the ulnar artery, in cases of high division of the brachial. A well-marked
groove is usually found behind the process, in which the nerve and artery are
lodged. This arch is the homologue of the supracondyloid foramen found in
many animals, and probably serves in them to protect the nerve and artery
from compression during the contraction of the muscles in this region.
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to recall by Mullsons Health & Wellness at any time.
15. ELBOW AND WRIST:
a. The axilla or armpit is a pyramidal shaped space that provides passage for
the axillary artery and brachial plexus from the posterior triangle;e of the neck
into the arm.
b. The elbow joint is a hinge joint between the distal portion of the humerus and
the ulna. Two movements can occur at this joint - flexion and extension. The
muscles responsible for these movements , their nerve supply and vascular
supply are contained within the compartments of the arm. The arm is that
region of the upper limb between the shoulder joint and the elbow joint.
It is divided into 2 compartments: an anterior or flexor compartment and
a posterior or extensor compartment. Muscles in the former compartment flex
the elbow joint and are involved in supination of the proximal radioulnar joint.
Muscles in the latter compartment extend the elbow joint.
c. The proximal and distal radioulnar joints are pivot joints between the
respective portions of the radius and ulnar. Movements of pronation and
supination take place at these joints. In addition, the radius and ulnar are
connected by a fibrous interosseous membrane that forms and non
moveable joint between these 2 bones called a syndesmosis.
d. The wrist joint is a very complex type of joint between the distal end of the
radius, a fibrocartilaginous disc at the distal end of the ulna, the carpal (wrist
) bones and the proximal portion of the metacarpal bones. These complex
articulations form and ellipsoidal type synovial joint at which the movements
of flexion-extension and abduction or radial deviation - adduction or ulnar
deviation can occur. The forearm connects the elbow with the wrist an can
also be divided into 2 compartments: an anterior or flexor compartment and a
posterior or extensor compartment. Muscles in the former compartment
pronate the radioulnar joints, flex the wrist and also flex the digits. Muscles in
the latter compartment help supinate the radioulnar joints, extend the wrist
and help extend the digits.
The anatomy of these regions is covered in the required readings and outlined
below. You will need to understand the anatomy of this region in order to
appreciate how the elbow, radioulnar and wrist joints function and how to use
your knowledge to examine these joints.
16. THE AXILLA:
a. Boundaries:
i. Anterior Wall
 Pectoralis major and pectoralis minor muscles
 Anterior axillary fold = lower portion of pectoralis major
ii. Posterior Wall
 Latissimus dorsi, subscapularis and teres major muscles
 Posterior axillary fold = portion of the latissimus dorsi muscle
iii. Medial Wall
 Serratus anterior muscle and the ribs to which it is attached
iv. Lateral wall
 Coracobrachialis muscle and shaft of the humerus
v. Apex
 Clavicle, scapula, 1st. rib
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vi. Floor
 Skin and axillary fascia extending between anterior and posterior
axillary folds
b. Spaces:
i. Quadrangular
 Lateral border - surgical neck of humerus
 Medial border - long head of triceps brachii muscle
 Superior border - teres minor muscle
 Inferior border - teres major muscle
 Contents
a. Axillary nerve
b. Posterior humeral circumflex artery
ii. Triangular:
 Lateral border - long head of triceps brachii muscle
 Superior border - teres minor muscle
 Inferior border - teres major muscle
 Contents
a. Circumflex scapular branch of subscapular artery
c. Contents:
i. Axillary sheath
 Fascial sheath derived from fascia covering scalene muscles in neck
 Contains
a. Proximal position of axillary artery
b. Cords of brachial plexus
c. Terminal portion of axillary vein
d. Vasculature:
i. Axillary Artery
- Continuation of subclavian artery into axilla
a. Name changes as subclavian passes distal to 1st rib
- Becomes brachial artery after passing distal to teres major
muscle
- Branches (read text for distribution of arterial branches)
1. Thoracoacromial trunk
2. Lateral thoracic
3. Anterior and Posterior humeral circumflex arteries
4. Subscapular
- Muscular
- Circumflex scapular
ii. Axillary Vein
- Continuation of brachial vein into axilla
a. Name changes after passing proximal to teres major muscle
- Drains into subclavian vein
1. Name changes as it passes proximal to 1st rib
- Receives cephalic vein
iii. Axillary lymph nodes
- Drain upper limb, breast , and skin of chest wall
- Enlargement could indicate infections & / or tumors from these areas
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iv. Scapular anastomosis
- Brings axillary artery into connection with the subclavian artery
a. Collateral route should blockage occur in subclavian artery
- Branches
1. Subclavian artery
- Transverse cervical
- Suprascapular arteries
- Arteries supply dorsal scapular muscles
2. Axillary
- Circumflex scapular
17. THE ARM:
a. Bones
i. Humerus
b. Flexor (Anterior) Compartment
i. Muscles
 Biceps brachii
 Brachialis
 Coracobrachialis
ii. Muscle Function(s)
iii. Nerve Supply
 Musculocutaneous
 Motor to muscles in anterior brachial compartment
 Sensory to lateral portion of forearm
iv. Blood Supply
 Brachial artery
 Muscular branches
 Superior ulnar collateral
 Inferior ulnar collateral
c. Extensor (Posterior) Compartment
i. Muscles
 Triceps brachii
 Anconeus
ii. Muscle Function(s)
iii. Nerve Supply
 Radial
1. Motor to triceps brachii
2. Sensory to posterior and lateral regions of arm
iv. Blood Supply
 Deep (profunda) brachial
1. Muscular branches
2. Middle collateral
3. Radial Collateral
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
18. THE SHOULDER GIRDLE:
The shoulder or pectoral girdle consists of articulations between the clavicle,
scapula and the proximal end of the humerus. The sternoclavicular articulation is
the only bony link between the upper limb and the axial skeleton. Movements at
this joint are largely passive in that the occur as a result of active movements of
the scapula. Through the acromioclavicular articulation, the clavicle can act as a
strut maintaining the upper limb away from the thorax permitting a greater range
of upper limb motion. This joint also helps provide static stability to the upper limb
reducing the need to use muscle energy to keep the upper limb in its proper
alignment. The glenohumeral articulation (shoulder joint) has the greatest range
of motion of any joint in the body. The mobility of the shoulder joint is necessary
for placement of the hand to maximize manipulation. The scapula is suspended
on the thoracic wall by muscle forming a \"functional joint\" called the
scapulothoracic joint. These muscles act to stabilize and/ or to actively move the
scapula. Active movements of the scapula help increase the range of motion of
the shoulder joint.
a. Components of the shoulder girdle:
i. Bones
 Clavicle
 Scapula
 Proximal end of humerus
ii. Articulations
1. Acromioclavicular Joint
a. Planar type joint between lateral portion of the clavicle and the
acromion of the scapula.
2. Sternoclavicular Joint
a. Sellar joint between the medial end of the clavicle and the
manubrium of the sternum.
3. Glenohumeral ( Shoulder ) Joint
a. Ball and socket articulation between head of humerus and
glenoid cavity.
b. Favors mobility over stability
4. Scapulothoracic \"Joint\"
a. Scapula suspended on rib cage by muscles
i. Highly mobile
b. Scapula movement increases range of motion at the shoulder
joint
b. Muscles acting on the shoulder girdle:
i. Extrinsic - Suspend scapula from the trunk .Stabilize and/or actively
moves scapula
1. Trapezius
2. Levator Scapulae
3. Rhomboid Major and Minor
4. Serratus Anterior
5. Pectoralis minor
ii. Intrinsic - Attach scapula to humerus
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
1. Deltoid
2. Teres Major
3. Rotator Cuff (active stabilization of shoulder joint)
a. Supraspinatus
b. Infraspinatus
c. Teres Minor
d. Subscapularis
iii. Attach trunk to humerus
1. Latissimus dorsi
2. Pectoralis Major
iv. Attachments and Functions
c. Stability of the shoulder girdle:
i. Acromioclavicular Joint
1. Ligaments
a. Acromioclavicular
b. Coracoclavicular
c. Conoid
d. Trapezoid
2. Functions
a. Bind clavicle to scapula supporting weight of upper limb
minimizing use of muscle energy
3. Shoulder Separation
a. Tearing of acromioclavicular and /or coracoclavicular ligaments
b. Clavicle overrides acromion
c. Weight of upper limb pulls scapula and acromion inferiorly below
clavicle
ii. Sternoclavicular Joint
1. Ligaments
a. Sternoclavicular
b. anterior and posterior
c. Interclavicular
d. Costoclavicular
2. Fibrocartilage Disc
a. Strengthens articulation
iii. Glenohumeral Joint
1. Capsule
 Attaches from glenoid cavity to anatomical neck of humerus
 Least amount of support inferiorly
2. Ligaments
a. Coracoacromial
 Helps resist upward displacement of the head of the
humerus
b. Coracohumeral
 Strengthens superior portion of capsule
 Some support during shoulder abduction
c. Transverse Humeral Ligament
 Holds long head of biceps in the groove
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to recall by Mullsons Health & Wellness at any time.
d. Glenohumeral Ligaments - 3 parts all attach from upper margin
of glenoid cavity and strengthen anterior portion of capsule
 Superior - over the humeral head to a depression above the
lesser tuberosity
 Middle - in front of humerus to lower lesser tuberosity
 Inferior - to lower part of the anatomical neck
3. Rotator Cuff Muscles
a. Active stabilizers of shoulder joint
 Act throughout entire range of motion at shoulder
b. Depress head of humerus in glenoid cavity when humerus
moves
Prevents compression of structures between humeral head and
acromion
c. Muscles also help rotate shoulder
iv. Scapulothoracic Articulation
1. Stability
a. Dependent upon activity of extrinsic muscles
b. Winged scapula
2. Alignment
a. Upwardly rotated and elevated position of scapula at rest
-Action of trapezius muscle
d. Movements of the sternoclavicular joint:
i. Passive movements.
 Acromial end moves as consequence of movements of the scapula
 Sternal end of clavicle moves in a direction opposite from that of the
scapula.
ii. Types of Movements
 Protraction - scapula is retracted causing the sternal end to move
forward
 Retraction - scapula is protracted causing the sternal end to move
backward
 Elevation - scapula is depressed causing the sternal end to move
upward
 Depression - scapula is elevated causing the sternal end to move
downward
iii. Muscles Acting on Sternoclavicular Joint
 The muscles acting on the Sternoclavicular joint are outlined in Chart
1. These are the same muscles that act on the scapula.
 Movements of the Sternoclavicular joint and the muscles producing
these movements are outlined in Chart 2. Remember the SC joint
moves in a direction opposite from the way in which the scapula
moves.
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to recall by Mullsons Health & Wellness at any time.
e. Movements of the scapula:
i. Types
1. Elevation - moving the superior border of the scapula and the
acromion in an upward direction.
2. Depression - moving the superior border of the scapula and the
acromion in an downward direction.
3. Upward Rotation - Moving the scapula so that the glenoid cavity
faces upward.
- Increased the ranges of motion during abduction and/or flexion of
the shoulder.
4. Downward Rotation - moving the scapula so that the glenoid cavity
faces inferiorly.
 Increases range of motion during extension and / or adduction of
the shoulder.
5. Protraction ( Abduction) - moving the scapula away from the midline
6. Retraction (Adduction) - moving the scapula toward the midline
ii. Muscles Acting to Move Scapula
1. Very mobile
 Muscles suspend scapula from vertebral column and chest wall
 Axis around which scapulae move changes
 Muscles attach to scapula obliquely
a. Produce many motions
2. Movements
3. Muscle Synergy at the Shoulder Joint
 Retraction of the Scapula
Trapezius -- retract and rotates upward
Rhomboids -- retract and rotate downward
 Upward rotation of the Scapula
Serratus anterior -- protracts and rotates upward
Trapezius -- Retract and rotates upward
f. Movements of the glenohumeral joint:
i. Properties
1. Movements of the shoulder joint (glenohumeral joint) usually involve
moving the humerus on the scapula.
2. All movements are to be studied starting from the anatomical
position
3. Axis of motion
 Flexion - Extension
o Coronal axis through head of humerus
 Abduction /Adduction
o Sagittal axis through humeral head
 Rotation
o Longitudinal axis through shaft of humerus
ii. Types of Movements
1. Flexion moving the humerus forward and upward in the sagittal
plane.
2. Extension - bringing the arm down to the side in the sagittal plane.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
Hyperextension - moving the arm in the sagittal plane behind the
body.
3. Abduction - moving the arm in the coronal plane away from the
midline
Stages:
initiate -supraspinatus
900 - deltoid
1800 - deltoid with upward rotation of scapula
4. Adduction - moving the arm in the coronal plane towards the midline.
5. Inward Rotation - rotating the arm in a transverse plane so that the
anterior surface of the bone turns inward.
6. Outward Rotation - rotating the arm in a transverse plane so that the
anterior surface of the bone turns outward.
iii. Scapulohumeral Rhythm
1. Coordinated movements of the scapula and the humerus increasing
the range of motion at the glenohumeral joint
 Most noticeable during complete flexion and abduction of the
shoulder
 2 - 30 of humeral abduction is associated with 1 - 20 of scapula
rotation
iv. Movements of the Shoulder Joint
MOVEMENTS of the SHOULDER JOINT indicates which muscles
interact to produce a given movements of the shoulder
g. Clinical anatomy of the shoulder joint:
i. Dislocation
1. Weakness of rotator cuff tendons and / or trauma
2. Head of humerus subluxes (separated ) from glenoid cavity of
humerus
3. Usually occurs when humerus is in position of abduction or flexion
- Least amount of contact between apposing bony surfaces
4. Occurs in an inferior direction
- Weakest region of capsule
- Humerus pulled either anterior to or posterior to shoulder joint
depending upon which rotator cuff muscles are injured.
5. Arm hangs limp at side with a prominent \"step deformity\" (space)
between acromion and humeral head
ii. Impingement Syndrome
1. Weakness or fatigue of rotator cuff muscles
2. Activity of shoulder joint accompanied by intense pain
- Movements of abduction and flexion usually more painful
- Painful arc
(Very painful abducting from neutral position to horizontal. Then pain
subsides)
3. Compression of supraspinatus tendon between head of humerus
and acromion.
iii. Nerve Lesions Lesions to components of the brachial plexus, especially
those components associated with the C 5 and/or C 6 nerve roots, will
have and major effect on the ability of the shoulder girdle to carry out
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to recall by Mullsons Health & Wellness at any time.
normal functions. Often, the signs and symptoms concerning loss or
reduction in function can be used to localize the site of the nerve lesion.
The effects of various types of nerve lesions can have on the shoulder
girdle is summarized below:
1. Accessory nerve - innervates the trapezius muscle. Paralysis of this
muscle will result in a marked drooping and down turning of the
affected shoulder at rest because of the loss of the ability of the
trapezius to elevate and upwardly rotate the scapula. The latter loss
will also prevent the patient from abducting their arm above the
horizontal ( shoulder level).
2. Dorsal Scapular nerve - innervates the rhomboideus muscles. Any
attempt to retract the scapula will be accompanied by a marked
upward rotation of the shoulder because the rhomboideus can no
oppose the upward rotation on the scapula exerted by the trapezius.
The patient will have difficulty retracting the scapula against
resistance on the affected side.
3. Long thoracic nerve - Innervates the serratus anterior muscle.
Active contraction of this muscle results in scapula protraction and
upward rotation. When the scapula is passively protracted by action
of the pectoralis major muscle on the humerus , the serratus anterior
acts to stabilize the scapula and keep it applied to the thoracic wall.
Such action occur when a boxer throws a jab or a cross. Paralysis of
the serratus anterior prevents the scapula from moving smoothly
across the thoracic wall resulting in a bowing out of the medial
border of the scapula. This condition is called \"winged\" scapula. In
addition, the ability to actively upwardly rotate the shoulder is
diminished and the patient can not abduct the humerus above the
horizontal.
4. Suprascapular nerve - innervates the supraspinatus and
infraspinatus muscles. Paralysis of this nerve will result is weakness
of the rotator cuff muscles resulting in pain form impingement and an
inability of the patient to begin shoulder abduction. Such patients
tend to swing the affected limb away from their side in order to
provide momentum to start abduction.
5. Axillary nerve - innervates the deltoid and teres minor muscles.
Since the deltoid plays a major role in movement of the
glenohumeral joint, paralysis will cause a loss &/or weakness of
most shoulder functions. Symptoms of deltoid paralysis include:
 Loss or roundness to the shoulder and a very visible acromion
process
 Inability to abduct the glenohumeral joints more than a few
degrees away from the side.
 Inability to laterally rotate the humerus
 Weakened movements of glenohumeral flexion and extension
 Loss of sensation just below the point of the shoulder
6. C5, C6 root damage ( Erb's palsy) - axons from the C5 and C6
ventral rami innervate the following muscles acting on the shoulder
girdle:deltoid, supraspinatus, infraspinatus , teres minor,
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to recall by Mullsons Health & Wellness at any time.
subscapularis. Lesion to these roots will result in paralysis of these
muscles.
deltoid
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to recall by Mullsons Health & Wellness at any time.
E. LEVERS:
Classes of levers. (a) In a first-class lever, the fulcrum (F) is set up between the resistance (R) and the
effort (M). (b) In a second-class lever, the resistance is between the fulcrum and the effort. (c) In a third-
class lever, the effort is between the fulcrum and the resistance.
The musculoskeletal system includes bones, joints, skeletal muscles, tendons, and
ligaments. Muscles generate force; tendons transfer it to bones; and the bones move if
enough force is transmitted. The force must be enough to overcome the weight of the
moving body part, gravity, and other external resistance. Motion occurs at joints
associated with one or both ends of the bone.
The force is produced in the muscle belly, which consists of muscle tissue. Tendons
are basically connected bundles of collagen. They are classified as dense regular
connective tissue and arise partially from the connective tissue coverings of muscle fibers
and fiber groups. Tendons attach to the external membrane of a bone, the periosteum,
which covers the bone except at joint surfaces. A few muscles bypass tendons and
attach directly to the periosteum. Other muscles attach to skin (muscles of facial
expression), to other muscles, or to fascia, which are connective tissue sheets between
muscles.
The surfaces of the bone making up the joint have a layer of hyaline cartilage, the
articular cartilage, which forms a smooth surface for easy movement. Bone ends may be
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surrounded by a joint capsule, which secretes fluid for lubrication and nutrition. Joint
motion is usually pain free, but age, injury, and some diseases damage the articular
cartilage, resulting in arthritis.
Biomechanics applies the principles of physics to human movement. Some joints
work like levers, others like pulleys, and still others like a wheel-axle mechanism. Most
motion uses the principle of levers. A lever consists of a rigid \"bar\" that pivots around a
stationary fulcrum. In the human body, the fulcrum is the joint axis, bones are the levers,
skeletal muscles usually create the motion, and resistance can be the weight of a body
part, the weight of an object one is acting upon, the tension of an antagonistic muscle,
and so forth.
Levers are classified by first, second, and third class, depending upon the relations
among the fulcrum, the effort, and the resistance. First-class levers have the fulcrum in
the middle, like a seesaw. Nodding the head employs a first-class lever, with the top of
the spinal column as the fulcrum. Second-class levers have a resistance in the middle,
like a load in a wheel-barrow. The body acts as second-class lever when one engages in
a full-body push-up. The foot is the fulcrum, the body weight is the resistance, and the
effort is applied by the hands against the ground.
Third-class levers have the effort (the muscle) in the middle. Most of the human
body's musculoskeletal levers are third class. These levers are built for speed and range
of motion. Muscle attachments are usually close
to the joint. As the length of the lever increases, the possible speed increases, but so
does the force required to produce it. For instance, the forearm is a third-class lever,
controlled by the biceps muscle. A longer forearm can produce faster motion of the hand,
but requires more effort to move than a shorter forearm.
A few muscle-bone connections work on the principle of a pulley, which changes the
direction of an applied force. A classic example is the patella (kneecap), which alters the
direction in which the quadriceps (patellar) tendon pulls on the tibia.
Muscles play four roles in producing joint movements: agonist (prime mover),
antagonist, synergist, and fixator. A given muscle can play any of these roles, often
moving from one to the next in a series during an action. Agonists and antagonists are
opposing muscles. This means that when an agonist creates tension, the antagonist
produces an opposing tension, thereby contributing to control at the joint. When one lifts
a glass of water from the table to one's mouth, for example, the biceps brachii muscle
acts as an agonist to flex the elbow, while the triceps brachii acts as an antagonist to
keep the elbow from flexing too fast or too far. Synergists aid the motion of an agonist.
Although every musculotendinous unit (muscle belly and tendons attaching it to the
bone) has a specific name, it is common to group muscles according to the motion they
create. Flexors create motion that would bring the distal segment closer to the torso,
while abductors cause a limb to move laterally, away from the body.
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to recall by Mullsons Health & Wellness at any time.
I. THE FORCES INVOLVED:
The amount of force placed on your back under certain conditions can be surprising.
Anytime you bend or lean over to pick something up, you put tremendous pressure
on your lower back.
To demonstrate this, think of your back as a lever. With the fulcrum in the center of
the lever, how many pounds would it take to lift a ten pound object?
A. 5 pounds
B. 10 pounds
C. 15 pounds
When you add in the 105 pounds of the average human upper torso, you see that
lifting a ten pound object actually puts 1,150 pounds of pressure on the lower back.
And if you've gained weight...
Given these figures, it is easy to see how repetitive lifting and bending can quickly
cause back problems. Even leaning forward while sitting at a desk or table can
eventually cause damage and pain.
II. POSTURE AND BODY MECHANICS:
Following these principles will allow improved back safety. Rotation or torque of the
low back has created thousands of injuries with healthcare providers. Transfers are
generally used to mobilize patients between bed, wheelchair, toilet and tub. There
are many different types of transfers. Squat pivot, stand pivot and the two-man lift
are just a few. PTAs should be proficient with all of these lifts upon completion of their
program.
The rules of lifting are as follows:
1. Maintain a wide base of support with the lift.
2. Lift with your legs and not your back.
3. Use momentum to your advantage.
4. Maintain an upright back posture position during the lift.
5. It is easier to push than to pull.
6. Test the load prior to the lift or transfer.
7. Get help if it is necessary to safely lift the load.
8. If injured seek immediate medical intervention immediately.
9. Tighten your abdominal muscles with the lift.
10. Use a staggered stance to distribute forces properly.
11. Don’t twist. Turn your feet. If you twist, you could increase torque on your back and
lower extremities, which could result in back injury.
12. Hold the patient or object close to your body to decrease the lever arm force
required.
13. Ask the patient if they are able to communicate to repeat back your instructions for
the transfer to clarify the desired action.
14. Have the patient shift or scoot their weight to the edge of the chair or wheelchair prior
to transfer whenever indicated.
15. Prepare for a worst case scenario and predetermine your course of action if the lift or
transfer is not going to go smoothly.
16. If you get a bad start during a transfer, do not force it. Sit the patient back down and
try again.
Every person has a different body build and posture. This can lead to a pre-disposition to
injury if certain characteristics are found.
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to recall by Mullsons Health & Wellness at any time.
F. MUSCULAR SYSTEM:
Muscular system can be classified into the following three categories:
 A muscle cell not only has the ability to propagate an action potential along its cell
membrane, as does a nerve cell, but also has the internal machinery to give it the
unique ability to contract.
 Most muscles in the body can be classified as striated muscles in reference to the
fact that when observed under a light microscope the muscular tissue has light and
dark bands or striations running across it. Although both skeletal and cardiac muscles
are striated and therefore have similar structural organizations, they do possess
some characteristic functional differences.
 In contrast to skeletal muscle, cardiac muscle is a functional syncytium. This means
that although anatomically it consists of individual cells the entire mass normally
responds as a unit and all of the cells contract together. In addition, cardiac muscle
has the property of automaticity which means that the heart initiates its own
contraction without the need for motor nerves.
 Non-striated muscle consists of multi-unit and unitary (visceral) smooth muscle.
Visceral smooth muscle has many of the properties of cardiac muscle. To some
extent it acts as a functional syncytium (e.g., areas of intestinal smooth muscle will
contract as a unit. Smooth muscle is part of the urinary bladder, uterus, spleen,
gallbladder, and numerous other internal organs. It is also the muscle of blood
vessels, respiratory tracts, and the iris of the eye.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
I. SKELETAL MUSCLES:
In order for the human being to carry out the many intricate movements that must be
performed, approximately 650 skeletal muscles of various lengths, shapes, and
strength play a part. Each muscle consists of many muscle cells or fibers held
together and surrounded by connective tissue that gives functional integrity to the
system.
Three definite units are commonly referred to:
 Endomysium—connective tissue layer enveloping a single fiber;
 Perimysium—connective tissue layer enveloping a bundle of fibers;
 Epimysium—connective tissue layer enveloping the entire muscle
II. MUSCLE ATTACHMENT AND FUNCTION:
For coordinated movement to take place, the muscle must attach to either bone or
cartilage or, as in the case of the muscles of facial expression, to skin. The portion of
a muscle attaching to bone is the tendon. A muscle has two extremities, its origin and
its insertion.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
III. STRUCTURAL ORGANIZATION OF A MUSCLE FIBER:
A muscle fiber is a single muscle cell. If we look at a section of a fiber we see that it is
complete with a cell membrane called the sarcolemma and has several nuclei located
just under the sarcolemma—it is multinucleated. Each fiber is composed of numerous
cylindrical fibrils running the entire length of the fiber.
IV. MYOFILAMENTS:
The thick and thin myofilaments form the contractile machinery of muscle and are
made up of proteins. Approximately 54% of all the contractile proteins (by weight) is
myosin. The thick myofilament is composed of many myosin molecules oriented tail-
end to tail-end at the center with myosin molecules staggered from the center to the
myofilament tip. The second major contractile protein is actin. Actin is a globular
protein.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
V. SARCOPLASM:
The sarcoplasm (cytoplasm of the muscle cell) contains Golgi complexes near the
nuclei. Mitochondria are found between the myogibrils and just below the
sarcolemma. The myofibrils are surrounded by smooth endoplasmic reticulum
(sarcoplasmic reticulum) composed of a longitudinally arranged tubular network
(sarcotubules). The complex (terminal cistern-T tubule-terminal cistern) formed at this
position is known as a triad. The T tubules function to bring a wave of depolarization
of the sarcolemma into the fiber and thus into intimate relationship with the terminal
cisternae.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
VI. EXCITATION:
Contraction in a skeletal muscle is triggered by the generation of an action potential
in the muscle membrane. Each motor neuron upon entering a skeletal muscle loses
its myelin sheath and divides into branches with each branch innervating a single
muscle fiber, forming a neuromuscular junction. Each fiber normally has one
neuromuscular junction that is located near the center of the fiber. A motor unit
consists of a single motor neuron and all the muscle fibers innervated by it. The
motor end plate is the specialized part of the muscle fiber’s membrane lying under
the neuron.
Overview of triadic signal transduction process underlying excitation-contraction coupling in skeletal
muscle fibres. Changes in membrane polarity are sensed by the alpha-1 dihydropyridine receptor
(DHPR) and are followed by conformational changes in the transverse tubular (TT) receptor which
allow its II-III loop domain to directly interact with a cytoplasmic domain of the ryanodine receptor
(RyR) of the junctional sarcoplasmic reticulum (SR). Transient opening of the Ca2+-release channel
triggers a massive release of Ca2+-ions into the cytosol. Subsequently, excessive local Ca2+-ions
probably activate non-junctional RyRs, which are not directly coupled to the voltage sensor. Clusters
of the high-capacity Ca2+-binding protein calsequestrin (CSQ) provide a junctional SR Ca2+-pool for
fast ion release and can therefore be considered positive regulators of the RyR. Once the Ca2+-
signal reaches the myofibrillar apparatus, the second messenger binds to troponin c (TnC) and
thereby allows a proper interaction between actin and myosin filaments resulting in muscle
contraction.
Diagramatic presentation of skeletal muscle proteins involved in the excitation-contraction-relaxation
cycle. Triads are composed of transverse tubules (TT) and two surrounding terminal cisternae of the
sarcoplasmic reticulum (SR). Located in the TT is the multimeric dihydropyridine receptor (DHPR) with
its five subunits, the voltage-sensing alpha-1 subunit, the transmembrane alpha-2/delta and gamma
subunits, as well as the cytosolic beta subunit. The ryanodine receptor (RyR) Ca2+-release channel is
enriched in the junctional SR membrane. Tightly associated with the receptor are two auxiliary
proteins, the immunophilin protein of 12 kDa (FKBP12) and the Ca2+-binding component calmodulin
(CaM), which both modulate the opening time of the RyR. The Ca2+-binding proteins calsequestrin
(CSQ), calreticulin (CAL), sarcalumenin (SAR) and histidine-rich Ca2+-binding protein (HCP) are
thought to be involved in Ca2+-storage and the fine regulation of the RyR. Junctin (JN) represents a
CSQ-binding protein. Triadin (TRI) clusters and the 90 kDa junctional face protein (JFP) are probably
involved in maintaining receptor interactions and the overall architectural arrangement of triad
junctions. The SR Ca2+-ATPase (SERCA) represents the major energy-dependent Ca2+-reuptake
mechanism in skeletal muscle fibres and this enzyme is responsible for initiating the muscle relaxation
step. In addition, a surface Ca2+-pump (PMCA) and a Na+/Ca2+-exchanger, which is indirectly driven
by the sarcolemmal Na+/K+-ATPase, exist in skeletal muscle. Complex interactions between these
various Ca2+-channels, Ca2+-binding proteins and Ca2+-pumps provide the molecular basis which
regulates muscle Ca2+-homeostasis
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
VII. CONTRACTION:
According to the sliding filament theory (Huxley) the sacromere response to
excitation involves the sliding of thin and thick myofilaments past one another making
and breaking chemical bonds with each other as they go. Neither the thick nor thin
myofilaments change in length. If we could imagine observing this contraction under
a light microscope we would see the narrowing of the “H” and “I” bands during
contraction while the width of the “A” band would remain constant.
VIII.MUSCLE TWITCH:
A muscle’s response to a single maximal stimulus is a muscle twitch. The beginning
of muscular activity is signaled by the record of the electrical activity in the
sarcolemma. The latent period is the delay between imposition of the stimulus and
the development of tension.
IX. TETANUS:
When a volley of stimuli is applied to a muscle, each succeeding stimulus may arrive
before the muscle can completely relax from the contraction caused by the preceding
stimulus. The result is summation, an increased strength of contraction. If the
frequency of stimulation is very fast, individual contractions fuse and the muscle
smoothly and fully contracts. This is a tetanus.
X. ENERGY SOURCES:
In any phenomenon including muscular contraction the energy input to the system
and the energy output from the system are equal. Let us consider first the energy
sources for muscular contraction. The immediate energy source for contraction is
ATP which can be hydrolyzed by actomyosin to give ADP, Pi , and the energy which
is in some way associated with cross-bridge motion.
G. TYPES OF MUSCLE FIBERS:
Skeletal muscle fibers can be described, on the bases of structure and function, as
follows:
1. White (fast) fibers – contract rapidly; fatigue quickly; energy production is mainly via
anaerobic glycolysis; contain relatively few mitochondria; examples are the muscles
of the eye.
2. Red (slow) fibers – contract slowly; fatigue slowly; energy production is mainly via
oxidative phosphorylation (aerobic); contain relatively many mitochondria; examples
are postural muscles.
3. Intermediate fibers – have structural and functional qualities between those of white
and of red fibers.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
H. CAPSULAR PATTERN:
The characteristic ranges of restricted movement exhibited by a joint. Examining this characteristic is
common in assessing and treating persons diagnosed with arthritic conditions. (Know this
information for the FSBPT's NPTE exam.)
Joint Capsular Pattern
Temporomandibular Opening
Occipitoatlanto Extension & side flexion equally limited
Cervical Spine Side flexion & rotations equally limited, extension
Glenohumeral Lateral rotation, abduction, medial rotation
Sternoclavicular Pain at extreme range of movement
Acromioclavicular Pain at extreme range of movement
Humeroulnar Flexion, extension
Radiohumeral Flexion, extension, supination, pronation
Proximal Radioulnar Supination, pronation
Distal Radioulnar Pain at extremes of rotation
Wrist Flexion & extension equally limited
Trapeziometacarpal Abduction, extension
MCP and IP Flexion, extension
Thoracic Spine Side flexion & rotation equally limited, extension
Lumbar Spine Side flexion & rotation equally limited, extension
SI, Symphysis Pubis, & Sacrococcygeal Pain when joints stressed
Hip Flexion, Abduction, medial rotation (order varies)
Knee Flexion, extension
Tibiofibular Pain when joint stressed
Talocrural Plantar flexion, dorsiflexion
Subtalar (Talocalcaneal) Limitation of varus range of movement
Midtarsal Dorsiflexion, plantar flexion, adduction, medial rotatio
First MTP Extension, flexion
Second to Fifth MTP Variable
IP Flexion, extension
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
Humeroul
Cervical Spine
Glenohumeral
Radiohumeral
Proximal
Radiohumeral
Distal Radioulnar
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
I. PHYSIOTHERAPY SPECIAL TESTS:
C-spine: T-Spine: L-Spine:
Quadrant Test C-spine Slump Tension Test Kernig’s Test
Vertebral Artery Test Passive Neck Flexion SLR
Alar Ligmanet Test SIJ Compression/Distraction Femoral nerve Stretch
Cranial-Atlas Lift Compression/Distraction Hoover Test
Chin Tuck/Reverse Chin tuck SIJ Distraction/Compression
Valsalva
SI Testing: Hip: Knee:
Meniscal- McMurray’s, Apley’s Compression,
Standing Flexion test Percussion Test Bounce Home
Patella- Q angle, Perkin’s test, Apprehension
Long Sitting Test Thomas Test Test, Plica Stutter, Grind Test
Straight Leg Raise Torque Test ITB- Ober’s Test, Noble’s Compression
Ligamentoous: Lachman’s, Recurvatum, A/P
Prone Knee Bend Sign of the Buttock Drawer Test, Varus/Valgus Tests
Gillet’s Test Faber’s Test
Leg Length Test Ober’s Test
Piriformis Test
Ankle: Soulder: Elbow:
Rotator Cuff Tear: Supraspinatus, Drop
Anterior Drawer Arm Test Tinnel’s sign
Impingement: Hawkin’s, Neer’s Test,
Talar Tilt Painful Arc Pinch Grip Test
Biceps Tendinitis: Speed’s, Yeargeson’s,
Tib/Fib Compression Ludington’s Varus/Valgus Test
Lax Capsule: Sulcus sign, Apprehension
Thompson’s test Wartenberg’s Sign
Other Common Tests: AC Jt. Shear Test,
Percussion Test Apley’s Scratch Test Medial Epicondylitis Test
Homan’s Sign Lateral Epicondylitis Test
Forefoot Varus/Valgus Elbow Flexion Test
Tinnel’s Wrist/Hand:
Bunnel-Litter Test
Varus/Valgus Stress Test
Murphy’s sign
Hand Volume Test
Finkelstein Test
Tinnel’s sign
Allen’s Test
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
I. STORK TEST:
Test for measuring patient's ability to maintain balance. Positive test can be indicative for
many disorders. With your hands on your hips, stand upright on a firm surface with your
weight supported on your stronger leg. Place the sole of the other foot against the knee of
your supporting leg. Close your eyes and ask a partner to time how long you can maintain
your pose. You may need to sway and shift to maintain balance, but the timing should stop
as soon as you move your supporting foot.
Stork stand test
A test of balance. The subject
with eyes closed stands
upright for as long as possible
on a firm surface, hands on
hips, weight supported on the
stronger leg, and the sole of
other foot resting against the
knee of the supporting leg.
Balancing ability is reflected by
how long the subject can
maintain the one-legged
stance without moving the
supporting foot.
Gender Excellent Above Average Average Below Average Poor
Male >50 sec 50 - 41 sec 40 - 31 sec 30 - 20 sec <20 sec
Female >30 sec 30 - 23 sec 22 - 16 sec 15 - 10 sec <10 sec
J. PHYSIOTHERAPY ASSESSMENT:
C1/C2 Neck Flexion/Extension L1-L2 Iliopsoas
C3/C4 Upper Trap L3-L4 Quadriceps
C5 Shoulder Abduction L4 Tib. Anterior
C6 Bicep/ Wrist Extension L5 EHL
C7 Triceps/ Wrist Flexion L4-L5 Heel Walk
C8 EPL/ Long Finger Flexors L5-S1 Toe Extensors
T1 Interossei S1 Ankle Eversion
S1-S2 Planter Flexion
S2 Toe Flexors
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
K. TYPES OF FRACTURES:
Chondral fracture Involves cartilage alone
Osteochondral fracture Involves cartilage and subjacent bone
Closed (simple) fracture Skin is intact
Open fracture Skin is broken
Involves the entire circumference (tubular bone) or both cortical surfaces
Complete fracture (flat bone) of a bone
Incomplete fracture Break in the cortex does not extend completely through the bone
Comminuted fracture Involves more than two fracture fragments
Butterfly fragment Wedge-shaped fracture fragment arising from the shaft of a long bone
Segmental fracture Fracture lines isolate a segment of the shaft of the tubular bone
Impaction fracture Occurs when one fragment of bone is driven into an apposing fragment
An impaction fracture that results when the forces occur between a hard
Depression fracture bone surface and a softer surface
Compression fracture An impaction fracture involving vertebral bodies
Occurs at a site of previous abnormality, often by means of a stress that
Pathologic fracture would not normally cause fracture
Bone bruise Trabecular microfracture
Stress fracture Occurs after repeated cyclic loading
Greenstick fracture Perforates cortex and ramifies in medullary bone
Buckling fracture Causes buckling of cortex
Bowing fracture Plastic response to longitudinal compression
Insufficiency fracture Results from normal stress on a bone with deficient elasticity
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.1.2 MUSCULOSKELETAL CONDITIONS AND TREATMENTS:
 Physiotherapists who practice in this field have postgraduate (Masters Level)
qualifications that provide them with advanced skills in managing musculoskeletal
problems. They are experts in the assessment, diagnosis and effective treatment of
patients with musculoskeletal pain and dysfunction.
 When consulting, a Specialist Musculoskeletal Physiotherapist will initially conduct a
detailed examination of the patient to determine the individual’s overall physiology and
function. This assists the therapist in developing a more holistic approach to the patient’s
problem taking into account all the contributing factors, and also in planning an
individually tailored treatment and rehabilitation program.
The most common problems treated by a Musculoskeletal Physiotherapist include:
 SPORTS INJURIES:
Muscle tears, ligament and joint strains, cartilage damage and tendon problems all
improve more rapidly and effectively with physiotherapy. Early treatment minimizes pain,
swelling and tissue damage, prevents stiffness and ensures a quicker return to sports
and other activities.
 SHOULDER PAIN AND INJURIES:
There are many problems that can affect this area and limit everyday activity including
frozen shoulder, arthritis and impingement. It is often important to examine and correct
functional patterns in this region to alleviate pain and prevent recurrence.
 KNEE PAIN:
Knee pain is extremely common and can affect people of any age. Arthritis, general wear
and tear and sports injuries are common in this area.
 FRACTURES AND DISLOCATIONS:
Physiotherapy acts to increase the healing rate and help restore full function once the
bones have healed.
 BACK PAIN AND SCIATICA:
Back Pain and Sciatica can take many forms. The most common causes are joint and
disc damage, wear and tear, prolapsed discs and strains caused by poor movement
patterns and poor muscular stability. Sciatica refers to neural pain that is felt down the leg
and is caused by problems with the back.
 NECK PAIN AND HEADACHES:
Problems in joints, nerves and muscles in the neck often cause pain in the neck, head,
face and shoulders. Problems from the neck can also refer pain down into the arms and
hands.
 WORK RELATED PROBLEMS (RSI):
Periods of prolonged sitting at a desk can result in pain in the neck and back. A lack
of movement and activity can also make the nerves in the arms and hands very sensitive
and result in pain in these areas.
Physiotherapists treat a broad spectrum of problems and can do more than just
alleviate the pain. With a range of methods at their disposal, a mix of careful mobilization
and manipulation, specific exercise therapy, electrotherapy, postural and ergonomic
advice can all be used to improve movement and prevent the problem recurring.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
A. LEGG-CALVE-PERTHES DISEASE:
Poor blood supply to the superior aspect of the femur. Most common in boys ages 4-10.
The femur ball flattens out and deteriorates. 4x higher incidence in boys + Bony cresent
sign.
Symptoms: Tests: Treatment:
Hip and Knee pain. X-ray Hip. Surgery.
Limited AROM and PROM. Test ROM of hip Physical therapy.
Pain with gait and unequal leg length. Brace.
Bedrest
B. DEVELOPMENTAL DYSPLASIA OF THE HIP:
Abnormal development of the hip joint found that is congenital.
Symptoms: Tests: Treatment:
Fat rolls asymmetrical US Cast
Abnormal leg length X-ray of hips Surgery
AROM limited AROM testing of hips Physical Therapy
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
C. SLIPPED CAPITAL FEMORAL EPIPHYSIS:
2x greater incidence in males, most common hip disorder in adolescents. The ball of the
femur separates from the femur along the epiphysis.
Symptoms: Tests: Treatment:
Hip pain X-ray Surgery
Gait dysfunction Palpation of the hips
Knee pain
Abnormal Hip AROM
D. POLYMYALGIA RHEUMATICA:
Hip or shoulder pain disorder in people greater than 50 years old.
Symptoms: Tests: Treatment:
Shoulder pain ESR increased Pain management
Hip pain CPK Corticosteroids
Fever Hemoglobin low
Anemia
Fatigue
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
E. SYSTEMIC LUPUS SERYTHEMTOSUS:
Autoimmune disorder that affects joints, skin and various organ systems. Chronic and
inflammatory. 9x more common in females.
Symptoms: Tests: Treatment: Monitor the patient for:
Butterfly rash CBC NSAIDS Seizures
Weight loss Chest X-ray Protective clothing Infection
Fever ANA test Cytotoxic drugs Hemolytic anemia
Hair loss Skin rash observation Hydroxychloroquine Myocarditis
Abdominal pain Coombs' test Infection
Mouth sores Urine analysis Renal failure
Fatigue Test for various antibodies
Seizures
Arthritis
Nausea
Joint pain
Psychosis
F. SCLERODERMA:
Connective tissue disease that is diffuse.
Symptoms: Tests: Monitor the patient for:
Wheezing Monitor skin changes Renal failure
Heartburn Chest x-ray Heart failure
Raynaud's phenomenon Antinuclear antibody test Pulmonary fibrosis
Skin thickness changes ESR increased
Weight loss
Joint pain
SOB
Hair loss
Bloating
G. RHEUMATOID ARTHRITIS:
Inflammatory autoimmune disease that affects various tissues and joints.
Symptoms: Tests: Treatment:
Fever Rheumatoid factor tests Physical therapy
Fatigue C-reactive protein Moist heat
Joint pain and swelling Synovial fluid exam Anti-inflammatory drugs
ROM decreased X-rays of involved joints Corticosteroids
Hand/Feet deformities ESR increased Anti-malarial drugs
Numbness Cox-2 inhibitors
Skin color changes Splinting
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
H. JUVENILE RHEUMATOID ARTHRITIS:
Inflammatory disease that occurs in children.
Types: Symptoms: Tests: Treatment:
Pauciarticular JRA- 50% Painful joints ANA test Physical therapy
Polyarticular JRA- 40% Eye inflammation HLA antigen test Corticosteroids
Systemic JRA- 10% Fever CBC NSAIDS
Rash Physical exam of joints Infliximab
Temperature changes
(joints) X-rays of joints Hydrochloroquine
Poor AROM Eye exam Methotrexate
RA factor test
I. PAGET’S DISEASE:
Abnormal bone development that follows bone destruction.
Symptoms: Tests: Treatment: Monitor the patient for:
Increased alkaline
Joint pain phophatase levels NSAIDS Spinal deformities
X-rays- abnormal bone
Bow legged appearance development. Calcitonin Hear loss
Hearing loss Bone scan Plicamycin Paraplegia
Neck and back pain Etidronate Heart failure
Headaches Tiludronate Fractures
Sharp bone pain Surgery
J. OSTEOARTHRITIS:
Chronic condition affecting the joint cartilage that may result in bone spurs being
formed in the joints.
Symptoms: Tests: Treatment:
Join pain X-ray Physical therapy
Morning stiffness Passive testing of joints Cox 2 inhibitors
Limited AROM NSAIDS
Weight bearing increases symptoms Joint injections
Aquatic exercises
Surgery
K. GOUT:
Uric acid development in the joints causing arthritis.
Stages: Symptoms: Tests: Monitor the patient for:
Asymptomatic Joint edema Uric acid in the urine Kidney stones
Acute Fever Synovial biopsy Kidney disorders
Lower extremity and/or
Intercritical upper extremity joint pain Synovial analysis
Chronic
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
L. FIBROMYALGIA:
Joint, muscle and soft tissue pain in numerous locations. Presence of tender points
and soft tissue pain.
Symptoms: Tests: Treatment:
Fatigue Rule-out diagnosis. Anti-depressants
Body aches Physical therapy
Poor exercise capacity Stress Management
Muscle/Joint pain Massage
Support group
M. DUCHENNE MUSCULAR DYSTROPHY:
Genetically X-linked recessive type of muscular dystrophy that starts in the lower
extremities. Dystrophin-protein dysfunction.
Symptoms: Tests: Treatment: Monitor the patient for:
Falls CPK levels increased Physical therapy Contractures
Fatigue Cardiac testing Braces Pneumonia
Muscle weakness EMG Mobility assistance Respiratory failure
Gait dysfunction Muscle biopsy testing CHF
Scoliosis Cardiomyopathy
Joint contractures Limited mobility
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
N. ANKYLOSING SPONDYLITIS:
Vertebrae of the spine fuse.
Symptoms: Tests: Monitor the patient for:
Limited AROM X-ray spine Pulmonary fibrosis
Back and neck pain CBC Aortic valve stenosis
Joint edema ESR test Uveitis
Fever Weight loss NSAIDS Surgery
HLA-B27 antigen test
O. COMPARTMENT SYNDROME:
Impaired blood flow and nerve dysfunction caused by nerve and blood vessel
compression.
Symptoms: Tests: Treatment:
Severe pain Muscular length testing Surgery
Weakness Physical Therapy
Skin color changes
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
P. MCMURRAY:
How is a meniscus injury diagnosed?
Test for meniscal tears. The orthopaedic surgeon will first take a history
'Click' is positive. of the injury to help determine if the signs and
symptoms might suggest meniscal damage.
Next the doctor will evaluate the knee for
swelling and tenderness in a physical examination.
The knee will be tender when pressed on the injured
side where the tibia and femur meet. The McMurray's
maneuver is a test in which the doctor applies
pressure and moves the knee from straight to bent to
straight again to see what positions cause pain or
catching (indications of a meniscal tear).
The doctor may use imaging to assess the amount of
damage. X-rays can show any fractures or arthritic
conditions in the knee. A narrow joint space or bone
changes indicate bone-on-bone rubbing and arthritis.
the diagnosis is still not clear, an MRI (Magnetic
Resonance Image) may be ordered to reveal damage
to ligamaments and menisci. This exam is 70 - 95%
accurate in revealing meniscal tears, and can also
show any ligament damage.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
Q. COXA VARA/VALGA:
COXA VARA COXA VALGA
Smaller angle shaft-neck Bigger angle shaft-neck
Shorter limb Longer limb
Anterior pelvic rotation Posterior pelvic rotation
Internal femoral torsion External femoral torsion
Subtalar joint pronation Subtalar joint supination
Coxa vara is a deformity of the hip, whereby the angle between the ball and the shaft of the
femur is reduced to less than 120 degrees. This results in the leg being shortened, and
therefore a limp occurs. It is commonly caused by injury, such as a fracture. It can also occur
when the bone tissue in the neck of the femur is softer than normal, meaning it bends under
the weight of the body. This may either be congenital, also known as Mau-Nilsonne
Syndrome, or the result of a bone disorder. The most common cause of coxa vara is either
congenital or developmental. Other common causes include metabolic bone diseases (e.g.
Paget's disease of bone), post Perthes deformity, osteomyelitis, and post traumatic (due to
improper healing of a fracture between the greater and lesser trochanter). Shepherds Crook
deformity is a severe form of coxa vara where the proximal femur is severely deformed with a
reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequellae of
osteogenesis imperfecta, Pagets disease, osteomyelitis, tumour and tumour-like conditions
(e.g. fibrous dysplasia).
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
R. ROTATOR CUFF REPAIR:
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.1.3 GAIT ANATOMY:
A. FUNCTIONS OF THE LOWER EXTREMITY:
Bipedalism is the process by which we are able to stand upright and to move about on 2 limbs
Bipedalism imparts three unique functions on the lower limbs. The limbs must
 bear weight
 provide a means for locomotion
 maintain equilibrium.
The lower limbs are adapted for stability rather than range of motion and that stability is
achieved at most of the major joints of the lower limb through the use of strong ligaments and
tight fitting bony surfaces rather than the expenditure of energy in the form of muscle
contraction.
I. WEIGHT BEARING PROPERTIES:
1. Support weight of head and torso with minimal expenditure of energy
2. Bony Features
a. Relatively large areas of articulation
b. Close pack fit of articular surfaces of bones involved in the formation of joints
i. Hip joint
c. Wide surface areas
i. Knee joint
d. Weight supporting arches
i. Arches of the foot
3. Ligaments
a. Strong
b. Maintain stable configuration
II. CENTER OF GRAVITY:
1. Centre of mass of body generally falls halfway between iliac crests and in front of
second sacral vertebra
2. Position
a. Posterior to hip joint
b. Anterior to knee joint
c. Anterior to ankle joint
III. STABILITY:
1. Position of joints during normal upright standing
a. Due to centre of mass of body
2. Can be maintained while bearing weight with minimal expenditure of energy (muscle
contraction)
3. Stable position maintained through use of :
a. Ligaments
b. Close packing of joints
4. Position
a. Hip joint = extension
b. Knee joint = extension
c. Ankle joint = dorsiflexion no ligamentous support
e. Foot = supinated position
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
B. LOCOMOTION:
I. POSITION OF THE LOWER EXTREMITY:
1. Weight bearing / Fixed
a. Motion occurs with foot fixed to ground
b. Limb is in good position to support weight
2. Non weight bearing / Free
a. Foot is not in contact with the ground
b. Limb is not in a position to support weight
3. Same relative motion occurs in both position
a. Different bones will move
II. MOVEMENTS OF THE LOWER EXTREMITY:
1. Hip Joint
a. Weight bearing - pelvis moves on femur
b. Non weight bearing - femur moves on pelvis
c. Types
i. Flexion - Extension
ii. Abduction - Adduction
iii. Medial rotation - Lateral rotation
2. Knee Joint
a. Weight bearing - femur moves on tibia
b. Non weight bearing - tibia moves on femur
c. Types
i. Flexion - Extension
ii. Medial rotation - Lateral rotation
3. Ankle Joint
a. Weight bearing - tibia and fibula moves on foot
b. Non weight bearing - foot moves on tibia and fibula
c. Types
d. Dorsiflexion - Plantar flexion
4. Foot (Tarsal Joints)
a. Pronation - Supination
C. THE GAIT CYCLE:
I. DEFINITION:
The rhythmic alternating movements of the 2 lower extremities which result in the forward
movement of the body. Simply stated, it is the manner in which we walk.
II. PHASES
a. STANCE ( support) PHASE - Begins when the heel of the forward limb makes contact
with the ground and ends when the toe of the same limb leaves the ground.
i. Heel Strike - heel of forward / reference foot touches the ground
ii. Mid Stance - foot is flat on the ground and the weight of the body is directly over
the supporting limb.
iii. Toe Off - Only the big toe of the forward / reference limb in contact with the
ground.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
b. SWING ( unsupported ) PHASE - Begins when the foot is no longer in contact with the
ground. The limb is free to move.
i. Acceleration - the swinging limb catches up to and passes the torso
ii.Deceleration - forward movement of the limb is slowed down to position the foot
for heel strike.
c. DOUBLE SUPPORT - both limbs are in contact with the ground simultaneously.
d. GAIT CYCLE - the activity that occurs between heel strike of one limb (reference
limb) and the subsequent heel strike of that same limb.
II. ANALYSIS OF THE GAIT CYCLE - JOINT POSITION:
1. Heel Strike
a. Ankle joint = is in a neutral position. That is, it is neither dorsiflexed nor plantar
flexed
b. Knee joint = flexed
i. Weight of body behind knee
ii. Slight flexion helps absorb the impact of the foot contacting the ground from
impact between
c. Hip joint flexed
i. Lengthens limb in preparation for contact between heel and ground. Helps
provide for proper placement of foot so that the heel make contract with the
ground.
d. Foot = supinated
2. Midstance
a. Ankle joint = dorsiflexed
b. Knee joint = extended
i. Lengthens limb to help support weight of torso which is now directly over limb
c. Hip joint = Neutral
d. Foot = Slight pronation
3. Toe Off
a. Ankle joint = plantar flexed
i. Triceps surae (superficial muscles in posterior compartment of leg) begin to
contract strongly bringing the ankle joint into a plantar flexed position
b. Knee joint = flexed
i. Contraction of the gastrocnemius muscle , one of thew triceps surae muscles,
causes active flexion of the knee joint
ii. Shorten limb to allow clearance from ground
c. Hip joint = Extended
i. Torso on the opposite side has moved forward of reference limb
b. Foot = supinated
4. Acceleration
a. Ankle joint = neutral
b. Knee joint = flexed
i. Shorten limb to maintain foot off of the ground
c. Hip joint = flexed
i. Limb catches up to and then passes the torso
b. Foot = slight pronation
5. Determinants of Position
1. Active factors
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to recall by Mullsons Health & Wellness at any time.
a. Muscle activity is responsible for determining the position of the joint
2. Passive factors
a. Position of the joint is determined by forces such as gravity or movement of
the opposite side of the body.
STRIDE
STANCE SWING
WEIGHT SINGLE LIMB
INITI LOAD MID TERM PRE INITI MID TERM
AL ING STAN INAL SWIN AL SWIN INAL
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
III. MUSCLE ACTIVITY (Chart I)
MUSCLE ACTIVITY DURING GAIT
INTERVAL JOINT POSITION MUSCLE ACTIVITY
Acceleration to Heel Strike Hip Flexed Gluteus Maximus
Hamstrings
Gluteus medius & minimus
Knee Flexed Quadriceps femoris
Ankle Neutral Anterior crural muscles
Heel Strike to Midstance Hip Neutral Gluteus medius & minimus
Knee Extended Quadriceps femoris
Ankle Dorsiflexed Gastrocnemius; soleus
Tarsal Inverted Tibialis anterior
Tibialis posterior
Midstance to Toe Off Hip Extended -
Knee Flexed Gastrocnemius
Ankle Plantar flexed Gastrocnemius; soleusThe gait cycle can
Toe Off to Acceleration Hip Flexed Iliopsoas
Adductors longus, brevis, magnus
Knee Flexed Gastrocnemius
Ankle Neutral Anterior crural muscles
Tarsal Neutral -
D. INITIAL CONTACT:
Initial contact is an instantaneous point in time only and occurs the instant the foot of the
leading lower limb touches the ground. Most of the motor function that occurs during initial
contact is in preparation for the loading response phase that will follow. Initial contact
represents the beginning of the stance phase. Heel strike and heel contact serve as poor
descriptors of this period since there are many circumstances when initial contact is not made
with the heel alone. The term \"foot strike\" sometimes is used as an alternative descriptor.
E. LOADING RESPONSE:
The loading response phase occupies about 10 percent of the gait cycle and constitutes the
period of initial double-limb support. During loading response, the foot comes in full contact
with the floor, and body weight is fully transferred onto the stance limb.
The initial double-support stance period occasionally is referred to as initial stance. The term
foot flat is the point in time when the foot becomes plantar grade. The loading response period
probably is best described by the typical quantified values of the vertical force curve. The
ascending initial peak of the vertical force graph reveals the period of loading response.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
F. MIDSTANCE:
Midstance represents the first half of single support, which occurs from the 10- to 30-
percent periods of the gait cycle. It begins when the contralateral foot leaves the ground
and continues as the body weight travels along the length of the foot until it is aligned
over the forefoot. The descending initial peak of the vertical force graph reveals the
period of midstance.
G. TERMINAL STANCE:
Terminal stance constitutes the second half of single-limb support. It begins with heel rise and
ends when the contralateral foot contacts the ground. Terminal stance occurs from the 30- to
50- percent periods of the gait cycle. During this phase, body weight moves ahead of the
forefoot.
The term heel off is a descriptor useful in observational analysis and is the point during the
stance phase when the heel leaves the ground. The ascending second peak of the vertical
force graph demonstrates the period of terminal stance.
Roll off describes the period of late stance (from the 40- to 50- percent periods of the gait
cycle) when there is an ankle plantarflexor moment and simultaneous power generation of the
triceps surae to initiate advancement of the tibia over the fulcrum of the metatarsal heads in
preparation for the next phase.
H. PRESWING:
Preswing is the terminal double-limb support period and occupies the last 12 percent of stance
phase, from 50 percent to 62 percent. It begins when the contralateral foot contacts the
ground and ends with ipsilateral toe off. During this period, the stance limb is unloaded and
body weight is transferred onto the contralateral limb. The descending portion of the second
peak of the vertical force graph demonstrates the period of preswing.
I. TERMINAL CONTACT:
 Terminal contact is a term rarely used, describes the instantaneous point in the gait cycle
when the foot leaves the ground. It thus represents either the end of the stance phase or
the beginning of swing phase. In pathologies where the foot never leaves the ground, the
term foot drag is used. In foot drag, the termination of stance and the onsetof swing may
be somewhat arbitrary.
 The termination of stance and the onset of swing is defined as the point where all portions
of the foot have achieved motion relative to the floor. Likewise, the termination of swing
and the onset of stance may be defined as the point when the foot ends motion relative to
the floor. Toe off occurs when terminal contact is made with the toe.
J. INITIAL SWING:
The initial one-third of the swing period, from the 62- to 75-percent periods of the gait cycle, is
spent in initial swing. It begins the moment the foot leaves the ground and continues until
maximum knee flexion occurs, when the swinging extremity is directly under the body and
directly opposite the stance limb.
K. MIDSWING:
Midswing occurs in the second third of the swing period, from the 75- to 85-percent periods of
the gait cycle. Critical events include continued limb advancement and foot clearance. This
phase begins following maximum knee flexion and ends when the tibia is in a vertical position.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
L. TERMINAL SWING:
In the final phase of terminal swing from the 85- to 100-percent periods of the gait cycle, the
tibia passes beyond perpendicular, and the knee fully extends in preparation for heel contact.
M. GAIT RLA:
Rancho Los Amigos Sub-phases
Contralateral toe off Contralateral initial contact
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to recall by Mullsons Health & Wellness at any time.
2.1.4 ROM OF A PATIENT:
A. ROM:
Range of Motion of a patient may be needed to maintain a patient’s mobility.
 Stretching of a patient’s muscles and joints may be more difficult that it seems. When
you stretch muscles and joints, you always have the chance of injuring the patient. The
medical principle of “Do No Harm” definitely applies with ROM exercises.
 There are multiple types of ROM. PROM, AAROM, and AROM are the key types of
ROM.
 PROM is range of motion that is passive. Basically, the patient offers no assistance
with PROM. Over-stretching with range of motion may lead to injury to the joint and
muscle. AAROM is active assistive range of motion, where the patient helps some;
however, the assistant offers the additional assistance to complete the available range.
AROM is active range of motion that patients perform on their own. However, the
patient may not have full AROM of multiple joints. Contractions in debilitated patients
are common in the knees, ankles, shoulders, and pelvis.
 Some stretches require AROM, followed by PROM to complete the available range of
motion. Never force a joint or muscle that exhibits abnormal resistance, increased
pain, or facial grimacing. Always observe the patient’s face while performing range of
motion exercises.
 Never “bounce the tissue” when performing stretching, and hold your stretches over
60 seconds to the patient’s tolerance. Tissue fibres do not have the opportunity to
“stretch out” if the stretch is not held for sixty seconds. However, if these fibres are
over stretched a strain may be the result in some cases.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
B. PAIN:
 Pain is defined as an unpleasant sensory experience associated with potential or
actual tissue damage according to many health organizations. Pain can be
interpreted in many ways. Generally pain is scaled on a 0-10 intensity scale. Zero
is no pain, while ten is the most unbearable pain possible. Physical therapist
assistants should ask the intensity of a patient’s pain prior to reporting the
supervisor and the location of a patient’s pain. Point tenderness can be a key
indicator in determining if a fracture has occurred.
 Patients deal with pain in many different ways. Some patients can become violent
when dealing with pain. However, almost every patient wants the pain to go away.
Patients with long term or chronic pain may develop addictions; however, patients
that are not in pain and taking pain medications are more likely to become addicted
to painkillers.
 Always assume that a patient is in pain if they tell you they are hurting. Don’t jump
to conclusions even if they have a pattern of exaggeration. If a patient has difficulty
identifying their pain level on the pain scale, use a visual scale to help determine
the patient’s pain level.
 Patients with addictions to pain medications may go to extreme measures to
maintain their addictions. For example in extreme cases, patients may even hide
extra pain medication inside body orifices to hide medications from hospital staff. If
you identify a medication on the floor or in the bed of a patient, collect it and deliver
it to a nursing supervisor. The patient may have simply not taken their prescribed
medication, or they may be hiding something.
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to recall by Mullsons Health & Wellness at any time.
2.1.5 AMBULATING A PATIENT:
 In addition, physical therapist assistants will be asked to assist in the ambulation of
patients. Gait that requires assistance may require quick responses by the PTA for
balance correction. Be prepared to “catch” any patient with gait and always use a gait
belt for safety. Be aware of all lines and tubing with gait. Moreover, if the patient has a
feeding or PEG tube, place the gait belt above the stomach level to avoid disturbing the
PEG site in case of balance correction with the gait belt as needed. This should also be
done with surgical incisions as well.
 Stand slightly behind and to the weak side of the patient with gait to increase safety. In
addition, determine if the patient has any special weight bearing precautions prior to
ambulation. An assistive device may be necessary if the MD has determined weight-
bearing status were off-loading an extremity is necessary.
 Get assistance if the patient has multiple lines, IV pole, and other equipment attached to
them. It is difficult to push an IV pole down the hall and safely guard a patient against
falls. Remember to use a gait belt, if you think the patient has a risk of falls. Falls in the
elderly can be especially dangerous. Osteoporosis can limit bone integrity during falls. If
a patient falls on your shift, a x-ray may need to be performed to rule out fracture and
injury.
 If the patient has a catheter, keep the catheter below the level of the bladder during gait.
Never attach the catheter to your person with gait or transfers, because sudden
movements may cause extreme pain for the patient. In addition, kinks in the catheter line
may cause autonomic dysreflexia, which is a medial emergency. Never let catheter lines
touch the ground. It is a violation of health standards.
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Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
3.0 NEUROMUSCULAR PHYSICAL THERAPY:
Neuromuscular Physiotherapy involves the examination, treatment, and instruction of persons in order to
detect, assess, prevent, correct, alleviate, and limit physical disability and bodily malfunction.
Purpose:
The purpose of neuromuscular Physiotherapy is to help individuals experiencing structural distortion,
biomechanical dysfunction, and the accompanying pain that is often symptomatic of the underlying
problem. It is used to locate and release tissue spasms and hypercontraction; eliminate trigger points that
cause referred pain; restore postural alignment, proper biomechanics and flexibility to the tissues; rebuild
the strength of injured tissues and assist venous and lymphatic flow.
Precautions:
A physician's referral is recommended.
Description:
The practice of neuromuscular Physiotherapy includes the administration, interpretation, and evaluation
of tests; measurements of bodily functions and structures; and the planning, administration, evaluation, and
modification of treatment and instruction, including the use of physical measures, activities, and devices, for
preventive and therapeutic purposes. Neuromuscular Physiotherapy may also be referred to as
neuromuscular re education, physical therapy, or physiotherapy.
Neuromuscular Physiotherapy is employed to treat patients with a variety of health conditions and
diseases including accident victims, and individuals with disabling conditions such as low back pain,
arthritis, heart disease, fractures, head injuries, and cerebral palsy.
In an effort to restore, maintain, and promote overall fitness and health, neuromuscular
physiotherapists examine patients' medical histories, test and measure patients' strength, range of motion,
balance, coordination, posture, muscle performance, respiration, and motor function. Neuromuscular
physiotherapists determine patients' ability to be independent and reintegrate into the community or
workplace. Based on a patient's medical history and test results, therapists develop treatment plans that
describe treatment strategy, purpose, and anticipated outcome.
Neuromuscular Physiotherapy treatment often includes exercise for patients who have been
immobilized or who lack flexibility, strength, or endurance. As part of the treatment, patients are
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encouraged to improve flexibility, range of motion, strength, balance, coordination, and endurance. The
goal is to improve an individual's function at work and home.
Neuromuscular Physiotherapy may involve the use of electrical stimulation, hot packs, cold
compresses, or ultrasound to relieve pain and reduce swelling. Traction or deep-tissue massage may be
employed to relieve pain. Patients are instructed in the use of assistive and adaptive devices including
crutches, prostheses, and wheelchairs. Patients are often shown how to perform exercises to do at home.
During treatment, neuromuscular physiotherapists document the patient's progress, conduct periodic
examinations, and modify treatments when necessary. Therapists rely on this documentation to track the
patient's progress, and identify areas requiring more or less attention.
Neuromuscular Physiotherapy may be used to treat a wide range of patients with conditions presenting
in areas such as paediatrics, geriatrics, orthopaedics, sports medicine, neurology, and cardiopulmonary
physical therapy.
Length of treatment varies depending upon several factors, including the severity of the condition being
treated. Treatment costs also vary depending upon a number of factors including geographic location and
the diagnostic tests conducted. Many insurance policies cover neuromuscular Physiotherapy treatments
provided that a physician's referral is obtained prior to treatment.
There are a number of alternative neuromuscular therapies. Among the most popular are the
following:
Alexander technique
The goal of this discipline is to bring the body's muscles into natural harmony. Hence it can aid in the
treatment of a wide variety of neurological and musculoskeletal conditions, including disorders of the neck,
back and hip; traumatic and repetitive strain injuries; chronic pain; arthritis; breathing and coordination
disorders; stress related disorders; and even migraine.
People with sciatica, scoliosis, osteoporosis, osteoarthritis, rheumatoid arthritis, and neck and low back
syndrome may find the Alexander technique useful in improving overall strength and mobility. Others with
Lyme disease, chronic fatigue syndrome, lupus, or fibromyalgia may use it for pain management. It is also
used to improve functioning in people with multiple sclerosis, stroke, or Parkinson's disease. Because the
technique requires active participation by the patient, it is impossible to test its effectiveness with
conventional scientific procedures.
Aston patterning
This specialized program of physical training and massage is designed to relieve muscle tension and
pain, speed recovery from injuries, and aid in general relaxation and stress reduction. It is particularly
appropriate for such problems as back and neck pain, headache, and repetitive stress injuries like tennis
elbow. (straightening your hair)
Like most forms of bodywork and movement training, Aston patterning does not lend itself to controlled
clinical trials, and its effectiveness has therefore not been scientifically verified. Furthermore, it requires a
significant patient commitment; it involves much more than a program of passive massage.
Feldenkrais
The Feldenkrais method is a supportive therapy that may help in situations where improved movement
patterns (and awareness of those patterns) can help with recovery from illness or injury. Practitioners
consider it useful for many types of chronic pain, including headache, temporomandibular joint disorder,
other joint disorders, and neck, shoulder, and back pain. It is sometimes used as supportive therapy for
people with neuromuscular disorders, such as multiple sclerosis, cerebral palsy and stroke. It is also helpful
for improving balance, coordination, and mobility. Many athletes, dancers, and other performers use the
Feldenkrais method as part of their overall conditioning.
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to recall by Mullsons Health & Wellness at any time.
Hellerwork
Hellerwork is a combination of deep tissue massage and movement re education. It is advocated by its
practitioners for a variety of problems related to muscle tension and stress. Hellerwork is said to relieve
respiratory problems, sports injuries, and pain in the back, neck, and shoulders. Like most forms of
bodywork, it has under-gone little in the way of scientific testing.
Trager
This light, gentle form of massage seeks to release deeply ingrained tensions, promoting a sense of
relaxation and freedom. It may be helpful for those with chronic neuromuscular pain, including back
problems and sciatica, and it has also been advocated for stress-related conditions, high blood pressure,
strokes, migraine, and asthma. Proponents say that it can benefit patients with polio, multiple sclerosis,
and muscular dystrophy as well.
Preparation
There are no typical pre-treatment preparations. However, a physician's referral is recommended.
Aftercare
Patients are often shown how to perform exercises to do at home.
Results
There are a number of beneficial results realized through neuromuscular therapy, including decreased body
toxicity, greater flexibility, greater freedom of movement, increased circulation, increased energy and
vitality, increased sense of well-being, and improved postural patterns.
Health care team roles
Neuromuscular physiotherapists often consult and practice with physicians, dentists, nurses, educators,
social workers, occupational therapists, speech-language pathologists, rehabilitation counsellors, vocational
counsellors, and audiologists.
Neuromuscular physiotherapists practice in hospitals, clinics, and private offices. They may also treat
patients in the patient's home or at school.
Over two-thirds of neuromuscular physiotherapists are employed in either hospitals or physiotherapists'
offices. Other work settings include home health agencies, outpatient rehabilitation centres, physicians'
offices and clinics, and nursing homes. Some neuromuscular physiotherapists maintain a private practice
and provide services to individual patients or contract to provide services in hospitals, rehabilitation centres,
nursing homes, home health agencies, adult day-care programs, or schools. They may be engaged in
individual practice or be part of a consulting group. Some therapists teach in academic institutions and
conduct research.
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to recall by Mullsons Health & Wellness at any time.
3.1 PNF (PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION):
3.1.1 DEFINITION (S)
 Proprioceptive: the ability to sense movement of the tissues. Proprioceptors =
Sensory receptors which are stimulated by some aspect of body position or movement
(i.e., muscle length or tension, joint angle, head position, etc.). A few examples are the
muscle spindles, G.T.O.'s, joint connective tissue, skin exteroceptors, eyes, ears, and
the inner ear receptor.
 Neuromuscular: Pertaining to nerves and muscles.
 Facilitation: “To make easier”. Increased ease of performance of any action, resulting
from the lessening of nerve resistance by the continued successive application of the
necessary stimulus (Webster). ** The Inhibition of abnormal tone and abnormal
movement patterns in favor of more normal tone is an inherent component of a
definition of facilitation.
PNF may be defined as a method of promoting or hastening the response of the
neuromuscular mechanism through stimulation of the proprioceptors.
The principles, philosophy and procedures of PNF were developed from the principles
of human anatomy, physiology, growth and development, kinesiology, behavioral sciences
and neurophysiology. Specifically:
1. Neurophysiology from the work of Sherrington, Coghill, and McGraw.
2. Motor development from the work of Gessell.
3. Normal adult subject responses from the work of Hellebrandt.
4. Conditioning of reflexes from the work of Pavlov.
3.1.2 PHILOSOPHY:
 PNF was developed from the premise that all human beings, whether they have a
disability or not, have untapped existing potential.
 The effectiveness of any treatment program is dependent upon both the therapist and
patient having well defined goals and the intention that those goals will be achieved.
 The ability to learn is an individual characteristic. Therefore, treatment programs and
techniques are tailored to the individual with his ability to cooperate and learn
considered.
 Treatment is directed towards patient education and the improvement of the patient's
performance of functional activities.
 The treatment approach is always positive, reinforcing, and utilizes that which the
patient can do on a physical and emotional level.
 When treating a patient the therapist must remember that all problems, neurological
and orthopedic, affect the system as a whole. Therefore, the approach should be
integrated; addressing sensory, musculoskeletal, and psychological elements to
ensure that each treatment is directed at a total human being not a specific problem.
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to recall by Mullsons Health & Wellness at any time.
3.1.3. TREATMENT PURPOSE:
The purpose of PNF treatment is to assist the patient to attain the highest level of function
possible through the development of the most efficient neuromuscular system.
1. Evaluation provides for the selection of appropriate techniques, and is a process that
continues through the entire treatment. The therapist evaluates the strengths and
abilities of the patient and uses these to help correct deficiencies.
2. Appropriate techniques are selected to facilitate normal spinal and subcortical reflexes
to enhance the development of optimal posture and movement.
 Direct vs. indirect technique: Direct techniques are those applied to the affected
are a while indirect techniques facilitate over flow excitation or enhance relaxation
effects in an affected part through application of techniques in another area.
Indirect techniques are more appropriate when dealing with pain or extreme
weakness while direct techniques provide specific mobilization or strengthening
effects.
 Techniques are based on neuroreflexive responses and can therefore be applied
with or without patient cooperation.
3. To achieve optimal functions:
 Complex skills (tasks) are broken down into their component parts; step by step
instruction is used.
 The ability to perform the whole skill is facilitated through the learning of the pattern
and through attention to specific deficits. (Whole part whole learning)
 The development of motor control and the interaction of stability and mobility are
taken into account.
4. The emphasis of PNF is on regaining motor control, restoring quality of motion and on
training reciprocal motion. Abnormal tone, posture and movement are treated by direct
or indirect inhibition/facilitation.
5. Tapping a maximal response (applying appropriate resistance) is the most effective
way to increase awareness, power, and endurance. Repetition of the response
promotes retention of motor learning i.e., allows the motion to become automatic.
6. Continued and consistent activity is essential to improve and maintain the power,
endurance, and coordination of the neuromuscular system. Therefore, an intense
program provides for the greatest improvement.
3.1.4. DEVELOPMENTAL ISSUES:
PNF is based on normal development and follows the basic rules of motor development.
1. Normal motor development has direction - control develops cephalo to caudal,
proximal to distal, total (mass) movement to specific motion. You must first develop
adequate function of the head, neck and trunk before refining function of the
extremities.
2. Normal development follows an order but does not progress step by step. Patients
need to begin working on the next developmental level before the preceding level is
perfected.
3. Motor control/ability is sequenced also, and progresses as follows:
 Mobility - the availability of ROM to complete a movement and the presence of
sufficient motor unit activity to initiate/perform the movement.
 Stability - the ability of postural muscles to maintain a contraction against gravity or
resistance (tonic stability), and the ability of antagonist muscles to simultaneously
contract around and stabilize a joint (co-contraction).
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 Controlled mobility - the ability to move a proximal body part over a fixed distal
segment (closed chain wt bearing).
 Skill - the ability to hold proximally while a distal segment moves in space to
manipulate the environment.
3.1.5 PATTERNS:
1. The patterns of motion for PNF are mass movement patterns. Mass movement is a
characteristic of normal motor activity and is in keeping with Beevor's axiom that \"the
brain knows nothing of individual muscle action, but knows only of movement\"
2. These mass movement patterns are spiral and diagonal in character and closely
resemble the movements used in sports and in work activities. The spiral and diagonal
character is in keeping with the spiral and rotatory characteristics of the bones and
joints and the joint capsule structure. This type of motion is also in harmony with the
topographical alignment of the muscles from origin to insertion and with the structural
characteristics of the individual muscles.
3. Each spiral and diagonal pattern of the extremity consists of a three-component motion
with respect to the joints participating in the movement. The patterns of the extremities
are named for the three components of motion occurring at the proximal joints or pivots
of action: the shoulder and the hip. The three components include flexion or extension,
abduction or adduction, and internal or external rotation. As a pattern of motion is
initiated, rotation enters the motion first. The intermediate joints, the elbow and knee,
may remain straight or they may flex or extend.
4. The patterns of the head and neck and the upper trunk are described as flexion or
extension with rotation to the left or right.
5. The diagonal line of movement is referred to as the \"groove\" of the pattern. It is the
optimal line of movement produced by the optimal or maximal contraction of the major
muscles involved from their lengthened state to their shortened state. The patient will
be strongest in this \"groove\". When the pattern is out of the groove, there may be an
increase in abnormal tone, loss of power, loss of active ROM, etc.
6. The pattern of muscles contracting towards their shortened state is termed the agonist
pattern. The pattern of muscles contracting to return the extremity to the original
position is termed the antagonist pattern.
7. Preparatory Commands vs Action Commands: Given it's strong emphasis on patient
learning, PNF places a lot of emphasis on verbal instruction to the patient. Preparatory
commands are explanations of your expectations; action commands involve direction
to the patient regarding how to perform during the exercise.
3.1.6 BASIC PNF PRINCIPLES:
A. MANUAL CONTACT (MC):
Motor responses are often influenced by the stimulation of skin and other receptors.
So, you can enhance the appropriate motor response by using the proper MC. At all
times in a treatment, the PT needs to be consistent and specific with the MC's for each
patient to allow for accurate assessment and treatment response.
I. MOTOR RESPONSES AFFECTED BY MC:
1. STRENGTH OR POWER:
Increased strength of contraction will occur when the PT applies the proper
contact to the segment being facilitated. The proper placement should be
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specific to either the surface corresponding to the direction of movement or the
actual muscle in which a stronger contraction is desired.
2. DIRECTION OF MOVEMENT:
A specific MC applied to the correct surface will enhance movement in a
certain direction.
II. APPLICATION OF APPROPRIATE MC:
MC's are designed to decrease conflicting sensory input so that the patient's
response is easier and more precise. The lumbrical grip utilizes the intrinsic
muscles of the hand, which decreases the potential for grabbing the patient or
touching too many surfaces - provides efficient facilitation while imparting a feeling
of security.
 The contact surfaces should be the palm, the thenar and hypothenar
eminences and the finger pads, not the fingertips. The amount of contact
depends on the body part being resisted and the size of the patient. The grip
should be comfortable, not painful, as pain inhibits appropriate response.
 Identify specific location for contact. The point of MC may vary from patient to
patient for many of the patterns. The correct contact is that specific point which
facilitates the appropriate contraction in the correct direction. A general
guideline is to choose a surface that faces directly into the line of movement
desired. The force of or strength of contact may need to be decreased when
working into new, previously painful degrees of range of motion, or when the
patient is very acute.
B. PT BODY POSITION AND MECHANICS:
The principles of manual contact and appropriate resistance can only compliment each
other if the therapists' body position and mechanics are correct.
I. BODY POSITION:
The PT's body should be positioned at either end of the desired movement,
with shoulders and hips facing in the direction of that movement. The PT's
forearms should always be pointed in the direction of the movement desired,
even if the body can not be in the exact diagonal or groove.
II. BODY MECHANICS:
 How the PT moves directly influences how the patient moves. The movement
of the PT must be a mirror image of the patient's movement to assure proper
direction and strength of movement throughout the entire range of motion.
 PT should position spine in neutral and maintain the neutral position
throughout movement, with movement occurring from the legs and hips.
 Weight shift or movement by the PT should always be in the direction you
desire the patient to move.
 Weight shift or movement by the PT should be in direct proportion to the
patient's movement.
 The PT's body position should always allow for the resistance to come from the
HEIGHT OF PHYSIOTHERAPY PT's trunk and pelvis, not the extremities.
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C. APPROPRIATE RESISTANCE:
Equals to the amount of resistance that facilitates the desired or appropriate smooth
and coordinated contraction, i.e. the amount of resistance that facilitates the greatest
force on the patient's part.
I. Appropriate resistance is used to facilitate two different types of muscular
contractions:
1. Isotonic - a contraction in which the intention is movement. (3 types)
 Concentric: shortening contraction; resistance is applied throughout the
desired or available active ROM. Movement occurs in an arc of motion and
resistance varies throughout the arc according to the strength and
coordination of the patient. Commands: \"push\", \"pull\".
 Eccentric: controlled lengthening contraction. Resistance can be applied
throughout any part of the ROM. Commands: \"let go slowly\", \"let me push
you slowly\"
 Maintained isotonic: contraction in which the patient's intent is to move,
but the therapist's resistance is too great to allow motion. May be used
initially to facilitate stabilization or awareness of position. Command: \"keep
it there\", \"don't let me push you down\".
2. Isometric - static contraction. Intention is to maintain a contraction against
external resistance. No joint motion occurs. Build contraction slowly, match
patient's force. Command: \"hold it, don't let your hand move\".
II. Resistance can facilitate irradiation, which is \"the spreading of a muscular
response from one muscle group to another by altering the emphasis of
resistance\". It can occur ipsilateral, contralateral, extremity to trunk, trunk to
extremity. Proper positioning (patient and PT), MC, and resistance are necessary
to assure a normal versus abnormal associated response.
III. True resisted exercise stimulates the muscle spindle, joint receptors, and patient's
awareness. However, initially appropriate resistance will be THAT AMOUNT that
best suits the patient. Passive range of motion may be an appropriate resistance
for some patients, and will initially increase patient awareness. Don't confuse the
PNF term \"appropriate resistance\" with the physiological concept of resistance
against an active effort.
IV. Remind patient to breathe to avoid fatigue, to facilitate efficient movement and to
prevent an abnormal response.
D. TRACTION AND APPROXIMATION:
I. TRACTION:
Elongation of a segment to increase muscular response or promote movement
especially of the flexor mm groups, may decrease pain in joints.
II. APPROXIMATION:
Compression of a segment to increase muscular response and promote postural
stability especially in extensor mm groups. Effects joint receptors, as well as
muscles, enhance patient's ability to \"hold\". Also used to stimulate normal postural
reactions.
III. The effects of traction and approx. blend with resistance to ensure smooth and
appropriate resistance. They assist the resistance, not the movement.
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E. QUICK STRETCH (QS):
I. Quick stretch is used to facilitate a stretch reflex in a group of muscles. A stretch
reflex is a spinal reflex used in conjunction with the techniques and procedures of
PNF to facilitate a reflex contraction. The stretch reflex is best facilitated through a
quick stretch.
 To perform a quick stretch, first position a group of muscles (in the pattern) in
their fully lengthened range (starting position for most patterns). The quick
stretch is superimposed over the elongated position by quickly but gently
elongating the muscles further. Combine QS with a verbal command to get a
volitional effort from the patient when possible. The quick stretch may also
be super-imposed on an existing contraction.
 The reflex response is reinforced by the immediate application of appropriate
resistance. The appropriate resistance must occur within the first few
degrees of movement or effects of stretch reflex will be decreased.
II. In application, the stretch reflex is used to achieve and enhance normal movement
by:
1. Facilitating initiation of motion
2. Increasing strength of muscle contraction
3. Increasing endurance by decreasing muscle fatigue and decreasing effort
needed to produce movement
4. Influencing the direction of movement
III. Contraindications to the use of QS are hyperactive stretch reflex not under
voluntary control (spasticity) and pain.
F. VERBAL COMMANDS (VC):
 Together with MC, verbal commands provide PT with the primary tools for
establishing communication and cooperation.
 Should be simple, concise, audible and specific. The quality of the VC influences
the quality of the response.
o Verbal cues are used to:
o Coordinate volitional effort with facilitated reflex response
o Define the type of muscular contraction desired
o Define direction of motion
o Signal timing of relaxation of contraction
o Facilitate increased arousal and responsiveness
o Stimulate generalized relaxation
G. VISUAL STIMULI:
Vision is important in the normal development and coordinated use of the body.
During treatment, properly directed use of vision assists in:
 Initial learning of activities
 Identifying directions of motion
 Identifying position in space
 Directing the motion of the head, trunk and extremities across midline on the same
side
 Increasing ROM
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H. NORMAL TIMING:
= sequence of muscle contraction which occurs in any motor activity, creating the
result of a coordinated movement.
PT must recognize normal timing of an activity and adjust the resistance and/or VC
to facilitate the relearning (or reinforcement) of this timing. PNF techniques often
identify rotation as the first component of the sequence.
I. REPETITION:
Necessary to the learning process and to the development of strength and endurance.
3.1.7 TECHNIQUES:
(The methods with which to treat specific problems.) PNF techniques are used to promote
desired types muscular contractions and may be applied throughout a pattern or may be
restricted to the lengthened, mid-, or shortened ranges.
A. TECHNIQUES(MOTOR CONTROL):
That can be used to attain more than one level of motor control. (I.e. mobility, stability,
controlled mobility and/or skill)
I. Slow Reversal (SR)
= reversal of antagonists, designed to facilitate coordinated reciprocal contractions.
Alternating, slow, rhythmical concentric contractions of all the components of
agonist and antagonistic patterns are performed without relaxation between
reversals.
Neurophysiological Rationale (NPR) - Sherrington's Law of successive
induction, which states that an agonist is facilitated by the preceding
contraction of its antagonist. On applications, increased resistance to the
stronger pattern will facilitate a more forceful contraction in the weaker.
USES - improve coordination and ability to smoothly reverse directions,
improve strength, increase ROM, prevent or relieve fatigue.
II. Slow Reversal Hold (SRH) - adds a gradually applied isometric contraction at end
of range.
NPR - increases gamma motorneuron activity so the muscle spindles are
less likely to become slack at end of range, thus allowing spindle afferents to
continue to fire and cause motor unit facilitation.
USES - facilitation of improved muscle contractions and strength (plus
all of USES for slow reversals).
III. Repeated Contractions (RC) (Repeated Quick Stretch)
Repeated use of the stretch reflex to initiate a muscular response, or to
strengthen a pre-existing contraction.
Several applications:
 very weak muscle (trace - poor) at lengthened range to initiate pattern
 moderate weak muscle (fair)to keep contraction strong throughout ROM
 muscle with unequal strength in different parts of the ROM - use where
weakness exists
NPR - rapid and substantial external stretches of entire muscle will
activate primarily afferents of the mm spindle. As with all QS, need to add
resistance to facilitate gamma system to keep muscle taut to increase
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sensitivity to stretch and spindle bias.
USES - decrease weakness and muscle imbalance.
IV. Timing for Emphasis (TE)
Adjustment of the resistance and/or verbal commands to facilitate a better
response in the weakest part of the pattern and facilitate normal timing - uses the
irradiation from the effort of the strong to help improve the efforts of the weak. (ex.
isometric of strong components followed by QS and isotonic contraction of weaker
components)
NPR - overflow, irradiation
USES - when weakness in a movement pattern is restricted to only one
component, such as the wrist, elbow, shoulder.
V. Agonistic Reversals (AR)
Use of a combination of isotonic contractions of the agonist without relaxation
emphasizes control of movement by promoting the ability to coordinate switching
between concentric, maintained isotonic, and eccentric contractions.
NPR - combining internal and external stretch of the intrafusal fibers
which should enhance firing of spindle afferents. Helps improve contractions
via primary and gamma stimulation.
USES - treats deficiencies in strength, ROM, and the ability to perform
the contractions increases patient awareness of the motion. Very good at
improving a patient’s ability to grade contractions and switch between
different types of contractions.
B. TECHNIQUES TO PROMOTE MOBILITY:
(Mobility = the ability to initiate/perform movement, and the availability of a functional
ROM through which to move)
1. Rhythmic Initiation (RI)
Technique designed to assist patients who have difficulty initiating a movement or
controlling a contraction. This is essentially the \"PROM\" component of PNF.
RI is a beginning treatment. Improvement, and change of technique (changes
from RI to SR), occurs as movement of body part progresses from completely
passive to AA exercise to AR exercise as patient relaxes and gains control.
NPR - relaxation of vestibular system with decreased input to reticular
formation (calming).
USES - promote relaxation, increase ROM and give initial sense of the
speed/timing, direction, and quality of motion desired.
2. Hold - Relax (HR)
Isometric technique used to increase ROM and to facilitate relaxation on one side
of the joint (due to muscle tightness) when pain is present.
Consists of an isometric contraction of all components of the range-limiting or
antagonistic mm groups. Pattern is elicited in non-painful range at point of
limitation of the available ROM. Let isometric build slowly, then ask for complete
relaxation. Move limb actively (pt) or passively (PT) through newly gained ROM to
new point of limitation. Technique is repeated several times.
NPR - some fatigue of muscle occurs causing relaxation; GTO
stimulation will inhibit motorneurons of the contracting muscle; takes
advantage of post contractile inhibition
USES -- increase ROM and mobility of extremity
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to recall by Mullsons Health & Wellness at any time.
C. CONTRACT RELAX (CR):
Combination of an isotonic contraction of the rotary component and a maintained
isotonic contraction of the other 2 components of the antagonistic pattern, used to
increase ROM and facilitate relaxation when there is decreased ROM on one side of
the joint. Patient's intent will be to move, therapist however allows only rotational
motion. Pt then relaxes and moves or is moved into new ROM.
Difference between HR and CR:
 With HR, intention is to hold, not move.
 Build up/release of resistance in more abrupt with CR,
 Gradual with HR.
 CR is not used in the presence of pain.
NPR - fatigue is greater influence secondary to more volitional motor unit
recruitment, rotation is a relaxing component in a hypercontractile pattern.
D. TECHNIQUES TO PROMOTE STABILITY:
(Ability to maintain a contraction against gravity and the ability to develop co-
contraction around a joint)
I. Alternating Isometrics (AI)
o Isometric of musculature on one side of joint followed immediately by holding
of antagonistic muscle.
o Intermediate step to Rhythmic Stabilization
USES - promote postural (static) stability
II. Rhythmic Stabilization (RS)
 Isometric technique used to increase stability; involves reversal of antagonists.
Isometrics of agonist/antagonist patterns are simultaneously and then
alternately elicited by the PT to get co contraction. Relaxation not allowed.
 Resistance of isometric contraction is slowly graded from agonist to antagonist.
NPR - fatigue of motor units leads to decreased muscle tension and
relaxation; reciprocal inhibition.
USES - increases circulation, improves posture and balance control,
promotes dynamic stability and co-contraction.
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to recall by Mullsons Health & Wellness at any time.
3.3 HAND MOTOR SEGMENTS:
Ulnardistribution_and_system_5 To me it was very hard to learn from which segments the muscles of
the wrist and hand stem, especially since the median nerve stems from the entire range of the
brachial plexus. I have developed this system to easily remember the segmental innervations of
muscles innervated by the radial, median and ulnar nerve. The location of the notation of segments is
logical for movement, and makes it easy to derive which muscle it is about. This knowledge is
required to work with the system. It is primarily developed for myself, but if anyone has problems
learning this too, and needs extra info, place a request in the reaction for this item.
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3.4 EMG DIAGNOSTIC:
 Insertional activity (Increases with disease)
 MUP (amount of Motor Unit Potentials; decreases with LMN injury)
 ∆ MUP configuration (incr) – re-inntervation
 Spontaneous EMG activity:
 Fibrillation (independent contractions of individual muscle fibres)
 Fasciculation’s (spontaneous contractions of most fibres in MU)
 Complete LMN lesions: fibrillation potentials
 Partial LMN lesions: Fibre + Fasc potentials
 NVC (nerve conduction velocity)
 Decreases with peripheral neuropathy
 Slowed with focal compression
Strength Duration durve:
 Position on graph will vary; longer and more intense at denervation
 Rheobase (minimum contraction threshold)
 Chronaxie (duration of electr. Stim at 2 x Rheobase)
 Chronaxie is lower (0,03 ms) with intact nerve than denervated muscle (10 ms)
 An EMG is done by inserting electrodes in fine needles into the muscles being tested, and by placing
electrodes on the skin over peripheral nerves.
 The presence, size, and shape of the wave form produced on the oscilloscope (the action potential)
provide information about the ability of the muscle to respond to nervous stimulation.
 Each muscle fibre that contracts will produce an action potential, and the size of the muscle fibre
affects the rate (how frequently an action potential occurs) and size (amplitude) of the action
potential(s).
 An EMG may be used to evaluate a variety of problems, including the following:
 Nerve damage from compression by a disk in the neck or the back
 Nerve compression from carpal tunnel syndrome
 Neuromuscular diseases such as amyotrophic lateral sclerosis (ALS), poliomyelitis, myasthenia gravis
and muscular dystrophy
 Peripheral neuropathy caused by such conditions as diabetes, pernicious anemia and heavy metal
toxicity
 In many instances, an EMG can provide critical diagnostic information that cannot be obtained in any
other way. Although there is some discomfort associated with the procedure, an EMG is usually done
on an outpatient basis.
3.4.1 PREPARATION:
No special preparation is usually necessary.
3.4.2 PROCEDURE:
 A needle electrode is inserted through the skin into the muscle.
 The electrical activity detected by this electrode is displayed on an oscilloscope.
 You may be asked to contract the muscle.
3.4.3 HOW IT FEELS:
 There may be some discomfort with insertion of the electrodes. Afterward, the examined
muscle may feel tender or bruised.
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to recall by Mullsons Health & Wellness at any time.
2.2.4 SPINAL SPECIALIZATION:
 Anterior spinothalamic tract - Dull Aching pain
 Lateral spinothalamic tract - Discriminative fast pain
 Fasciculus Gracilis/cutaneus - Discriminative touch, propriosepsis
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3.5 NERVE INJURY:
 Neuropraxia: Least severe injury. Conduction block at damaged site. All structures intact. No
Wallerian degeneration* but focal demyelination. Complete recovery in 3-6 weeks.
 Axontmesis: Disruption of axons and surrounding endoneurial sheaths. Perineurium and epineurium
are intact. Wallerian degeneration* occurs. Distal conduction velocity may be preserved up to 7 days
after damage. Recovery after several months.
 Neurontmesis: Most severe injury. Complete disruptions of endoneurium, perineurium and
epineurium. Wallerian degeneration occurs. Recovery through surgery with variable prognoses. (no
recovery to complete recovery)
 Wallerian degeneration: axonal enlargement into amorphorous mass, breakdown of the axons,
schwann cell ingestion of fragmented myelin to provide clean endoneurial tubes for advancement of
regenerating axons.
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to recall by Mullsons Health & Wellness at any time.
3.6 PHASES AND SYNNERGY PATTERNS AFTER CVA:
 Transischemic attack
 Flaccidity
 Spasticity
 Synergy
3.6.1 LOWER EXTREMITY:
 Typically hip extension, Flaccidit
 Internal rotation,
 Adduction,
 Knee extension,
 Ankle plantar flexion with inversion of the foot.
3.6.2 UPPER EXTREMITY:
 Shoulder/scapular depression (downward rotation and retraction),
 Humeral adduction/internal rotation,
 Elbow flexion,
 Forearm pronation (rarely supination), and
 Wrist/finger flexion (thumb-in-hand position).
Spasticity
TRANSISCHEMIC ATTACK
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to recall by Mullsons Health & Wellness at any time.
3.7 BRACHIAL PLEXUS:
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to recall by Mullsons Health & Wellness at any time.
3.7.1 BRAIN LOBES:
The brachial plexus is a somatic nerve plexus formed by intercommunications among the
ventral rami of the lower four cervical nerves ( C 5 - C 8) and the first thoracic nerve (T 1).
The plexus is responsible for the motor innervation to all of the muscles of the upper
limbwith the exception of the trapezius and levator scapula. It supplies all of the cutaneous
innervation of the upper limb with the exception of the area of the axilla( armpit) (supplied
by the intercostobrachial nerve), an area just above the point of the shoulder (supplied by
supraclavicular nerves) and the dorsal scapular area which is supplied by cutaneous
branches of dorsal rami. The brachial plexus communicates with the sympathetic trunk by
gray rami communicates that join all the roots of the plexus and are derived from the
middle and inferior cervical sympathetic ganglia and the first thoracic sympathetic ganglion.
Prefixed Brachial Plexus—Occurs when the C 4 ventral ramus contributes to the
brachial plexus. Contributions to the plexus usually come from C 4 - C 8.
Postfixed Brachial Plexus—Occurs when the T 2 ventral ramus contributes to the
brachial plexus. Contributions to the plexus usually come from C 6 - T 2.
A. FORMATION OF THE BRACHIAL PLEXUS:
I. ROOTS:
1. The ventral rami of spinal nerves C5 to T1 are referred to as the roots of the
plexus.
II. TRUNKS:
1. Shortly after emerging from the intervertebral foramina , these 5 roots unite to
form three trunks.
2. The ventral rami of C5 & C6 unite to form the Upper Trunk.
3. The ventral ramus of C 7 continues as the Middle Trunk.
4. The ventral rami of C 8 & T 1 unite to form the Lower Trunk.
III. DIVISIONS:
1. Each trunk splits into an anterior division and a posterior division.
2. The anterior divisions usually supply flexor muscles
3. The posterior divisions usually supply extensor muscles.
a. Cords
I. The anterior divisions of the upper and middle trunks unite to form the
lateral cord.
II. The anterior division of the lower trunk forms the medial cord.
III. All 3 posterior divisions from each of the 3 cords all unite to form the
posterior cord.
IV. The cords are named according to their position relative to the axillary
artery.
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IV. TERMINAL BRANCHES:
ARE MIXED NERVES CONTAINING BOTH SENSORY AND MOTOR AXONS.
1. Musculocutaneous nerve is derived from the lateral cord.
a. This nerve innervates the muscles in the flexor compartment of the arm
b. Carries sensation from the lateral ( radial) side of the forearm.
2. Ulnar nerve is derived from the medial cord
a. Motor innervation is mainly to intrinsic muscles of the hand
b. Sensory innervation is from the medial (ulnar) 1 & 1/2 digits ( the 5th. and
1/2 of the 4th. digits).
3. Median nerve is derived from both the lateral and medial cords
a. Motor innervation is to most of the flexors muscles in the forearm and
intrinsic muscles of the thumb (thenar muscles).
b. Sensory innervation is from the lateral ( radial) 3 & 1/2 digits ( the thumb
and first 2 and 1/2 fingers).
4. Axillary nerve is derived from the posterior cord.
a. Motor innervation is deltoid and teres minor muscles that act on the
shoulder joint.
b. Sensory innervation is from the skin just below the point of the shoulder.
5. Radial nerve is also derived from the posterior cord.
a. Called “Great Extensor Nerve” because it innervates the extensor muscles
of the elbow, wrist and fingers.
b. Sensory innervation is from the skin on the dorsum of the hand on the
radial side.
V. BRANCHES:
Nerves that are branches from portions of the brachial plexus usually contain only
1 type of axon; either sensory or motor)
1. From the Roots
a. Dorsal Scapular nerve
 Derived from C5 root
 Motor nerve to the Rhomboideus major and minor muscles
2. Long Thoracic nerve
 Derived from C 5,6,7
 Innervates the serratus anterior muscle
3. From the Upper Trunk
a. Nerve to subclavius muscle
b. Suprascapular nerve
 Innervates supra and infraspinatus muscles
4. From the Lateral Cord
a. Lateral Pectoral nerve
 Innervates the clavicular head of the pectoralis major muscle
5. From the Medial Cord
a. Medial Pectoral nerve
 Innervates the sternocostal head of the pectoralis major muscle
 Innervates the pectoralis minor muscle
b. Note : the medial and lateral pectoral nerve often join together to act
as a single nerve innervating both the pectoralis major & minor
muscles
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c. Cutaneous Branches
 Medial brachial cutaneous
i. Carries sensation from the lower medial portion of the arm
 Medial antebrachial cutaneous
ii. Carries sensation from the medial (ulnar portion of the
forearm)
VI. DISTRIBUTION OF ROOTS:
1. Definitions
a. Spinal Segment
 Region of spinal cord giving origin to a specific spinal nerve
b. Dermatome
 Region on the surface of the skin from which sensation is carried
by cutaneous branches of a single spinal nerve
c. Myotome
 Those muscles receiving innervation from axons derived from a
single spinal nerve &/or the ventral ramus of a spinal nerve
 Most muscles are innervated by axons from more than one spinal
nerve
 Predominant spinal nerve determines myotome segment
d. Segmental Innervation
 involves understanding the manner in which the ventral rami of
spinal nerves are distributed to the various dermatomes and
myotomes of a given region such as the upper limb
2. Lesion
a. Damage to a structure, in this case a nervous structure. The structure
damaged could be the spinal cord, a spinal nerve , a nerve root (ventral
ramus ) or a branch of a ventral ramus
b. Site of a lesion can be determined by the extent of muscle damage and /
or loss of sensation
c. Muscles usually receive their innervation from axons derived from more
than one spinal segment. Predominant spinal nerve determines myotome
spinal segment
d. Peripheral Nerve Lesion
 Paralysis of muscles supplied by the damaged nerve
 Loss of sensation from cutaneous region supplied by the damaged
nerve
 Examples
i. Trauma
 Usually leads to loss of nerve function
ii. Entrapment
 Nerve passing though a muscle or defined space
o Musculocutaneous nerve passing through
coracobrachialis muscle
o Carpal Tunnel Syndrome
 Diminished function but no total loss
e. Spinal Cord lesion
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i.
All muscles supplied by spinal nerves below the site of the lesion are
paralyzed
ii. Loss of sensation below the site of the lesion
iii. Lesions are referred to as the lowest portion of the spinal cord that
functions
 a C5 spinal cord lesion means all spinal nerves below the 5th.
cervical nerve are no longer able to function.
f. Nerve Root (Ventral Ramus) Lesion
i. All muscles supplied by a given nerve root will be weakened
 most muscles receive their innervation from axons derived from
more than one spinal segment.
ii. Dermatome of that nerve root will have reduced sensation
(paraesthesia)
- spinal nerves overlap in each dermatome
3. Root Distribution in Brachial Plexus
a. Axons within each individual nerve root are distributed to many nerve
branches
b. Axons contributing to the formation of a given nerve form the segment of
that nerve
 Axillary nerve ( C 5,6) has axons derived from the ventral rami of C 5
and C6.
 Ulnar nerve (C8, T1)has axons derived from ventral rami C8 and T 1
 Long Thoracic nerve ( C 5,6,7) has axons derived from ventral rami
C5, C6, and C7
c. For convenience, in figure 5 nerve roots C 5,6 are considered together as
are nerve roots C8 and T1
d. C5 & 6
 Distributed to muscles acting on the shoulder and elbow
e. C8,T1
 Distributed to the intrinsic muscles of the hand
VII. LESIONS OF THE BRACHIAL PLEXUS:
1. Very common
2. A knowledge of the muscles innervated by branches of the brachial plexus and
the action(s) of these muscles and areas of anesthesia &/or paraesthesia will
enable the future clinical to determine the localization (site) of a given lesion.
3. Chart 1 reviews the types of motor and sensory deficits produced as a result of
lesions to different parts of the brachial plexus
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3.8 DERMATOMES AND PEREPHIRAL INNERVATION:
The nerves that innervate the wrist and hand exit the spinal cord as spinal roots C5 - T2. These
spinal roots traverse the brachial plexus and emerge as the peripheral nerves. When discussing
the nerve distribution of the wrist and hand, one can either discuss dermatomes or peripheral nerve
distribution.
3.8.1 DERMATOMES:
A dermatome is the area of skin supplied by nerves originating from a single spinal nerve
root. The spinal roots innervating the wrist and hand are C5, C6, C7, C8, T1, and T2.
A. CLINICAL SIGNIFICANCE:
Dermatomes are useful in neurology for finding the site of damage to the spine.
Because painful dermatomes are symptoms, not causes, of the underlying problem,
surgery should never be determined by a pain. Aching in a dermatomic area indicates
a lack of oxygen to the nerve as occurs in inflammation somewhere along the path of
the nerve. Pain in a dermatomic area (that is not accompanied by heat, as would occur
in infection) is indicative of a referral pattern from some other source. This \"other
source\" will not be painful until it is palpated and is usually found (according to Head)
on the left side of the vertebral column at the level or one level above or below the
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dermatomal region of the experienced pain. This information is important in the clinical
relevance of dermatomes in that dermatomes are not good measures of dysfunction
(that is, non-pathological states as experienced by most people in chronic pain). A
compressed spinal nerve, for example, will show as a loss of motor function (i.e. as
loss of muscle mass in a proscribed area and/or as an inability to use the muscle
against gravity elsewhere on the body) but may or may not exhibit symptoms in the
dermatomic area covered by the compressed nerve.
Viruses that infect spinal nerves such as Herpes zoster infections (shingles), can
reveal their origin by showing up as a painful dermatomic area. Herpes zoster, a virus
that is dormant in the dorsal root ganglion, migrates along the spinal nerve to affect
only the area of skin served by that nerve. Symptoms are usually unilateral but in the
immune suppressed, they are more likely to become bilateral and symmetrical,
meaning that the virus is present in both ganglia of a dorsal root ganglion pair.
B. IMPORTANT DERMATOMES AND ANATOMICAL LANDMARKS:
C2 - posterior half of the skull cap T5 - Inframammary fold.
C3 - area correlating to a high turtleneck shirt T6/T7 - xiphoid process.
T10 - umbilicus (important for
C4 - area correlating to a low-collar shirt early appendicitis pain)
C6 - (radial nerve]]) 1st digit (thumb) T12 - pubic bone area.
C7 - (median nerve) 2nd and 3rd digit L1 - inguinal ligament
C8 - (ulnar nerve) 4th and 5th digit, also the funny bone L4 - includes the knee caps
T4 - nipples.
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Thoracic
d t
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3.8.2 PERIPHERAL NERVE INNERVATION:
A. PERIPHERAL NERVE INNERVATION OF LOWER EXTREMITY:
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I. SENSORY:
1. Lateral cutaneous nerve of the thigh (L23):
a. Nerve travels beneath the inguinal ligament where it can be compressed
causing meralgia paresthetica.
b. Affects the lateral aspect of the upper thigh.
c. Treatment: conservative with steroids or physical therapy or cut lateral
cutaneous nerve.
2. Obturator nerve (L23):
a. Nerve runs along anterior portion of pelvis and exits medial to the femoral
vein.
b. Innervates proximal inner portion of thigh.
3. Femoral nerve (L234):
a. Innervates distal 1/3 of the anteromedial aspect of the thigh.
b. Also innervates the medial aspect of the lower leg via the saphenous
nerve.
4. Sciatic nerve (L45S123):
a. Comprised of two main nerves – common peroneal (L45S12) and tibial
(L45S123).
i. Peroneal most commonly injured:
1. Peroneal has two divisions: superficial and deep; if the superficial
branch is involved then there will be hypalgesia on the
anterolateral aspect of the foot.
2. If the deep division is affected there will be weakness in
dorsiflexion and inversion of the foot with a sensory loss between
the web area of the first two toes.
ii. Tibial nerve:
1. Innervates the flexors of the foot and plantar flexion of the ankle;
lesions affect plantar flexion of ankle and flexion of toes.
II. MOTOR:
I. Iliopsoas; L23; femoral nerve; hip flexion.
II. Quadriceps femoris; L34; femoral nerve; knee extension.
III. Adductor longus; L3; obturator nerve.
IV. Gluteus medius/minimus (thigh abduction and medial rotation); L5; superior
gluteal nerve.
V. Gluteus maximum (thigh abduction with patient prone);S1; inferior gluteal
nerve Remember: inferior gluteal nerve comes out underneath piriformis
muscle while superior gluteal nerve comes out above the piriformis muscle.
VI. Biceps femoris; S1; sciatic nerve; hip extension.
VII. Tibialis anterior (dorsiflexion and inversion); L4; deep peroneal nerve.
VIII. Extensor hallicus longus; L5; deep peroneal.
IX. Peroneus longus and brevis; (plantar flexion and eversion); L5; superficial
peroneal nerve Remember: superficial peroneal nerve is lateral to deep
peroneal nerve and tibial nerve is posterior to both.
X. Posterior tibialis (plantar flexion and inversion); L4; tibial nerve.
XI. Gastrocnemius; S1; tibial nerve; plantar flexion.
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3.8.3 CNS:
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A. THE HUMAN CENTRAL NERVOUS SYSTEM:
The central nervous system is made up of the:
 Spinal cord and
 Brain
I. THE SPINAL CORD:
 Conducts sensory information from the peripheral nervous system (both
somatic and autonomic) to the brain
 Conducts motor information from the brain to our various effectors
 Skeletal muscles
 Cardiac muscle
 Smooth muscle
 Glands
 Serves as a minor reflex centre
1. WHITE MATTER VS. GRAY MATTER:
Both the spinal cord and the brain consist of
 white matter = bundles of axons each coated with a sheath of myelin
 gray matter = masses of the cell bodies and dendrites — each covered
with synapses.
In the spinal cord, the white matter is at the surface, the gray matter inside.
In the brain of mammals, this pattern is reversed. However, the brains of
\"lower\" vertebrates like fishes and amphibians have their white matter on the
outside of their brain as well as their spinal cord.
2. THE MENINGES:
Both the spinal cord and brain are covered in three continuous sheets of
connective tissue, the meninges. From outside in, these are the
 Dura mater pressed against the bony surface of the interior of the
vertebrae and the cranium
 The arachnoid
 The pia mater
The region between the arachnoid and pia mater is filled with
cerebrospinal fluid (CSF).
3. THE EXTRACELLULAR FLUID (ECF) OF THE CENTRAL NERVOUS
SYSTEM:
The cells of the central nervous system are bathed in a fluid that differs
from that serving as the ECF of the cells in the rest of the body.
 The fluid that leaves the capillaries in the brain contains far less protein
than \"normal\" because of the blood-brain barrier, a system of tight
junctions between the endothelial cells of the capillaries. This barrier
creates problems in medicine as it prevents many therapeutic drugs from
reaching the brain.
o cerebrospinal fluid (CSF), a secretion of the choroid plexus. CSF
flows uninterrupted throughout the central nervous system
o through the central cerebrospinal canal of the spinal cord and
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o through an interconnected system of four ventricles in the brain.
CSF returns to the blood through veins draining the brain.
4. THE SPINAL CORD:
31 pairs of spinal nerves arise along the spinal cord. These are \"mixed\"
nerves because each contains both sensory and motor axons. However, within
the spinal column,
 All the sensory axons pass into the dorsal root ganglion where their cell
bodies are located and then on into the spinal cord itself.
 All the motor axons pass into the ventral roots before uniting with the
sensory axons to form the mixed nerves.
The spinal cord carries out two main functions:
 It connects a large part of the peripheral nervous system to the brain.
Information (nerve impulses) reaching the spinal cord through sensory
neurons are transmitted up into the brain. Signals arising in the motor
areas of the brain travel back down the cord and leave in the motor
neurons.
 The spinal cord also acts as a minor coordinating center responsible for
some simple reflexes like the withdrawal reflex.
The interneurons carrying impulses to and from specific receptors and
effectors are grouped together in spinal tracts.
5. CROSSING OVER OF THE SPINAL TRACTS:
Impulses reaching the spinal cord from the left side of the body eventually
pass over to tracts running up to the right side of the brain and vice versa. In
some cases this crossing over occurs as soon as the impulses enter the cord.
In other cases, it does not take place until the tracts enter the brain itself.
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II. THE BRAIN:
 Receives sensory input from the spinal cord as well as from its own nerves
(e.g., olfactory and optic nerves)
 Devotes most of its volume (and computational power) to processing its
various sensory inputs and initiating appropriate — and coordinated — motor
outputs.
1. THE HUMAN BRAIN:
The brain of all vertebrates develops from three swellings at the anterior
end of the neural canal of the embryo. From front to back these develop into
the
 Forebrain (also known as the prosencephalon)
 Midbrain (mesencephalon)
 Hindbrain (rhombencephalon)
The brain receives nerve impulses from
 the spinal cord and
 12 pairs of cranial nerves
o Some of the cranial nerves are \"mixed\", containing both
sensory and motor axons
o Some, e.g., the optic and olfactory nerves (numbers I and II)
contain sensory axons only
o Some, e.g. number III that controls eyeball muscles, contain
motor axons only.
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2. THE HINDBRAIN:
The main structures of the hindbrain (rhombencephalon) are the
 Medulla oblongata
 Pons and
 Cerebellum
Medulla oblongata
The medulla looks like a swollen tip to the spinal cord. Nerve impulses arising here
 Rhythmically stimulate the intercostal muscles and diaphragm making
breathing possible [More]
 Regulate heartbeat
 Regulate the diameter of arterioles thus adjusting blood flow.
The neurons controlling breathing have mu (µ) receptors, the receptors to which
opiates, like heroin, bind. This accounts for the suppressive effect of opiates on
breathing. [Discussion] Destruction of the medulla causes instant death.
3. PONS:
The pons seems to serve as a relay station carrying signals from various
parts of the cerebral cortex to the cerebellum. Nerve impulses coming from the
eyes, ears, and touch receptors are sent on the cerebellum. The pons also
participates in the reflexes that regulate breathing.
The reticular formation is a region running through the middle of the
hindbrain (and on into the midbrain). It receives sensory input (e.g., sound)
from higher in the brain and passes these back up to the thalamus. The
reticular formation is involved in sleep, arousal (and vomiting).
4. CEREBELLUM:
The cerebellum consists of two deeply convoluted hemispheres. Although
it represents only 10% of the weight of the brain, it contains as many neurons
as all the rest of the brain combined.
Its most clearly understood function is to coordinate body movements.
People with damage to their cerebellum are able to perceive the world as
before and to contract their muscles, but their motions are jerky and
uncoordinated.
So the cerebellum appears to be a centre for learning motor skills (implicit
memory). Laboratory studies have demonstrated both long-term potentiation
(LTP) and long-term depression (LTD) in the cerebellum.
5. THE MIDBRAIN:
The midbrain (mesencephalon) occupies only a small region in humans (it
is relatively much larger in \"lower\" vertebrates). We shall look at only three
features:
 The reticular formation: collects input from higher brain centers and passes
it on to motor neurons.
 The substantia nigra: helps \"smooth\" out body movements; damage to the
substantia nigra causes Parkinson's disease.
 The ventral tegmental area (VTA): packed with dopamine-releasing
neurons that
 Are activated by nicotinic acetylcholine receptors and
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 Whose projections synapse deep within the forebrain.
The VTA seems to be involved in pleasure: nicotine, amphetamines
and cocaine bind to and activate its dopamine-releasing neurons and this may
account — at least in part (see below)— for their addictive qualities.
The midbrain along with the medulla and pons are often referred to as the
\"brainstem\".
6. THE FOREBRAIN:
The human forebrain (prosencephalon) is made up of
 A pair of large cerebral hemispheres, called the telencephalon. Because of
crossing over of the spinal tracts, the left hemisphere of the forebrain deals
with the right side of the body and vice versa.
 A group of structures located deep within the cerebrum, that make up the
diencephalon.
7. DIENCEPHALON:
We shall consider four of its structures: the
a. Thalamus:
 All sensory input (except for olfaction) passes through these paired
structures on the way up to the somatic-sensory regions of the
cerebral cortex and then returns to them from there.
 Signals from the cerebellum pass through them on the way to
the motor areas of the cerebral cortex.
 Lateral geniculate nucleus (LGN). All signals entering the brain
from each optic nerve enter a LGN and undergo some
processing before moving on the various visual areas of the
cerebral cortex.
b. Hypothalamus:
 The seat of the autonomic nervous system. Damage to the
hypothalamus is quickly fatal as the normal homeostasis of body
temperature, blood chemistry, etc. goes out of control.
 The source of 8 hormones, two of which pass into the posterior lobe of
the pituitary gland.
c. Posterior lobe of the pituitary:
Receives
 Vasopressin and
 Oxytocin
From the hypothalamus and releases them into the blood.
d. The Cerebral Hemispheres:
Each hemisphere of the cerebrum is subdivided into four lobes visible from
the outside:
 Frontal
 Parietal
 Occipital
 Temporal
Hidden beneath these regions of each cerebral cortex is
 An olfactory bulb; they receive input from the olfactory epithelia.
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 A striatum; they receive input from the frontal lobes and also from the
limbic system (below). At the base of each striatum is a
 Nucleus accumbens (NA).
The pleasurable (and addictive) effects of amphetamines, cocaine, and
perhaps other psychoactive drugs seem to depend on their producing
increasing levels of dopamine at the synapses in the nucleus accumbens (as
well as the VTA).
 A limbic system; they receives input from various association areas in the
cerebral cortex and pass signals on to the nucleus accumbens. Each
limbic system is made up of a:
 Hippocampus. It is essential for the formation of long-term memories.
The amygdala appears to be a centre of emotions (e.g., fear). It sends
signals to the hypothalamus and medulla, which can activate the flight or fight
response of the autonomic nervous system.
In rats, at least, the amygdala contains receptors for
 Vasopressin whose activation increases aggressiveness and other
signs of the flight or fight response;
 Oxytocin whose activation lessens the signs of stress.
The amygdala receives a rich supply of signals from the olfactory system, and
this may account for the powerful effect that odor has on emotions (and
evoking memories).
8. MAPPING THE FUNCTIONS OF THE BRAIN:
It is estimated that the human brain contains 100 billion (1011) neurons
averaging 10,000 synapses on each; that is, some 1015 connections. How to
unravel the workings of such a complex system?
Several methods have been useful.
o Histology
o Microscopic examination with the aid of selective stains has revealed many
of the physical connections created by axons in the brain.
o The Electroencephalograph (EEG)
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This device measures electrical activity (brain \"waves\") that can be detected at
the surface of the scalp. It can distinguish between, for example, sleep and
excitement. It is also useful in diagnosing brain disorders such as a tendency
to epileptic seizures.
9. DAMAGE TO THE BRAIN:
Many cases of brain damage from, for example,
 Strokes (interruption of blood flow to a part of the brain)
 Tumors in the brain
 Mechanical damage (e.g., bullet wounds)
have provided important insights into the functions of various parts of the brain.
Example 1:
Battlefield injury to the left temporal lobe of the cerebrum interferes with
speech.
Example 2: Phineas P. Gage
In 1848, an accidental explosion drove a metal bar completely through the
frontal lobes of Phineas P. Gage. Not only did he survive the accident, he
never even lost consciousness or any of the clearly-defined functions of the
brain. However, over the ensuing years, he underwent a marked change in
personality. Formerly described as a reasonable, sober, conscientious person,
he became — in the words of those observing him — \"thoughtless,
irresponsible, fitful, obstinate, and profane\". In short, his personality had
changed, but his vision, hearing, other sensations, speech, and body
coordination were unimpaired. (Similar personality changes have since been
often observed in people with injuries to their prefrontal cortex.)
The photograph (courtesy of the Warren Anatomical Museum, Harvard
University Medical School) shows Gage's skull where the bar entered (left) and
exited (right) in the accident (which occurred 12 years before he died of natural
causes in 1861).
10. STIMULATING THE EXPOSED BRAIN WITH ELECTRODES:
There are no pain receptors on the surface of the brain, and some humans
undergoing brain surgery have volunteered to have their exposed brain
stimulated with electrodes during surgery. When not under general anesthesia,
they can even report their sensations to the experimenter.
Experiments of this sort have revealed a band of cortex running parallel to
and just in front of the fissure of Rolando that controls the contraction of
skeletal muscles. Stimulation of tiny spots within this motor area causes
contraction of the muscles.
The area of motor cortex controlling a body part is not proportional to the
size of that part but is proportional to the number of motor neurons running to
it. The more motor neurons that activate a structure, the more precisely it can
be controlled. Thus the areas of the motor cortex controlling the hands and lips
are much larger than those controlling the muscles of the torso and legs.
A similar region is located in a parallel band of cortex just behind the
fissure of Rolando. This region is concerned with sensation from the various
parts of the body. When spots in this sensory area are stimulated, the patient
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reports sensations in a specific area of the body. A map can be made based
on these reports.
When portions of the occipital lobe are stimulated electrically, the patient
reports light. However, this region is also needed for associations to be made
with what is seen. Damage to regions in the occipital lobe results in the
person's being perfectly able to see objects but incapable of recognizing them.
The centers of hearing — and understanding what is heard — are located
in the temporal lobes.
11. CT = X-RAY COMPUTED TOMOGRAPHY:
This is an imaging technique that uses a series of X-ray exposures taken from
different angles. Thanks to computers, these can be integrated to produce a
three-dimensional picture of the brain. CT scanning is routinely used to quickly
diagnose strokes.
12. PET = POSITRON-EMISSION TOMOGRAPHY:
This imaging technique requires that the subject be injected with a
radioisotope that emits positrons.
 water labeled with oxygen-15 (H215O) is used to measure changes in
blood flow (which increases in parts of the brain that are active). The short
half-life of 15O (2 minutes) makes it safe to use.
 deoxyglucose labeled with fluorine-18. The brain has a voracious appetite
for glucose (although representing only ~2% of our body weight, the brain
receives ~15% of the blood pumped by the heart and consumes ~20% of
the energy produced by cellular respiration when we are at rest). When
supplied with deoxyglucose, the cells are tricked into taking in this related
molecule and phosphorylating it in the first step of glycolysis. But no further
processing occurs so it accumulates in the cell. By coupling a short-lived
radioactive isotope like 18F to the deoxyglucose and using a PET scanner,
it is possible to visualize active regions of the brain.
The images above (courtesy of Michael E. Phelps from Science
211:445, 1981) were produced in a PET scanner. The dark areas are
regions of high metabolic activity. Note how the metabolism of the occipital
lobes (arrows) increases when visual stimuli are received.
Similarly, sounds increase the rate of deoxyglucose uptake in the
speech areas of the temporal lobe.
The image on the right (courtesy of Gary H. Duncan from Talbot, J. D.,
et. al., Science 251: 1355, 1991) shows activation of the cerebral cortex by
a hot probe (which the subjects describe as painful) applied to the forearm
(which forearm?).
Most cancers consume large amounts of glucose (cellular respiration
is less efficient than in normal cells so they must rely more on the
inefficient process of glycolysis). Therefore PET scanning with 18F-
fluorodeoxyglucose is commonly used to monitor both the primary tumor
and any metastases.
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13. MRI = MAGNETIC RESONANCE IMAGING:
This imaging technique uses powerful magnets to detect magnetic molecules
within the body. These can be endogenous molecules or magnetic substances
injected into a vein.
14. FMRI = FUNCTIONAL MAGNETIC RESONANCE IMAGING:
fMRI exploits the changes in the magnetic properties of hemoglobin as it
carries oxygen. Activation of a part of the brain increases oxygen levels there
increasing the ratio of oxyhemoglobin to deoxyhemoglobin.
15. THE PROBABLE MECHANISM:
 The increased demand for neurotransmitters must be met by increased
production of ATP.
 Although this consumes oxygen (needed for cellular respiration),
 it also increases the blood flow to the area.
 So there is an increase — not a decrease — in the oxygen supply to the
region, which provides the signal detected by fMRI.
16. MAGNETOENCEPHALOGRAPHY (MEG):
MEG detects the tiny magnetic fields created as individual neurons \"fire\" within
the brain. It can pinpoint the active region with a millimeter, and can follow the
movement of brain activity as it travels from region to region within the brain.
MEG is noninvasive requiring only that the subject's head lie within a helmet
containing the magnetic sensors.
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2.2.11 CRANIAL NERVES:
The cranial nerves are composed of twelve pairs of nerves that emanate from the nervous
tissue of the brain. In order reach their targets they must ultimately exit/enter the cranium
through openings in the skull. Hence, their name is derived from their association with the
cranium. The function of the cranial nerves is for the most part similar to the spinal nerves,
the nerves that are associated with the spinal cord. The motor components of the cranial
nerves are derived from cells that are located in the brain. These cells send their axons
(bundles of axons outside the brain = a nerve) out of the cranium where they will ultimately
control muscle (e.g., eye movements) , glandular tissue (e.g., salivary glands) or specialized
muscle (e.g., heart or stomach). The sensory components of cranial nerves originate from
collections of cells that are located outside the brain. These collections of nerve cells bodies
are called sensory ganglia. They are essentially the same functionally and anatomically as
the dorsal root ganglia, which are associated with the spinal cord. In general, sensory
ganglia of the cranial nerves send out a branch that divides into two branches: a branch that
enters the brain and one that is connected to a sensory organ. Examples of sensory organs
are pressure or pain sensors in the skin and more specialized ones such as taste receptors
of the tongue. Electrical impulses are transmitted from the sensory organ through the ganglia
and into the brain via the sensory branch that enter the brain. There are two exceptions to
this rule that should be noted when the special senses of smell and vision are discussed. In
summary, the motor components of cranial nerves transmit nerve impulses from the brain to
target tissue outside of the brain. Sensory components transmit nerve impulses from sensory
organs to the brain.
Facial expression, wrinkle forehead, taste anterior
I- Olfactory- Smell VII- Facial - tongue
II- Optic- Vision acuity VIII- Vestibulocochlear - Auditory acuity, balance and postural responses
III- Oculomotor - Eye function IX- Glossopharyngeal - Taste on posterior 33% of the scale
IV- Trochlear - Eye function X- Vagus - Cardiac, respiratory reflexes
Sensory of the face,
V- Trigeminal - chewing XI- Spinal Accessory - Strength of trapezius and Sternocleidomastoid muscles
VI- Abducens - Eye function XII- Hypoglossal - Motor function of the tongue
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to recall by Mullsons Health & Wellness at any time.
2.2.12 SEGMENTAL TESTING:
Muscle test and Reflex
C5 - Deltoideus and Biceps
C6 - Biceps and Brachioradialis
C7 - Triceps and Triceps
C8 - Finger flexors and None
T1 - Intrinsics and None
L4 - Tibialis ant and Knee jerk
L5 - Ext hall long and None
S1 - Peroneus and Achilles tendon
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.3 CARDIOVASCULAR PHYSICAL THERAPY
Cardiovascular disease is not one condition. Rather, it is a name used to describe conditions
and diseases that affect the heart (\"cardio\") and blood vessels (\"vascular\") throughout the body.
There are more than 60 types of cardiovascular disease, ranging from the common (coronary heart
disease) to the not so common (tetralogy of Fallot). Some cardiovascular conditions are present at
birth, while others develop over many years. When talking about symptoms of cardiovascular
disease, it is not possible to provide a list, because each condition can have so many different
symptoms.
That being said, while cardiovascular disease can occur anywhere in the body, it does tend to
occur more frequently in the:
 Heart  Brain  Legs  Pelvis
2.3.1 SYMPTOMS AFFECTING THE HEART:
There are a number of different types of heart disease. The most common is coronary
heart disease (also called coronary artery disease). Coronary heart disease is the number
one cause of death in the United States. If the arteries that supply the heart with blood,
called the coronary arteries, are affected by coronary artery disease, you may have
symptoms that include:
 Chest pain or chest discomfort (angina)
 Pain in one or both arms, the left shoulder, neck, jaw, or back
 Shortness of breath
 Dizziness
 Faster heartbeats
 Nausea (feeling sick to your stomach)
 Abnormal heartbeats
A. HEART DEFINITIONS:
Coronary Circulation
RCA = Right Coronary Artery
LCA = Left Coronary Artery
LAD = Left Anterior Descending (one of main division of LCA)
Circ = Circumflex (other of main division of LCA)
Hemodynamics
HR = Heart Rate (number of heartbeats per minute)
SV = Stroke volume (normal about 70ml)
LVEDV = Left Ventricular End Diastolic Volume
CO = Cardiac output (amount of blood discharged per minute) -> SV x HR (nor = 6 to 7 l)
LVEDP = Left Ventricular End Diastolic Pressure (pressure in LV during diastole)
EF = Ejection Fraction (percentage of blood emptied from the ventricle during diastole;
clinically useful measure of LV function) --> SV/LVEDV; normal 60 to 70%
MVO2 = Energy cost to myocardium; measured by HR x SBP (=RBP)
RBP= Rate Pressure Produce
SBP = Systolic Blood pressure
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.3.2 SYMPTOMS AFFECTING THE BRAIN:
Arteries in the brain are most affected by two types of cardiovascular disease: build up of
plaque (atherosclerosis) and arterial embolism, which is when a blood clot gets stuck in a
small artery within the brain. If the arteries that supply your brain are affected by either of
these conditions, you may have symptoms of a stroke or a transient ischemic attack (also
referred to as a TIA or \"mini-stroke\").
Specific stroke and TIA symptoms can include:
 Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
 Sudden confusion or trouble speaking or understanding speech
 Sudden trouble seeing in one or both eyes
 Sudden dizziness, difficulty walking, or loss of balance or coordination
 Sudden severe headache with no known cause.
2.3.3 SYMPTOMS OF CARDIOVASCULAR DISEASE IN THE LEGS, PELVIS, OR ARMS:
If the arteries that supply your legs, pelvis, or arms are affected by cardiovascular disease,
you have symptoms of peripheral arterial disease (PAD). These symptoms can include:
 Claudication, which is a pain, ache, or cramp in the muscles. It occurs during exercise
and improves with rest.
 Cold or numb feeling in the feet or toes, especially at night.
2.3.4 EXERCISE FOR THE PREVENTION AND MANAGEMENT OF CARDIOVASCULAR
DISEASE:
Cardiovascular exercises are exercises that help to make your heart and lungs stronger
and healthier.
Your heart is a muscle, a lot like all the other muscles in your body. It pumps blood to and
from your organs, joints, and everywhere else in your body. When you are sleeping or lying on
the couch, it does not have to work very hard to pump the blood. When you stand up and move
around it has to work harder to pump blood.
Since your heart is a muscle, it can be \"out-of-shape\" just like the rest of your body. If your
heart is \"out-of-shape\" than it cannot pump the blood that it needs to, even when you are
performing easy activities.
It is common for people to have a heart attack when they shovel the driveway after the first
snowfall. This is usually because the person is not very active and shoveling a driveway is a
very strenuous activity. The heart cannot pump fast enough, and therefore a heart attack
occurs. If your heart is strong and healthy, it can pump blood with little effort whether you are
resting or doing an activity. It can compensate easily when it is worked harder while you shovel
snow, garden, clean the house, or walk down the street.
Your lungs also need to be strong and healthy in order to avoid injury. Your lungs exchange
oxygen and carbon dioxide to and from the blood in order to get the correct nutrients to all your
organs. Phlegm is made in the lungs to help protect them from diseases. When people are
inactive, phlegm sticks in the lungs and infections are more likely to occur. Carbon dioxide and
oxygen does not get in and out as easily and as a result it is harder to breathe.
Cardiovascular exercises have many positive effects on your health. Some of these are:
 Increase the strength of your heart muscle
 Increase the strength of the muscles that help you breathe
 Decrease your blood pressure and heart rate
 Decrease your cholesterol
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 Increase your whole body's strength and endurance
 Increased your body's resistance to infection
 Decrease feelings of being \"stressed\", increase your sense of well being, and increase your
concentration
Cardiovascular exercises can be activities like biking, walking, running, swimming, and
much more. They need to increase your heart rate and keep it elevated for 20 - 40 minutes of
exercise. There are many health conditions that require a change in this exercise regimen.
Some conditions may require an easier exercise, less time doing exercises, changes to make
the exercise safer, or professional supervision. Physiotherapists are very knowledgeable about
illnesses and injuries and can educate their patients about the safest mode of cardiovascular
exercise for them. They can also help their patients learn methods to fit exercise into their
lifestyle.
2.3.5 ETT:
ETT = exercise tolerance test (Maximal=to max heart rate, Submaximal=symptom limited)
Symptom limited ETT for Phase II, outpatient cardiac rehab.
Signs and symptoms of exertional intolerance:
1. Persistent dyspnea
2. Dizziness or confusion
3. Anginal pain
4. Severe leg Claudication
5. Excessive fatigue
6. Pallor, cold sweat
7. Ataxia, in coordination
8. Pulmonary rates
PERSISTENT
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to recall by Mullsons Health & Wellness at any time.
2.3.6 CARDIOLOGY:
 (This topic is from Nagmamaru (Physical Therapy Forum). He did a really good job
explaining the importance of cardiology.)
 First you have to know the function of the heart as a vital organ. Make sure you know
the circulation of blood from inf and superior vena cava to aorta. The heart sound will
be produced on CLOSURE of valves, that S1 correspond to closure of Mitral and
tricuspid valve and not Aortic and pulmonic valve which is your S2.They both occur
during systole or ventricular contraction.
 S1 marks the beginning of rapid ejection of blood so your aorta should be open! It
make sense right?S3 sound is associated with CHF(3 letter) and S4 for MI and
hypertension also known as atrial kick associated with hypertrophied ventricle, both
occur on diastole, with S3 produced after S2 and S4 before S1.S1 starts while blood is
pump out so to prevent back flow mitral valve should be close, once blood is ejected
and volume decreases mitral valve should open to refill(inc. PRELOAD) and to create
an increase pressure inside the heart for contraction to be effective (frank starling
law)aorta should be closed(S2).just remember its the closures of the valves that
creates the sound( as in closing door when your mad (BANG!!),hard to produce sound
when you open)).Should be remembered coz when you panic or get nervous you might
forget.
 Nothing much to know about coronary circulation except for (R) coronary artery that
supplies most(80%) of your SAnode(pace maker of the heart) and AV node as injury
can cause a fatal arrhytmia. Coronary arteries fill during DIASTOLE contrary to other
organs that fills during Systole. Most posterior part of heart is left atrium and
enlargement can cause dysphagia. The apex beat is located at 5th ICSLMCL, its the
most reliable way to assess heart rate when peripheral pulses are absent, too weak or
inaccessible. Make it a practice to appreciate abnormal heart sound and for accuracy
for patient with very weak pulses or having atrial/ventricular fib may present with
normal palpable pulses. Elderly have collapsable artery (pulse) not good to assess if
with heart condition. Brachial pulse is best for assessment in kids.
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 You should know the formula for blood pressure to understand the diseases esp CHF
and effects of meds on management of hypertension. Remember that BP is the
amount of pressure that the heart should have to pump the blood and distribute it to
circulation.
 BP=Cardiac output (CO) x total peripheral resistances (TPR)
 Your CO=stroke volume x HR. Your Stroke volume is the amt of blood inside the heart
being pump per contraction, Your TPR represents the resistance to blood flow primarily
due to arteries/arterioles which is your resistance vessels (remember how
atherosclerosis or hardening of your arteries lead to hypertension!).Stroke volume is
primarily dependent on the amount of blood that goes in your heart, the veins which is
your capacitance vessels, and the fluid both plasma and serum component of blood. It
is also dependent on how strong your heart contracts (contractile property of heart loss
in CHF).
 Now, what are the common meds and how they work? Initial management or meds will
include your diuretics (what makes you urinate) this should decrease the preload or
fluid that goes in as CO (same amt with what goes in)a little of after load(the load
similar to TPR).Should watch out for fainting or dizziness with sudden drop of BP.
Strong diuretics like LASIX (furosemide) can even include deafness bec. of loss of fluid
in your circular canal, or loss of potassium leading to arrythmia and weakness.
 2nd line is Beta blockers (those with OLOL, propranolol (inderal) metoprolol,atenolol,..)
will decrease BP by decreasing HR and force of contraction(dec. INOTROPIC
property).And since its a beta blocker it should be used with caution in patient with
asthma(treatment for asthma is beta agonist like albuterol)Should know that Beta 1 is
for the heart(u only have 1 heart) and beta 2 for Lungs(2 lobes) particularly on your
bronchus. In DM, beta blockers can masked the effect of TACHYCARDIA as sign of
hypoglycemia, you might think that your patient have normal HR but his HR without
beta blockers might be already more than 100.It can also increase blood glucose level.
Use RPE on exercise assessment instead of HR that is use on most cases. Other
relative or absolute CI is PVD, since it has an effect on smooth ms lining your
peripheral vessels leading to compromise blood flow.
 So, 3 things to remember: Asthma, DM and PVD. Learn the rationale so you wont
forget!
 May include CHF as CI but remember that it can be use once STABLE not on ACUTE
cases (previous and recent studies shows that like ACEI it can decrease mortality and
morbidity in post MI and CHF including HTN)
 Consistent effects of beta-blockers are dec. in BP and HR but for those with sudden
drop in BP a compensatory tachycardia may appear. FYI there is beta-blockers that
are selective and affect only B1 receptors, relatively safe for those with previous
condition that are CI.
 Popular drug like ACE inhibitors (CAPTOPRIL) which prevent conversion of
Angiogenesis I to angiotensin II which is a potent vasoconstrictors (inc. TPR) and
decrease preload like diuretics due to decrease production of aldosterone (salt
production Na (sodium)) Most common side effect is dry COUGH due to persistent
bradykinin production, may be present for several weeks ,may or may not persist.
Replace with ARB (angiotensin receptor blocker) those with SARTAN, no SE of cough.
Directly block receptors of Angiotensin II. Both are not safe for pregnant, teratogenic
effect bec. The fetus needs AII for renal development. Renal protective and prolong life
in DM and MI. May increase level of potassium in combination with
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SPIRINOLACTONE (Aldactone) a potassium sparing diuretics different from other
diuretics that dec.level of potasium, can also lead to arrhytmia. (brady arrhytmia)
remember potassium equals Repolarization!
 Other not so important meds: vasodilators/calcium channel blockers-blocks calcium
and relaxes arteries leading to vasodilation, (calcium equals contraction) some have
effect on veins decreasing preload, more blood remains on the capacitance vessels not
on the heart(nifedipine,hydralazine-can cause drug induced SLE,verapamil-
constipation).
 Alpha 1 blockers/antagonist-prevent release of NE (norepinephrine)-Prazosin
(MINIPRESS) known for the SE of FIRST DOSE EFFECT or sudden drop of BP
leading to syncope.
 Alpha II AGONIST (the only adrenergic agonist) Clonidine (CATAPRESS)
facilitates/stimulates reuptake of NE not to be release in presynaptic terminals.
Decrease TPR.SE includes sudden withdrawal lead to rebound hypertension.
 Remember that common cough and cold preparation that contains phenylephrine,
phenylpropanolamine (PPA) can cause hypertension due to their vasoconstrictive
effect in preventing congestion. TCA (tricyclicantidepressant) Amitryptylin (ELAVIL),
migraine (DOFRANIL)- can increase NE, serotonin and dopamine, which are dec. in-
patient with depression, but they also block alpha-adrenergic receptors (leading to
HYPOTENSION) and histamine leading to SEDATION. More reasons to get depress if
you fail to monitor vitals...
 Remember that you have Baroreceptors and chemoreceptors that regulate your HR
and BP. your Baroreceptors includes your carotid SINUS and aortic arch.
 Carotid sinus transmits via GLOSSOPHARYNGEAL nerve to medulla. Your AORTIC
arch transmits via VAGUS to medulla (respond only to increase in BP) vagus as
parasympathetic will dec. HR and BP. Carotid massage thru increase pressure in
carotid will stimulate Vagus leading to dec. HR then BP. Simply stated when you have
increase BP your parasympathetic response will be activated (dec. BP, contraction and
HR) and reverse with dec. BP as you activate your sympathetic or as you decrease
stimulation of parasympathetic signals coming from afferent receptors (CN 9 and
10)take note that 10 or vagus has also an efferent signals coming from medulla.
 REMEMBER that when you examine patency of carotids does it one at a time not
simultaneously or patient will faint. Wearing a turtle neck that’s to tight may do the
same thing. Other reason why strangulation lead to loss of consciousness.
 Remember that your medulla oblongata has CARDIOINHIBITORY (parasympathetic
via vagus nerve) as well as CARDIOACCELARATORY centre (sympathetic or
adrenergic via T1-T4 releasing NE and Epinephrine).
 Chemoreceptors from carotid and aortic BODIES which responds to dec. in PO2,inc.
CO2 and dec. ph.(acidosis).
 In response to cerebral ischemia (more of inc. in CO2 than dec. in O2) your body will
inc. ICP and inc. BP and HR as sympathetic response but with dec. in HR as O2 level
increases.
 Some terms to remember: Chronotropic describes property on inc. HR (chrono=time)
Inotropic (contractility) Dromotropic (pressure).
NOTE:
Additional info on anatomy, you should remember that Pulmonary artery and umbilical
arteries (foetal circulation) carries UNOXYGENATED blood contrary to other arteries that
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carries oxygenated blood(most O2 has been used once it pass the capillaries)same goes
with pulmonary and umbilical vein.
A. ANGINA:
 Angina is defined as chest pain due to ischemia, what makes it important is the
fact that it usually mark an impending or possible INFARCTION (cell death due to
necrosis or irreversible damage to myocardium) It is an imbalance of myocardial
oxygen supply and demand. Anything that use up Oxygen beyond the capacity of
the heart or impede flow can lead to ischemia.nicotine is a potent vasoconstrictor
and promoter of atherosclerosis together with LDL(the bad cholesterol,you go
down when your BAD, goes up to Heaven when good \"HDL\")Overeating can
increase blood flow to GIT compromising the coronary circulation, extreme cold
lead to vasoconstriction and heat can use up more O2.In hyperthyroidism there’s
an inc. in metabolic rate causing increase in oxygen demand leading to
tachycardia then heart failure or ventricular fibrillation the most common cause of
death.(Remember that TSH from pituitary should decrease as negative feedback
to INCREASE T3 and T4 which are your thyroid hormones produce by thyroid
gland which produces the s/sxs.(intolerance to heat coz already hot, decrease
weight in spite of increase in appetite, diarrhoea, etc.. ).
 Stable angina or sometimes called EXERTIONAL angina is ischemia that occur
during activity and relieved by vasodilator particularly NITROGLYCERIN (usually
less than 20min up to 3 doses if it persist possible MI).Appear at PREDICTABLE
Rate and Pressure product(RPR=HR x BP)which signifies myocardial work or
oxygen consumption and compensation.
 Unstable angina occurs with unpredictable RPR, still relieved by nitro-glycerine but
may take longer and higher risk for MI. To be precise any change in intensity and
occurrence (with rest or with effort) base from baseline should be considered as
UNSTABLE.
B. SILENT MI OR PAINLESS MI:
 Can occur on patient with DM (25%) due to neuropathy. Levine sign is when
patient put his fist on his chest as sign of severe chest pain may either be angina
or infarction (pain describe as impending doom or elephant sitting on chest)
 Myocardial infarction is permanent damage or irreversible damage to myocardium.
Can be full thickness (TRANSMURAL or Q wave infarct) or partial thickness,
subendocardium, subepicardial, itramural (Non Q wave MI). Usually the first
diagnostic test done in first 6 hrs is ECG or EKG (for European terminology) which
describes classic features such as ABNORMAL Q (for non ST elevation MI) ST
elevation for injury (remember that your prone to injury when your elevated) but
can also be for MI(ST elevation MI).
 T wave inversion for ischemia (Think of a cup that u INVERT, like ischemia
decrease in blood flow).
 Also remember that for ECG; P wave for atrial contraction/depolarization,QRS for
Venticular Depolarization,T wave for Ventricular Repolarization/Relaxation,so
what’s missing? ATRIAL Repolarization which occur at the same time as
Ventricular Depolarization that’s why its hidden in QRS.
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 Important ECG findings include loss or flattening of T wave or for severe
HYPOKALEMIA the appearance of \"U\" wave, HYPOKALEMIA (decrease in
Potassium), remember to associate T wave for K and REPOLARIZATION.
 Peaked or tall Twaves for HYPERKALEMIA, both may produced tachyarrhytmia,
atrial tachycardia for hypo and ventricular tachy or fibrillation, asystole for
Hyperkalemia.
 Prolong QT for hypocalcemia, and shortened QT interval for Hypercalcemia. Other
ECG findings may appear on different electrolyte imbalance but those mentioned
are CLASSIC, most common findings. Most common cause of death in MI is
ventricular fibrillation; the necrotic tissue will prevent the synchronus entry of
impulse producing short circuit and re-entry.
 Most common enzymes studies done includes CK MB (remains to be the gold
standard, with increase sensitivity, appear at 12-24 hrs after infarct present in
cardiac ms, and skeletal ms, disappear 2-3 days after) FYI the most SPECIFIC
enzyme is TROPONIN I present only on cardiac ms and appears earlier after 4hrs
but disappear after 10-14 days, the reason why CK MB remains to be the gold
standard is the fact that REINFARCTION is common to occur on the first week and
may not be detected by TROPONIN I which may still be at its peak level. Other not
so important enzymes includes CK a, SGOT and LDH.
 Also remember that MI is not common in patient younger than 35 y/o and other risk
factors includes: Obesity, hyperlipidemia (increase LDL, inc in HDL is cardio
protective), smoking, HTN, DM, inactivity, stress(type A personality have greater
risk of getting CAD or MI),increase Ho mocystine level.
 Non modifiable risk factors include age, race(black),gender(male)and family history
of CAD or heart disease. Don’t forget that a young athlete who had a sudden death
due to heart failure/attack may be suffering from HYPERTROPIC Cardiomyopathy.
Patient leaning forward to relieve pain that previously has viral infection may be
suffering from Pericarditis. Pain aggravated by trunk movement or tender on
palpation may have costochondritis. Associated with sour taste and relieved by
antacids may have PUD or GERD. Anxious and hyperventilating may interpret
SOB as pain may have HYPERVENTILATION syndrome aka HYSTERIA treated
not with oxygen (coz breathing stimulus is inc. CO2 not O2, he got more than
enough O2) but treated with breathing on brown non collapsable bag to breathe
the exhaled CO2, if you hate the person use plastic to cover the head(just kidding).
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to recall by Mullsons Health & Wellness at any time.
C. ANSWER THE QUESTIONS:
1. Define hypertension. What is the normal Blood Pressure as defined by recent JOINT
NATIONAL COMMISION on Hypertension (JNC 7).
2. Conditions needed before you make a diagnosis of hypertension.
3. Differentiate primary and secondary hypertension.
4. What are the common conditions for secondary hypertension?
5. Treatment for primary and secondary Hypertension.
 Hypertension is defined as PERSISTENT increase in BP with systolic greater or
equal to 140 or Diastolic Pressure of greater or equal to 90 mmHg.
 Normal BP <120 systolic and < 80 diastolic
 Prehypertension 120-139 S and 80-89 D
 Stage I 140-159 S and 90-99 D
 Stage II =or>160 S and =or>100
 It should be taken at least 2-3x on different occasion/situations for you to say its
persistent, before you diagnose Hypertension.
 Other terminologies used for increase BP includes:
 Hypertensive Urgency which is define as isolated increase in BP equal or greater
than 200/120,even on single/first episode and if with symptoms (headache,
papilledema, end organ damage, chest pain, angina, dizziness, BOV, mental
changes SZ)we change the term to HYPERTENSIVE EMERGENCY.
 Just like in a pregnant woman usually after the 20th week of gestation with
hypertension and proteinuria (proteins in urine),leg edema if patient has a change
in BP that is hypertensive we call it PREECLAMPSIA and if associated with
SEIZURE we call it ECLAMPSIA. Don’t forget this terminology coz its a common
condition and a must know.
 Believe it or not PREGNANT woman should have a decrease in BP from baseline
non pregnant state, despite an increase in Cardiac Output (approx.50%,due to
increase in plasma and HR) but a marked decrease in TPR due to an additional
PARALLEL circuit that was added to the circulation which comprises your placental
circulation.(remember the parallel and series of resistance in electro and physio?
when adding resistance or resistors in series the total is the sum of all the
individual resistance or greater than individual circuit and when parallel the
opposite. The total is always less than the individual circuit.)
If BP is 120/90 or 140/70 is/are this classified as HTN?
 Yes if taken more than 2-3x,no if not. The worst number is always to be considered
whether the Systolic or Diastolic. If your answer is right then for sure you
understand the concept.
 FYI elderly usually present with higher SYSTOLIC and normal Diastolic pressure
and we call it ISOLATED SYSTOLIC HYPERTENSION, studies have shown that
they have a higher risk of dying from stroke and heart attack compared to other
hypertensive individual.
 90-95 % of hypertension is classified as Primary or ESSENTIAL hypertension,
usually or most of the time its asymptomatic (what makes a STROKE a silent killer)
there’s no known cause aside from the fact that as we grow old our arteries
become non or less compliant, increasing the resistance of blood flow leading to
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increase in BP as the heart tries to maintain its function of maintaining a functional
ejection fraction to distribute blood on our organs.
 5-10% comprises your SECONDARY hypertension which is due to any disease
(structural , hormonal or even meds)that may contribute to increase in BP, usually
present on young individual <30-35 y/o associated with other s/sxs. Ex. Includes:
Hyperthyroidism (systolic hypertension with wide pulse pressure), Cushing,
Pheochromocytoma (episodic increase in BP due to inc. NE,E, adrenergics,
assoc. with flushing, palpitations etc),adrenal tumors, Coarctation of the
AORTA(present with HIGH BP on UE's and LOW BP on LE'S)Renal failure, Conns
dse (hyperaldosteronism), polycystic kidney dse, or even medications and
drugs(oral contraceptives-should be stopped, cocaine, thyroxine or thyroid
hormones, NSAID's(due to decrease production of a type of prostaglandins that
promotes vasodilation) phenylephrine or decongestant preparations.
 The treatment for Primary hypertension includes life style modification (low salt,
high fiber, stop smoking) with failure of LM after 6 mos-1 yr combine with
antihypertensive medications such as sympatholytics (beta-blockers, ACEI's,
calcium channel Blockers .. etc) and diuretics. May start immediately with meds if
with target organ damage or hypertensive emergency/urgency.
 The target or goal of BP management is <140/90,0r <130/80 for patient with DM,
Renal disease, or cardiovascular disease.
 While for secondary causes would usually involve surgery or by treating the
secondary cause(stop meds).Most are resistant to antihypertensive medications.
 Hypotension is usually define as Systolic less than 90 mmhg, or diastolic lower
than 60mmHg.Relative hypotension is decrease of equal or greater than 30mmHg
on systolic. For those with previous ischemia or MI, or heart failure its better to
maintain your diastolic at 70 for not to compromise coronary blood flow.
Incorporate the concepts in your practice. Should refer to MD for management if
with symptoms or persistent for further management.
 Remember that Vital signs are VITAL and we should treat it the same way...in short
take the vital signs of your patients!
 Fist you have to know the normal values of the ff:
 Ph(7.35-7.45),Pco2(35-45),HCO3(22-28).
 Believe me this is enough dont worry about the PO2.
 Remember that you should get the serum pH first then if its below 7.35 its
ACIDOSIS. Greater than 7.45 its ALKALOSIS.
 The pH is inversely proportional to Hydrogen meaning when you increase H you
dec. pH. An increase in CO2 will lead to decrease in pH or ACIDOSIS and an
increase in HCO3(bicarbonate-neutralize acid)lead to ALKALOSIS.
 Always associate CO2 with RESPIRATORY and HCO3 with METABOLIC.
 Increase in CO2=ACIDOSIS Increase in CHO3=ALKALOSIS
 HYPERVENTILATION and anything that increase your breathing or RR will BLOW
off your CO2 leading to RESPIRATORY ALKALOSIS.
 HYPOVENTILATION and anything that will decrease your RR will lead to retention
of CO2 leading to RESPIRATORY ACIDOSIS.
 If the primary cause of the problem is breathing we call it
 RESPIRATORY then it could either be acidosis or alkalosis depending on the
serum pH and of course if its not respiratory its METABOLIC.
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D. ANSWER THE CONDITIONS AS TO METABOLIC/RESPIRATORY, ACIDOSIS
/ALKALOTIC.
 Vomiting, hypocalcemia, diuretic abuse, anorexia and bulimia
 Laxative abuse, anti PUD meds,
 Diarrhoea, Renal failure,
 DM/DI, burn, malnutrition, hyperkalaemia, alcohol, salicylate intoxication or aspirin
intoxication.
 Asthma, COPD, GBS, MG, Parkinson’s, asbestosis, scoliosis, chronic bronchitis,
emphysema, post abdominal surgery. Opioids and barbiturates intoxication,
excessive anaesthesia.
 Pneumonia, pulmonary embolism, anxiety, pregnancy, liver disease
(hepatomegaly), sepsis, fever, cystic fibrosis, pneumothorax, atelectasis.
 What you have to remember is the fact that acid loss will lead to relative increase
in HCO3 leading to ALKALOSIS, when its bicarbonate its Metabolic, so for number
1. Its METABOLIC ALKALOSIS, your vomitus is sour bec. Its acid, your ions like
potassium and the electrolyte that goes with your acidic urine is acid.
2. Laxative abuse lead to alkalinization and hypocalcemia and anti ulcer medications
neutralizes your acid in your stomach leading to Met. Alkalosis.
3. When you pooh you have loss of bicarbonate that goes with your faeces. Imagine
if its acid, ouch!!! So its MET. ACIDOSIS. Renal failure leads to accumulation of
acids that cannot be excreted or decrease in bicarbonate production.
4. Stress (injury or burns) leads to production of LACTIC ACID, DM/DI leads to
metabolic acidosis due to production of ketones and effects of hyperglycaemia,
same goes with hyperkalaemia. Don’t confuse yourself on DI that urinates and
become dehydrated, remember that the urine in-patient with DI9DM type I) is hypo
tonic and they are hypernatremic. Retaining acids. So, Metabolic
ACIDOSIS.ASPIRIN is acid although it can stimulate your respiratory center to
hyperventilate leading to respiratory alkalosis but its dominantly metabolic acidosis
the reason why you might get a normal pH for this case.
5. Most respiratory conditions esp. COPD(expiratory difficulty) and restrictive lung
disease, breathing muscle paralysis or weakness, including meds with effects on
decreasing RR will lead to accumulation of CO2 leading to RESPIRATORY
ACIDOSIS.
6. Anything that will increase your breathing such as FEVER, sudden collapsed of
lung segment, non obstructive hyperventilation, hysteria or hyperventilation
syndrome (classic example of RESPIRATORY ALKALOSIS with tetany due to
relative hypocalcemia) Pneumonia almost always have fever, liver disease and
pregnant state produces progesterone that stimulate breathing. The classic case of
pulmonary embolism in post surgical patient who suffered fracture of the neck of
femur,2 days after had symptoms of tachypnea and die of PE due to fat embolism
or post partum with meconium aspiration.All of these will blow off your CO2 leading
to Respiratory Alkalosis.
Best to remember the pulmonary conditions that leads to respiratory ALKALOSIS then
the other respiratory conditions will be ACIDOSIS.
What does flaccidity tell you about your cardiovascular health?
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ANGINAL PAIN
DIZZINESS OR
CONFUSION
EXCESSIVE FATIGUE
SEVERE LEG
CLAUDICATION
PULMONARY
PALLOR, COLD
ATAXIA, IN CO ORDINATION SWEAT
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2.4 PULMONARY PHYSICAL THERAPY:
This lung disease is often associated with certain jobs such as miners, welders, and
construction workers. This is because inhaling dusts such as coal dusts and asbestos can cause
pulmonary fibrosis. It can also be caused by genetics, meaning you were born with it. However,
most commonly, pulmonary fibrosis develops without any known cause.
Pulmonary fibrosis is a disease where scar tissue develops in the lungs following many
infections and swelling. The scar tissue causes the lungs to become more stiff than normal. This
means that the lungs cannot expand like normal, and therefore less air can get in and out of the
lungs. This makes it very hard to breathe.
If inhaling dusts causes the fibrosis, the symptoms can sometimes be reversed by removing
the worker from the harmful environment or by using protective masks. If the worker is exposed for
a long period of time, the effects may be irreversible.
Genetic fibrosis or fibrosis caused by unknown causes, cannot be reversed.
Physiotherapists can help teach you how to manage your disease and how you can decrease
your risks of developing other complications. They can give you tips to help you breathe easier and
increase your ability to perform your normal daily activities.
2.4.1 RESTRICTIVE DISEASES:
Difficulty getting air into the lungs
 Decreased VC; Decreased TLC, RV, FRC
 Fibrosis
 Sarcoidosis
 Muscular diseases
 Chestwall deformities
2.4.2 OBSTRUCTIVE DISEASES:
Difficulty getting air out of the lungs
 Decreased VC; Increased TLC, RV, FRC
 Emphysema
 Chronic bronchitis
 Asthma
2.4.3 ABERRANT BREATHING PATTERNS:
 Apneutic (End inspiratory pause of 2-3 seconds before exhalation; caudal pontine lesions)
 Biot's (Ataxic, random shallow and deep with irregular pauses; disruption of medullary
neural pathways by trauma)
 Cheyne Stokes (TV increases, then decreases irregular, with apneu; increased intracranial
pressure, CVA, head injury, Brain tumors, heart failure, Opiates overdose)
Hyperventilation
 Hypoventilation
 Kussmaul (Deep labored breathing; acidosis)
 Paradoxal (Abdomen and chest do not expand during breathing in; use of help-muscles)
 Wheezing (Narrowing of airways; narrowing of airways)
 Stridor (sounds during breathing, expiratory or inspiratory; possibly alien object in airways)
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2.4.4 PHYSICAL THERAPY MANAGEMENT OF THE PATIENT WITH PULMONARY
DISEASE:
A. CASE TYPE / DIAGNOSIS:
This standard of care applies to any patient with obstructive or restrictive lung disease.
Obstructive lung disease includes emphysema, chronic bronchitis, asthma,
bronchiectasis and cystic fibrosis. Restrictive lung disease includes chest wall stiffness,
deformity due to scoliosis, respiratory muscle weakness secondary to neuromuscular
disease/disorders, tumor, atelectasis, pneumonia, interstitial fibrosis, occupational
disease (mesothelioma), sarcoidosis and pulmonary edema, effusion or embolus.
Patients status post (s/p) thoracic surgery or those who require prolonged intensive
care are not included under this standard of care.
B. INDICATIONS FOR TREATMENT:
 Admission to BWH for a new diagnosis or an exacerbation of an existing
pulmonary disease that leads to impaired motor function, range of motion, and
endurance that affects the patient’s functional independence.
 Admission to BWH for an unrelated illness or surgery and has since developed a
pulmonary dysfunction due to prolonged bed rest and/or as a complication of their
illness or treatment.
 Prevention of deconditioning and complications from bed rest associated with
hospital admission and pulmonary disease.
C. CONTRAINDICATIONS / PRECAUTIONS / CONSIDERATIONS FOR TREATMENT:
I. CONTRAINDICATIONS:
1. Pulmonary Embolism (PE)
a. The following are signs and symptoms of a PE and are indicative of an
emergent medical situation. Notify the RN/MD immediately if the patient
develops any of the following:
 Rapid onset of tachypnea
 Chest pain
 Anxiety
 Dysrhythmia
 Lightheadedness
 Hypotension
 Tachycardia
 Decreased SpO2
b. If you are treating a patient with a known PE, determine whether the
patient is therapeutically anticoagulated prior to treatment. See INR values
below.
c. INR: normal value 0.9 - 1.1, therapeutic range 2.0 – 3.0. Clarify activity orders
from MD if INR > 3.0 Generally therapy will be deferred if INR > 4.0
d. Inferior vena cava (IVC) filter may be placed when patients are at high risk
for developing a new or recurrent pulmonary embolism (PE).
i. Patients are usually on bed rest for 4-6 hours after the procedure. Physical
therapy may resume once activity orders are advanced. INR does not have
to be within therapeutic range after the filter is placed.
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II. PRECAUTIONS:
1. Vital Signs
a. Obtain parameters from the order entry
b. Or if there are none specified, use BWH Rehab Services guidelines:
 HR: 50-120 bpm SBP: 90-150 mmHg
 RR: <30 resting SpO2: > 90%
 Avoid 20 mmHg increase in BP
 Avoid 20 bpm increase in HR
2. Supplemental Oxygen
a. Wean oxygen only with MD order, e.g. “titrate O2 to Sats > 95%,” and
monitor oxygen saturation during treatment as indicated
b. Patients who do not require supplemental oxygen at rest, may require it
with activity.
III. CONSIDERATIONS:
1. Thoracentesis:
a. Percutaneous needle aspiration of pleural fluid. May be used as diagnostic
test or therapeutic procedure to relieve respiratory distress caused by a
large pleural effusion
b. A complication of the procedure may include a pneumothorax. Monitor
oxygen saturation during this treatment.
c. On the day of the thoracentesis, consider scheduling physical therapy
following the procedure and once the patient is cleared by chest x-ray,
since the patient should be less dyspneic with exertion.
2. Bronchoscopy:
a. Flexible scope used for diagnosis or treatment by directly visualizing the
upper airway and tracheobronchial tree.
b. The patient may require increased supplemental oxygen for up to 8 hours
following the procedure and may have decreased activity tolerance. Plan
physical therapy intervention accordingly.
IV. DISEASE SPECIFIC CONSIDERATIONS FOR TREATMENT:
1. For patients with obstructive lung disease focus on slow, prolonged
exhalations, pursed lip breathing, and frequent rest breaks when coughing
2. Patients with restrictive lung disease generally do better with exercises to
improve inspiration, e.g. diaphragmatic breathing, and exercises to improve
chest wall flexibility
V. PULMONARY FUNCTION TESTS (PFT):
1. Expiratory flow rates are a measure of how easily the lungs can be ventilated
and are a good indicator of the progression of COPD.
2. FEV1/FVC = 75-85% of predicted values in healthy individuals
3. Improvement in FVC or FEV1 of greater than 15% is considered significant.
Decrease in FVC or FEV1 of greater than 15% is considered abnormal.
VI. OBSTRUCTIVE SLEEP APNEA:
Sleep apnea, also called obstructive sleep apnea (OSA), is a common disorder
that affects more than 18 million people in the United States. In many of these
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people, the condition is undiagnosed. OSA takes its name from the Greek word
apnea, which means \"without breath.\" People with sleep apnea literally stop
breathing repeatedly during their sleep, often for a minute or longer and as many
as hundreds of times during a single night.
Sleep apnea can be caused by either complete obstruction of the airway
(obstructive apnea) or partial obstruction (obstructive hypopnea—hypopnea is
slow, shallow breathing), both of which can wake one up. There are three types of
sleep apnea—obstructive, central, and mixed. Of these, obstructive sleep apnea
(OSA) is the most common. OSA occurs in approximately 2 percent of women and
4 percent of men over the age of 35.
1. SLEEP APNEA CAUSES:
The exact cause of OSA remains unclear. The site of obstruction in most
patients is the soft palate, extending to the region at the base of the tongue.
There are no rigid structures, such as cartilage or bone, in this area to hold the
airway open. During the day, muscles in the region keep the passage wide
open. But as a person with OSA falls asleep, these muscles relax to a point
where the airway collapses and becomes obstructed.
When the airway closes, breathing stops, and the sleeper awakens to
open the airway. The arousal from sleep usually lasts only a few seconds, but
brief arousals disrupt continuous sleep and prevent the person from reaching
the deep stages of slumber, such as rapid eye movement (REM) sleep, which
the body needs in order to rest and replenish its strength. Once normal
breathing is restored, the person falls asleep only to repeat the cycle
throughout the night.
Typically, the frequency of waking episodes is somewhere between 10 and 60.
A person with severe OSA may have more than 100 waking episodes in a
single night.
Massively enlarged tonsils can cause episodes of cessation of breathing
known as obstructive sleep apnea. Cessation of breathing can last 10 seconds
or longer, causing extremely low levels of oxygen in the blood.
2. RISK FACTORS:
The primary risk factor for OSA is excessive weight gain. The
accumulation of fat on the sides of the upper airway causes it to become
narrow and predisposed to closure when the muscles relax.
Age is another prominent risk factor. Loss of muscle mass is a common
consequence of the aging process. If muscle mass decreases in the airway, it
may be replaced with fat, leaving the airway narrow and soft. Men have a
greater risk for OSA. Male hormones can cause structural changes in the
upper airway.
Other predisposing factors associated with OSA include:
 Anatomic abnormalities, such as a receding chin
 Enlarged tonsils and adenoids, the main causes of OSA in children
 Family history of OSA, although no genetic inheritance pattern has been
proven
 Use of alcohol and sedative drugs, which relax the musculature in the
surrounding upper airway
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 Smoking, which can cause inflammation, swelling, and narrowing of the
upper airway
 Hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post-polio
syndrome, neuromuscular disorders, Marfan's syndrome, and Down
syndrome
 Nasal congestion
 Studies have shown that the risk for obstructive sleep apnea is higher in
patients who have recently experienced a heart attack. Some physicians
recommend OSA screening in heart attack patients.
3. SIGNS AND SYMPTOMS:
The signs and symptoms of OSA result from disruption of the normal
sleep architecture. The frequent arousals and the inability to achieve or
maintain the deeper stages of sleep can lead to excessive daytime sleepiness,
non restorative sleep, automobile accidents, personality changes, decreased
memory, erectile dysfunction (impotence), and depression.
Patients rarely complain about frequent awakenings due to obstruction,
but awakenings do occur. Excessive daytime sleepiness may be mild or
severe, depending on the severity of the obstruction. In some cases, patients
continue to experience excessive daytime sleepiness while they are being
treated for obstructive sleep apnea.
Some patients suffering from OSA fall asleep in a non stimulating
environment, such as while reading in a quiet room. Others may fall asleep in a
stimulating environment, such as during business meetings, eating, and even
while having sex. Patients with OSA often complain of waking up feeling like
they had never slept at all. They often feel worse after taking a nap than they
did before napping.
The so-called drowsy driver syndrome, which a growing number of law
enforcement authorities believe to be responsible for many automobile
accidents, may result from OSA, which causes some drivers to fall asleep at
the wheel or to suffer from lack of alertness because of sleep deprivation.
Decreased alertness places a person at risk in a variety of potentially
hazardous situations. It is recommended that persons with excessive daytime
sleepiness not drive or operate dangerous equipment until their condition is
effectively treated. Other symptoms of OSA, such as morning headaches and
frequent urination during the night, may be caused by apneic events
themselves.
The physical signs that suggest OSA include loud snoring, witnessed
apneic episodes, and obesity. Patients with OSA often say that their only
problem is that their bed partner complains about their snoring. A large number
of snore’s are believed to have OSA. Many times, a sleep partner will witness
an apneic event.
Hypertension is prevalent in patients with OSA, although the exact
relationship is unclear. It has been shown, however, that treating OSA can
modestly lower blood pressure.
Not everyone who snores has sleep apnea, but if two or more of the above
symptoms are present the person should consider consulting a sleep
specialist. A high score on the Epworth Sleepiness Scale is also a strong
indicator of possible sleep apnea.
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4. OSA COMPLICATIONS:
The most obvious complication arising from OSA is diminished quality of
life brought on by chronic sleep deprivation and symptoms of the condition.
Coronary artery disease, cerebral vascular accidents (strokes), heart attack,
and congestive heart failure are being evaluated to define the exact nature of
their connection to OSA.
Some linkage between OSA and coronary artery disease, heart attack,
and stroke has been demonstrated, although it is still uncertain whether OSA
leads to an increased risk for these conditions or if both OSA and
cardiovascular problems are caused by a common problem, such as obesity.
Obstructive sleep apnea aggravates congestive heart failure by placing
stress on the heart during sleep. There is a high prevalence of OSA in patients
with congestive heart failure. Congestive heart failure patients also may have
central sleep apnea, a condition in which the brain signals the patient to stop
breathing for short periods of time.
Recent studies have indicated that there may be a link between OSA and
complications following surgery. Post-surgical complications may result from
disruptions in breathing caused by obstructive sleep apnea.
5. SLEEP APNEA DIAGNOSIS:
The primary method for diagnosing OSA at present is to have the patient
undergo a sleep study, known as polysomnography.
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A sleep technician administers and attends the study. To prepare the
patient for sleep study, numerous physiological monitors are attached to the
patient to record nighttimes breathing, brain activity, and physical activity.
Several electrodes are pasted to the patient's head to measure brain electrical
activity with an electroencephalogram, or EEG. Electrical activity in the brain
during the different stages of sleep is distinctly different from that while awake.
The EEG allows the physician to see if the patient is reaching all the stages of
sleep to the appropriate depth and if the patient is being aroused excessively
from these stages.
Electrodes are also taped to the skin near the outer edges of the eyes to
record data for an electrocculogram (EOG). This tells the examiner where the
patient is in rapid eye movement sleep (REM). A device is placed near the
patient's nose and mouth to measure airflow. Electrodes are connected to an
electromyogram (EMG) and taped or pasted on the patient's chin to detect
activity in the jaw muscles. The EMG detects the presence of REM sleep when
the jaw muscles relax.
Special belts are placed around the patient's chest and abdomen to detect
and record the rising and falling movements associated with the respiration. A
pulse oximeter, a noninvasive device for measuring oxygen content in the
blood, is attached to the finger, and electrodes to provide an electrocardiogram
(ECG) are attached to the chest to measure heart rate. Various types of
instruments, either straps around the feet or electrodes pasted to the lower
legs, measure leg movements, which may indicate another sleep disorder
called periodic limb movement disorder.
Obstructive sleep apnea is diagnosed if the patient has an apnea index
greater than 5, that is, has more than five apneic episodes per hour, or a
respiratory disturbance index (RDI), the combination of apneas and
hypopneas, greater than 10 per hour. In the appropriate clinical setting, sleep
apnea can be diagnosed by an RDI between 5 and 10. Experts disagree
somewhat on precisely where the diagnostic threshold lies, so a reliable
diagnosis needs to be made in the context of the individual. Furthermore, the
criteria are even less precise in children, making an individual approach to
diagnosis even more important.
Clinically speaking, an obstructive apnea is defined as a complete
cessation of airflow for more than 10 seconds with persistent respiratory effort.
An obstructive hypopnoea is defined as a partial reduction in air flow of
approximately 30% to 50% with persistent respiratory effort and a reduction in
oxygen saturation by at least 3% to 4% and/or an arousal from sleep.
The many physiological measurements taken usually enable the physician
to diagnose or reasonably exclude OSA. Sometimes, however, a patient does
not sleep long enough to obtain all the data needed. Polysomnography can not
provide data from patients who have mild OSA only at home or only after using
certain medications or alcohol but who do not experience any episodes during
the sleep study. Therefore, a polysomnogram must be interpreted with the
entire clinical picture in mind.
Another condition, called upper airway resistance syndrome, cannot be
seen on polysomnography. This syndrome is characterized by repetitive
arousals from sleep that probably result from increasing respiratory effort
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during narrowing of the upper airway. These patients suffer the same sleep
disruption and deprivation as other sleep apnea patients. In such cases, the
only abnormality that appears on the polysomnogram is recurrent arousal. It is
possible to measure an increase in the negative pressure exerted by the
patient in an effort to breathe against increasing resistance as the airway
narrows. This measurement of inspiratory pressure is not usually done during
a standard polysomnogram. Patients with upper airway resistance syndrome,
therefore, constitute a group whose OSA could be easily missed by the
polysomnogram.
Because polysomnography is expensive and labor intensive, efforts are
underway to find a better method of diagnosing or screening for OSA. The only
alternative at present is a procedure called overnight oximetry, which
measures a patient's oxygen saturations throughout the night. Overnight
oximetry is not considered completely adequate as a screening test, however,
as the oxygen levels in the blood of many patients with OSA do not provide the
information needed to understand their condition.
6. OSA TREATMENT:
Several treatment options exist for dealing with OSA. These include weight
reduction, oral appliances, positional therapy, positive pressure therapy, and
surgical options.
Weight gain is a significant risk factor for the development of OSA. While
sleep apnea usually can be corrected by weight loss, other factors involved in
the Pathophysiology of OSA, such as anatomic abnormalities, may cause the
condition to persist. However, the vast majority of OSA cases can be
improved, if not eliminated, with significant weight loss. The amount of weight a
patient needs to lose to achieve these benefits varies. Some may need only a
modest reduction in weight to gain improvement, while others require
significant weight loss. It is not necessary to slim down to \"ideal body weight\"
to achieve these benefits.
a. Oral Appliances:
Oral appliances used for the treatment of OSA generally come in two
categories:
 Mandibular advance devices and
 Tongue-retaining devices.
A variety of both types exists. Oral appliances may be used to treat
mild to moderate OSA.
Mandibular advance devices essentially consist of a plastic (or other
material) mold of the teeth. They resemble the athletic mouth guards
commonly used in boxing, football, and other contact sports. The mold for
the lower teeth is advanced further forward than the mold for the upper
teeth. Advancement of the lower teeth moves the jawbone forward and
opens the airway, preventing its collapse during sleep. These devices can
be particularly effective in treating positional OSA.
Tongue-retaining devices, which also resemble athletic mouth guards,
are suction devices that are placed between the upper and lower teeth.
The tongue sits in the suction device and is pulled forward during the night.
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Positioning the tongue forward may eliminate any obstruction caused by
the base of the tongue.
Oral appliances are best fitted by a dentist experienced in their use.
Patient compliance is essential in order for these devices to be effective.
Complications associated with oral appliances include temporal
mandibular joint pain and excessive salivation.
Positional therapy can be used to treat patients whose OSA is related
to body positioning during sleep. Most people with sleep apnea have
worse symptoms if they lie flat on their back during sleep. Indeed, most
bed partners know this from experience and often try to make their partner
move onto their side during the night to stop their snoring. There are
several strategies which can help patients who have mild apnea only when
lying on their back. One is to sew or attach a sock filled with tennis balls,
length-wise down the back of their pajama top or nightshirt. This makes it
uncomfortable for the sleeper to lie on their back, and they usually will
move onto their side. Another technique is to use positional pillows to
assist in sleeping on the side. Positional therapy has its limits, but it has
been tried with success in some patients.
b. Positive Pressure Therapy:
Positive airway pressure is a very effective therapy for obstructive
sleep apnea. It has three forms: continuous positive airway pressure
(CPAP), autotitration, and bi-level positive airway pressure.
Regardless of the mechanism used it is desirable to use the lowest
possible pressure to eradicate the sleep apnea. In most cases, positive
airway pressure is easier to tolerate at lower pressures. Every patient
requires a different pressure. To determine precisely the individual
patient's optimum airway pressure, it is necessary to titrate the pressure to
each individual patient during a polysomnogram. A polysomnogram will
show not only when the respiratory events have ceased, but also when the
arousals from the respiratory events occur.
CPAP, the more common of the three therapy modes, usually is
administered at bedtime through a nasal or facial mask held in place by
Velcro straps around the patient's head. The mask is connected by a tube
to a small air compressor about the size of a shoe box. The CPAP
machine sends air under pressure through the tube into the mask, where it
imparts positive pressure to the upper airways. This essentially \"splints\"
the upper airway open and keeps it from collapsing.
Approximately 55% of patients who use CPAP do so on a nightly basis
for more than 4 hours. It is the most commonly prescribed treatment for
OSA. The advantages of CPAP are that it is very safe and completely
reversible. Generally, it is quite well tolerated. The main disadvantage is
that it requires active participation every night; that is, patient compliance is
necessary for it to work.
Mask fitting is an essential element of a patient's success with positive
airway pressure therapy since it affects compliance and effectiveness of
treatment. Higher pressures can result in air leak and patient discomfort.
Demands on mask stability increase as pressure increases. Higher
pressures may also require tighter head gear to maintain an adequate seal
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contributing to the discomfort. When selecting a CPAP mask the following
factors should be considered:
 Comfort
 Quality of air seal
 Conveninence
 Quietness
 Airventing
Side effects of CPAP include contact dermatitis, skin breakdown,
mouth leaks, nasal congestion, runny nose (rhinorrhea), dry eyes, nose
bleeds (rare), tympanic membrane rupture (very rare), chest pain, difficulty
exhaling, pneumothorax (very rare), smothering sensation, and excessive
swallowing of air (aerophagia).
Nasal congestion often can be reduced or eliminated with nasal steroid
sprays and humidification placed into the machine. Rhinorrhea can be
eliminated with nasal steroid sprays or ipratroprium bromide nasal sprays.
Epistaxis is usually due to dry mucosa and can be combatted with
humidification. Dry eyes are usually caused by mask leaks and can be
eliminated by changing to a better fitting mask.
Autotitration devices are designed to provide the minimum necessary
pressure at any given time and change that pressure as the needs of the
patient change. Autotitration devices respond to different parameters and
rely on different algorithm so they do not all operate the same.
The AutoSet® by ResMed acts by monitoring the patient's inspiratory
flow-time curve. A flattening of the inspiratory flow-time curve typically
precedes an upper airway obstruction, which causes apnea, hypopnea, or
snoring. Monitoring and responding to the flow-time curve, reduces the
number of respiratory events and arousals improving sleep quality.
Bi-level positive airway pressure is a variation of CPAP. Most of the
problems patients experience with CPAP is caused by having to exhale
against a high airway pressure. Because the air pressure required to
prevent respiratory obstruction is typically less on expiration than on
inspiration, bi-level positive airway pressure machines are designed to
sense when the patient is inhaling and exhaling and to reduce the pressure
to a preset level on exhalation. Bi-level positive airway pressure machines
usually are used when the patient does not tolerate CPAP or when the
patient has more than one respiratory disorder.
7. SURGERY:
a. Minimally Invasive Treatment:
The Pillar® procedure, also called palatal restoration, is a relatively
new, minimally invasive procedure approved by the Food and Drug
Administration (FDA) to treat mild to moderate OSA caused by the soft
palate.
This procedure is performed in a physician's office, using local
anaesthesia. It involves implanting 3 small woven inserts into the soft
palate to help support and improve the structure of the palate, and reduce
airway obstruction.
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Following the procedure, most patients are able to resume normal
activities and diet the same day. Over-the-counter pain medications may
be used to relieve minor discomfort.
The Pillar® procedure has been shown to permanently reduce OSA in
approximately 80% of cases. Complications are rare and include partial
extrusion, which involves seeing or feeling the tip of the insert through the
surface of the soft palate. The inserts used can be removed and/or
replaced easily by a physician.
b. Surgical Treatment:
Several surgical procedures may be used for the treatment of OSA. These
include:
 Uvulopalatopharngeoplasty (UP3),
 Geniotubercle advancement,
 Hyoid myotomy
 Resuspension,
 Midface advancement,
 Tracheostomy.
In children, where the cause of OSA is usually tonsil and adenoid
enlargement, surgical removal of the enlarged tonsils and adenoids is the
treatment of choice for OSA.
Overall, uvulopalatopharneoplasty (UP3) is the most common surgical
procedure for treating OSA. This involves removing the uvula and some of
the surrounding soft palate. The idea behind UP3 is to eliminate the area
of obstruction or to widen the airway so it does not occlude completely.
UP3 eliminates OSA approximately 50% of the time. The complications of
UP3 include transient nasal reflux, nasal speech, minor loss of taste, and
tongue numbness.
There is significant discomfort after the surgery for about 2 weeks.
More significant, and infrequent, complications include permanent nasal
reflux, changes in the person's voice and palatal stenosis, which can make
OSA worse. UP3 is very effective for eliminating snoring. Because snoring
is generally the most easily measured sign of OSA, patients undergoing
UP3 are advised to undergo another sleep study 6 months after surgery to
verify its effectiveness.
Geniotubercle advancement and hyoid myotomy and resuspension are
sometimes done in conjunction with a UP3 or if a UP3 has proven
ineffective. The geniotubercle advancement is done by making a small cut
into the midline of the mandible (jawbone) and repositioning a small piece
of bone. This bone, the geniotubercle, attaches to the tongue muscles. As
the geniotubercle is pulled forward, the tongue is also pulled forward,
potentially relieving any airway obstruction caused by the base of the
tongue.
A hyoid myotomy is often performed in conjunction with the
geniotubercle advancement. The hyoid is a bone in the anterior upper
neck. This surgery is felt to advance the base of the tongue as well.
Complications from hyoid myotomy are rare but include dental nerve
anesthesia and mandibular fractures extending into the root system of the
teeth. A combined success rate of approximately 70% has been reported
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where UP3 has been combined with geniotubercle advancement and hyoid
myotomy.
Midface advancement consists of fracturing each side of the face in
the region of the upper jaw and both sides of the lower jaw, then
essentially pulling the face forward a few millimetres. Metal spacers are
then placed in the mid-face and the lower jaw to fill the gap between the
bones. This surgery is reserved for patients with significant apnea
untreatable with the other surgeries mentioned or CPAP. It has been
reported to be highly effective in eliminating obstructive sleep apnea.
Tracheostomy is the oldest surgical treatment for OSA still in
existence. It is done by making an incision in the lower neck and
penetrating the trachea. A plastic or metal tube is then inserted through the
skin into the trachea. This procedure is curative for OSA essentially in
100% of the patients. The tracheostomy site bypasses the area of
obstruction during sleep. The tracheostomy can be covered during the day
and opened at night. Because newer treatments have proven their
effectiveness, tracheostomy is now rarely used for OSA.
VII. MECHANICAL VENTILATION:
Mechanical ventilation is typically used after an invasive intubation, a
procedure wherein an endotracheal or tracheostomy tube is inserted into the
airway. It is used in acute settings such as in the ICU for a short period of time
during a serious illness. It may be used at home or in a nursing or rehabilitation
institution if patients have chronic illnesses that require long-term ventilation
assistance.
The main form of mechanical ventilation is positive pressure ventilation, which
works by increasing the pressure in the patient's airway and thus forcing air into
the lungs. Less common today are negative pressure ventilators (for example, the
\"iron lung\") that create a negative pressure environment around the patient's chest,
thus sucking air into the lungs.
Mechanical ventilation is often a life-saving intervention, but carries many
potential complications including pneumothorax, airway injury, alveolar damage,
and ventilator-associated pneumonia.[citation needed] For this reason the pressure
and volume of gas used is strictly controlled, and reduced as soon as possible.
1. NEGATIVE PRESSURE MACHINES:
The iron lung, also known as the Drinker and Shaw tank, was developed in
1929 and was one of the first negative-pressure machines used for long-term
ventilation. It was refined and used in the 20th century largely as a result of the
polio epidemic that struck the world in the 1940s. The machine is effectively a
large elongated tank, which encases the patient up to the neck. The neck is
sealed with a rubber gasket so that the patient's face (and airway) are exposed
to the room air.
While the exchange of oxygen and carbon dioxide between the
bloodstream and the pulmonary airspace works by diffusion and requires no
external work, air must be moved into and out of the lungs to make it available
to the gas exchange process. In spontaneous breathing, a negative pressure is
created in the pleural cavity by the muscles of respiration, and the resulting
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gradient between the atmospheric pressure and the pressure inside the thorax
generates a flow of air.
In the iron lung by means of a pump, the air is withdrawn mechanically to
produce a vacuum inside the tank, thus creating negative pressure. This
negative pressure leads to expansion of the chest, which causes a decrease in
intrapulmonary pressure, and increases flow of ambient air into the lungs. As
the vacuum is released, the pressure inside the tank equalizes to that of the
ambient pressure, and the elastic coil of the chest and lungs leads to passive
exhalation. However, when the vacuum is created, the abdomen also expands
along with the lung, cutting off venous flow back to the heart, leading to pooling
of venous blood in the lower extremities. There are large portholes for nurse or
home assistant access. The patients can talk and eat normally, and can see
the world through a well-placed series of mirrors. Some could remain in these
iron lungs for years at a time quite successfully.
Today, negative pressure mechanical ventilators are still in use, notably
with the Polio Wing Hospitals in England such as St. Thomas' (by Westminster
in London) and the John Radcliffe in Oxford. The prominent device used is a
smaller device known as the cuirass. The cuirass is a shell-like unit, creating
negative pressure only to the chest using a combination of a fitting shell and a
soft bladder. Its main use is in patients with neuromuscular disorders who have
some residual muscular function. However, it was prone to falling off and
caused severe chafing and skin damage and was not used as a long term
device. In recent years this device has re-surfaced as a modern polycarbonate
shell with multiple seals and a high pressure oscillation pump in order to carry
out biphasic cuirass ventilation.
2. POSITIVE-PRESSURE VENTILATORS:
The design of the modern positive-pressure ventilators were mainly based
on technical developments by the military during World War II to supply oxygen
to fighter pilots in high altitude. Such ventilators replaced the iron lungs as safe
endotracheal tubes with high volume/low pressure cuffs were developed. The
popularity of positive-pressure ventilators rose during the polio epidemic in the
1950s in Scandinavia and the United States. Positive pressure through manual
supply of 50% oxygen through a tracheostomy tube led to a reduced mortality
rate among patients with polio and respiratory paralysis. However, because of
the sheer amount of man-power required for such manual intervention,
mechanical positive-pressure ventilators became increasingly popular.
Positive-pressure ventilators work by increasing the patient's airway
pressure through an endotracheal or tracheostomy tube. The positive pressure
allows air to flow into the airway until the ventilator breath is terminated.
Subsequently, the airway pressure drops to zero, and the elastic recoil of the
chest wall and lungs push the tidal volume -- the breath -- out through passive
exhalation.
3. INDICATIONS FOR USE:
Mechanical ventilation is indicated when the patient's spontaneous ventilation
is inadequate to maintain life. It is also indicated as prophylaxis for imminent
collapse of other physiologic functions, or ineffective gas exchange in the
lungs. Because mechanical ventilation only serves to provide assistance for
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breathing and does not cure a disease, the patient's underlying condition
should be correctable and should resolve over time. In addition, other factors
must be taken into consideration because mechanical ventilation is not without
its complications (see below)
Common medical indications for use include:
 Acute lung injury (including ARDS, trauma)
 Apnea with respiratory arrest, including cases from intoxication
 Chronic obstructive pulmonary disease (COPD)
 Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) >
50 mmHg and pH < 7.25, which may be due to paralysis of the diaphragm
due to Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or
the effect of anaesthetic and muscle relaxant drugs
 Increased work of breathing as evidenced by significant tachypnea,
retractions, and other physical signs of respiratory distress
 Hypoxemia with arterial partial pressure of oxygen (PaO2) with
supplemental fraction of inspired oxygen (FiO2) < 55 mm Hg
 Hypotension including sepsis, shock, congestive heart failure
 Neurological diseases such as Muscular Dystrophy Amyotrophic Lateral
Sclerosis
4. TYPES OF VENTILATORS:
Ventilation can be delivered via:
 Hand-controlled ventilation such as:
Bag valve mask
o Bag valve mask
o Continuous-flow or Anaesthesia (or T-piece) bag
 A mechanical ventilator. Types of mechanical ventilators include:
o Transport ventilators. These ventilators are small, more
rugged, and can be powered pneumatically or via AC or DC
power sources.
o ICU ventilators. These ventilators are larger and usually run
on AC power (though virtually all contain a battery to facilitate
intra-facility transport and as a back-up in the event of a power
failure). This style of ventilator often provides greater control of
a wide variety of ventilation parameters (such as inspiratory
rise time). Many ICU ventilators also incorporate graphics to
provide visual feedback of each breath.
 NICU ventilators. Designed with the preterm neonate
in mind, these are a specialized subset of ICU
ventilators that are designed to deliver the smaller,
more precise volumes and pressures required to
ventilate these patients.
o PAP ventilators. These ventilators are specifically designed for
non-invasive ventilation. This includes ventilators for use at
home, in order to treat sleep apnea.
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5. MODES OF VENTILATION:
a. Conventional ventilation:
The modes of ventilation can be thought of as classifications based on how
to control the ventilator breath. Traditionally ventilators were classified
based on how they determined when to stop giving a breath. The three
traditional categories of ventilators are listed below. As microprocessor
technology is incorporated into ventilator design, the distinction among
these types has become less clear as ventilators may use combinations of
all of these modes as well as flow-sensing, which controls the ventilator
breath based on the flow-rate of gas versus a specific volume, pressure, or
time.
b. Breath termination:
In a volume-cycled ventilator the ventilator delivers a pre-set volume of gas
with each breath. Once the specified volume of breath is delivered, the
positive pressure is terminated after a certain specified time period. Both
pressure and volume modes of ventilation have their respective limitations.
Many manufacturers provide a mode or modes that utilize some functions
of each. These modes are flow-variable, volume-targeted, pressure-
regulated, time-limited modes (for example, pressure-regulated volume
control — PRVC). This means that instead of providing an exact tidal
volume each breath, a target volume is set and the ventilator will vary the
inspiratory flow at each breath to achieve the target volume at the lowest
possible peak pressure. The inspiratory time limits the length of the
inspiratory cycle and therefore the I:E ratio. Pressure regulated modes
such as PRVC or Auto-flow (Draeger) can most easily be thought of as
turning a volume mode into a pressure mode with the added benefit of
maintaining more control over tidal volume than with strictly pressure-
control.
c. Breath initiation:
The other method of classifying mechanical ventilation is based on how to
determine when to start giving a breath. Similar to the termination
classification noted above, microprocessor control has resulted in a myriad
of hybrid modes that combine features of the traditional classifications.
Note that most of the timing initiation classifications below can be
combined with any of the termination classifications listed above.
 Assist Control (AC). In this mode the ventilator provides a mechanical
breath with either a pre-set tidal volume or peak pressure every time
the patient initiates a breath. Traditional assist-control used only a pre-
set tidal volume--when a preset peak pressure is used this is also
sometimes termed Intermittent Positive Pressure Ventilation or IPPV.
However, the initiation timing is the same--both provide a ventilator
breath with every patient effort. In most ventilators a back-up minimum
breath rate can be set in the event that the patient becomes apnoeic.
Although a maximum rate is not usually set, an alarm can be set if the
ventilator cycles too frequently. This can alert that the patient is
tachypneic or that the ventilator may be auto-cycling (a problem that
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to recall by Mullsons Health & Wellness at any time.
results when the ventilator interprets fluctuations in the circuit due to
the last breath termination as a new breath initiation attempt).
 Synchronized Intermittent Mandatory Ventilation (SIMV). In this mode
the ventilator provides a pre-set mechanical breath (pressure or
volume limited) every specified number of seconds (determined by
dividing the respiratory rate into 60 - thus a respiratory rate of 12
results in a 5 second cycle time). Within that cycle time the ventilator
waits for the patient to initiate a breath using either a pressure or flow
sensor. When the ventilator senses the first patient breathing attempt
within the cycle, it delivers the preset ventilator breath. If the patient
fails to initiate a breath, the ventilator delivers a mechanical breath at
the end of the breath cycle. Additional spontaneous breaths after the
first one within the breath cycle do not trigger another SIMV breath.
However, SIMV may be combined with pressure support (see below).
SIMV is frequently employed as a method of decreasing ventilatory
support (weaning) by turning down the rate, which requires the patient
to take additional breaths beyond the SIMV triggered breath.
 Controlled Mechanical Ventilation (CMV). In this mode the ventilator
provides a mechanical breath on a preset timing. Patient respiratory
efforts are ignored. This is generally uncomfortable for children and
adults who are conscious and is usually only used in an unconscious
patient. It may also be used in infants who often quickly adapt their
breathing pattern to the ventilator timing.
 Pressure Support Ventilation (PSV). When a patient attempts to
breathe spontaneously through an endotracheal tube, the narrowed
diameter of the airway results in higher resistance to airflow, and thus
a higher work of breathing. PSV was developed as a method to
decrease the work of breathing in-between ventilator mandated
breaths by providing an elevated pressure triggered by spontaneous
breathing that \"supports\" ventilation during inspiration. Thus, for
example, SIMV might be combined with PSV so that additional breaths
beyond the SIMV programmed breaths are supported. However, while
the SIMV mandated breaths have a preset volume or peak pressure,
the PSV breaths are designed to cut short when the inspiratory flow
reaches a percentage of the peak inspiratory flow (e.g. 10-25%). New
generation of ventilators provides user-adjustable inspiration cycling
off threshold, and some even are equipped with automatic inspiration
cycling off threshold function. This helps the patient ventilator
synchrony[4]. The peak pressure set for the PSV breaths is usually a
lower pressure than that set for the full ventilator mandated breath.
PSV can be also be used as an independent mode.
 Continuous Positive Airway Pressure (CPAP). A continuous level of
elevated pressure is provided through the patient circuit to maintain
adequate oxygenation, decrease the work of breathing, and decrease
the work of the heart (such as in left-sided heart failure — CHF). Note
that no cycling of ventilator pressures occurs and the patient must
initiate all breaths. In addition, no additional pressure above the CPAP
pressure is provided during those breaths. CPAP may be used
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invasively through an endotracheal tube or tracheostomy or non-
invasively with a face mask or nasal prongs.
 Positive end-expiratory pressure (PEEP) is functionally the same as
CPAP, but refers to the use of an elevated pressure during the
expiratory phase of the ventilatory cycle. After delivery of the set
amount of breath by the ventilator, the patient then exhales passively.
The volume of gas remaining in the lung after a normal expiration is
termed the functional residual capacity (FRC). The FRC is primarily
determined by the elastic qualities of the lung and the chest wall. In
many lung diseases, the FRC is reduced due to collapse of the
unstable alveoli, leading to a decreased surface area for gas exchange
and intrapulmonary shunting (see above), with wasted oxygen
inspired. Adding PEEP can reduce the work of breathing (at low levels)
and help preserve FRC.
d. High Frequency Ventilation (HFV)
High-Frequency Ventilation refers to ventilation that occurs at rates
significantly above that found in natural breathing (as high as 300-900
\"breaths\" per minute). Within the category of high-frequency ventilation,
the two principal types are flow interruption and high-frequency oscillatory
ventilation (HFOV). The former operates similarly to a conventional
ventilator, providing increased circuit pressure during the inspiratory phase
and dropping back to PEEP during the expiratory phase. In HFOV an
electromagnetically controlled diaphragm drives the pressure wave similar
to a loudspeaker. Because this can rapidly change the volume in the
circuit, HFOV can produce a pressure that is lower than ambient pressure
during the expiratory phase. This is sometimes called \"active\" expiration. In
both types of high-frequency ventilation the pressure wave that is
generated at the ventilator is markedly attenuated by passage down the
endotracheal tube and the major conducting airways. This helps protect
the alveoli from volutrauma that occurs with traditional positive pressure
ventilation. Although the alveoli are kept at a relatively constant volume,
similar to CPAP, other mechanisms of gas exchange allow ventilation (the
removal of CO2) to occur without tidal volume exchange. Ventilation in
HFV is a function of frequency, amplitude, and I:E ratio and is best
described graphically as the area under the curve of an oscillatory cycle.
Amplitude is analogous to tidal volume in conventional ventilation; larger
amplitudes remove more CO2. Seemingly paradoxical, lower frequencies
remove more CO2 in HFOV whereas in conventional ventilation the
opposite is true. As frequency decreases, there is less attenuation of the
pressure wave transmitted to the alveoli. This results in increased mixing
of gas and thus ventilation. I-time is set as a percentage of total time
(usually 33%). Amplitude is a function of power and is subject to variability
due to changes in compliance or resistance. Therefore, power
requirements may vary significantly during treatment and from patient to
patient. Patient characteristics and ventilator settings determine whether
PaCO2 changes may be more sensitive to amplitude or frequency
manipulation. In HFOV, mean airway pressure (MAP) is delivered via a
continuous flow through the patient circuit which passes through a variable
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restriction valve (mushroom valve) on the expiratory limb. Increasing the
flow through the circuit and/or increasing the pressure in the mushroom
valve increases MAP. The MAP in HFOV functions similarly to PEEP in
conventional ventilation in that it provides the pressure for alveolar
recruitment.
e. Non-invasive ventilation (Non-invasive Positive Pressure Ventilation
or NIPPV):
This refers to all modalities that assist ventilation without the use of an
endotracheal tube. Non-invasive ventilation is primarily aimed at
minimizing patient discomfort and the complications associated with
invasive ventilation. It is often used in cardiac disease, exacerbations of
chronic pulmonary disease, sleep apnea, and neuromuscular diseases.
Non-invasive ventilation refers only to the patient interface and not the
mode of ventilation used; modes may include spontaneous or control
modes and may be either pressure or volume modes.
Some commonly used modes of NIPPV include:
 Continuous positive airway pressure (CPAP).
 Bi-level Positive Airway Pressure (BIPAP). Pressures alternate
between Inspiratory Positive Airway Pressure (IPAP) and a lower
Expiratory Positive Airway Pressure (EPAP), triggered by patient
effort. On many such devices, backup rates may be set, which deliver
IPAP pressures even if patients fail to initiate a breath.(Wheatley 2000
et all)
 Intermittent positive pressure ventilation (IPPV) via mouthpiece or
mask
f. Proportional Assist Ventilation (PAV):
Proportional Assist Ventilation (PAV) is a form of synchronised
ventilator support based upon the Equation of Motion in which the
ventilator generates pressure in proportion to the instantaneous patient
effort. Unlike other modes of partial support, there is no target flow, tidal
volume or pressure. PAV’s objective is to allow the patient to attain
ventilation and breathing pattern his ventilatory control system desires. The
main operational advantages of PAV are automatic synchrony with
inspiratory efforts, exhalation and adaptability to change in ventilatory
demand.
Proportional Assist Ventilation Plus — PAV+ (Puritan Bennett – 840
ventilator range, Proportional Pressure Support — PPS (Drager Evita
series)and Respironics BiPAP Vision PAV , are commercially available
implementations of PAV which automatically amplify the patient's own
spontaneous effort to breathe by increasing airway pressure during
inspiration proportionally to a set amplification factor.
In PAV+, the level of amplification, thus the level of work of breathing,
is set through a single setting (%support) and the pressure applied is
continuously and automatically adjusted based on measures (including
automatic assessment of Elastance and Resistance) taken throughout the
inspiratory cycle to maintain an appropriate level of support.
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to recall by Mullsons Health & Wellness at any time.
g. Adaptive Support Ventilation (ASV)
Adaptive Support Ventilation (ASV) is a positive pressure mode of
mechanical ventilation that is closed-loop controlled. In this mode, the
frequency and tidal volume of breaths of a patient on the ventilator are
automatically adjusted based on the patient’s requirements. The lung
mechanics data are used to adjust the depth and rate of breaths to
minimize the work rate of breathing. In the ASV mode, every breath is
synchronized with patient effort if such an effort exists, and otherwise, full
mechanical ventilation is provided to the patient.
ASV technology was originally described as one of the embodiments
of US Patent No. 4986268.[5] In this invention, a modified version of an
equation derived in physiology in 1950 [6] to minimize the work rate of
breathing in man, was used for the first time to find the optimum frequency
of mechanical ventilation. The rationale was to make the patient's
breathing pattern comfortable and natural within safe limits, and thereby
stimulate spontaneous breathing and reduce the weaning time. A
prototype of the system was built by the inventor in late 1980s. The
inventor is Dr. Fleur T. Tehrani who is a professor of electrical engineering
at California State University, Fullerton, in USA. Shortly after the Patent
was issued in 1991, Hamilton Medical, a ventilator manufacturing
company, contacted the inventor and discussed marketing the technology
with her. Some years later, Hamilton Medical marketed this closed-loop
technique under license of this Patent as ASV.
Since the issuance of the Patent, a number of articles have been
published by the inventor and her colleagues that are related to the
invention, and some of them describe further advancements of the closed-
loop techniques presented in the Patent.[7]
h. Neurally Adjusted Ventilatory Assist (NAVA)
NAVA is a new positive pressure mode of mechanical ventilation, where
the ventilator is controlled directly by the patient's own neural control of
breathing. The neural control signal of respiration originates in the
respiratory center, and is transmitted through the phrenic nerve to excite
the diaphragm. These signals are monitored by means of electrodes
mounted on a nasogastric feeding tube and positioned in the esophagus at
the level of the diaphragm. As respiration increases and the respiratory
center requires the diaphragm for more effort, the degree of ventilatory
support needed is immediately provided. This means that the patient's
respiratory center is in direct control of the mechanical support required on
a breath-by-breath basis, and any variation in the neural respiratory
demand is responded to by the appropriate corresponding change in
ventilatory assistance. Reference: New method permits neural control of
mechanical ventilation.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
6. CHOOSING AMONGST VENTILATOR MODES:
Assist-control mode minimizes patient effort by providing full mechanical
support with every breath. This is often the initial mode chosen for adults
because it provides the greatest degree of support. In patients with less severe
respiratory failure, other modes such as SIMV may be appropriate. Assist-
control mode should not be used in those patients with a potential for
respiratory alkalosis, in which the patient has an increased respiratory drive.
Such hyperventilation and hypocapnia (decreased systemic carbon dioxide
due to hyperventilation) usually occurs in patients with end-stage liver disease,
hyperventilatory sepsis, and head trauma. Respiratory alkalosis will be evident
from the initial arterial blood gas obtained, and the mode of ventilation can then
be changed if so desired.
 Positive End Expiratory Pressure may or may not be employed to
prevent atelectasis in adult patients. It is almost always used for
pediatric and neonatal patients due to their increased tendency for
atelectasis.
 High frequency oscillation is used most frequently in neonates, but is
also used as an always alternative mode in adults with severe ARDS.
 Pressure Regulated Volume Control is another option.
7. INITIAL VENTILATOR SETTINGS:
 The following are general guidelines that may need to be modified for the
individual patient.
a. Tidal volume, rate, and pressures
 For adult patients and older children
o Tidal volume is calculated in milliliters per kilogram. Traditionally
10 ml/kg was used but has been shown to cause barotrauma, or
injury to the lung by overextension, so 6 to 8 ml/kg is now common
practice in ICU. Hence a patient weighing 70 kg would get a TV of
420–480 ml. In adults a rate of 12 strokes per minute is generally
used.
o With acute respiratory distress syndrome (ARDS) a tidal volume of
6–8 ml/kg is used with a rate of 10–12 per minute. This reduced
tidal volume allows for minimal volutrauma but may result in an
elevated pCO2 (due to the relative decreased oxygen delivered)
but this elevation does not need to be corrected (termed
permissive hypercapnia)
 For infants and younger children
o Without existing lung disease—a tidal volume of 4–8 ml/kg to be
delivered at a rate of 30–35 breaths per minute
o With RDS—decrease tidal volume and increase respiratory rate
sufficient to maintain pCO2 between 45 and 55[vague]. Allowing
higher pCO2 (sometimes called permissive hypercapnia) may help
prevent ventilator induced lung injury
As the amount of tidal volume increases, the pressure required
administering that volume is increased. This pressure is known as the
peak airway pressure. If the peak airway pressure is persistently above 45
cmH2O (4.4 kPa) for adults, the risk of barotrauma is increased (see
below) and efforts should be made to try to reduce the peak airway
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pressure. In infants and children it is unclear what level of peak pressure
may cause damage. In general, keeping peak pressures below 30 cmH2O
(2.9 kPa) is desirable.
Monitoring for barotrauma can also involve measuring the plateau
pressure, which is the pressure after the delivery of the tidal volume but
before the patient is allowed to exhale. Normal breathing pattern involves
inspiration, then expiration. The ventilator is programmed so that after
delivery of the tidal volume (inspiration), the patient is not allowed to
exhale for a half a second. Therefore, pressure must be maintained in
order to prevent exhalation, and this pressure is the plateau pressure.
Barotrauma is minimized when the plateau pressure is maintained < 30–35
cmH2O.
b. Sighs:
An adult patient breathing spontaneously will usually sigh about 6–8 times
per hour to prevent microatelectasis, and this has led some to propose that
ventilators should deliver 1½–2 times the amount of the preset tidal volume
6–8 times per hour to account for the sighs. However, such high quantity of
volume delivery requires very high peak pressure that predisposes to
barotrauma. Currently, accounting for sighs is not recommended if the
patient is receiving 10-12 mL/kg or is on PEEP. If the tidal volume used is
lower, the sigh adjustment can be used, as long as the peak and plateau
pressures are acceptable.
Sighs are not generally used with ventilation of infants and young children.
c. Initial FiO2:
Because the mechanical ventilator is responsible for assisting in a patient's
breathing, it must then also be able to deliver an adequate amount of
oxygen in each breath. The FiO2 stands for fraction of inspired oxygen,
which means the percent of oxygen in each breath that is inspired. (Note
that normal room air has ~21% oxygen content). In adult patients who can
tolerate higher levels of oxygen for a period of time, the initial FiO2 may be
set at 100% until arterial blood gases can document adequate
oxygenation. An FiO2 of 100% for an extended period of time can be
dangerous, but it can protect against hypoxemia from unexpected
intubation problems. For infants, and especially in premature infants,
avoiding high levels of FiO2 (>60%) is important.
d. Positive end-expiratory pressure (PEEP):
PEEP is an adjuvant to the mode of ventilation used to help maintain
functional residual capacity (FRC). At the end of expiration, the PEEP
exerts pressure to oppose passive emptying of the lung and to keep the
airway pressure above the atmospheric pressure. The presence of PEEP
opens up collapsed or unstable alveoli and increases the FRC and surface
area for gas exchange, thus reducing the size of the shunt. For example, if
a large shunt is found to exist based on the estimation from 100% FiO2
(see above), then PEEP can be considered and the FiO2 can be lowered
(< 60%) in order to maintain an adequate PaO2, thus reducing the risk of
oxygen toxicity.
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In addition to treating a shunt, PEEP may also be useful to decrease
the work of breathing. In pulmonary physiology, compliance is a measure
of the \"stiffness\" of the lung and chest wall. The mathematical formula for
compliance (C) equals change in volume divided by change in pressure.
The higher the compliance, the more easily the lungs will inflate in
response to positive pressure. An underinflated lung will have low
compliance and PEEP will improve this initially by increasing the FRC,
since the partially inflated lung takes less energy to inflate further.
Excessive PEEP can however produce overinflation, which will again
decrease compliance. Therefore it is important to maintain an adequate,
but not excessive FRC.
Indications. PEEP can cause significant haemodynamic consequences
through decreasing venous return to the right heart and decreasing right
ventricular function. As such, it should be judiciously used and is indicated
for adults in two circumstances.
 If a PaO2 of 60 mmHg cannot be achieved with a FiO2 of 60%
 If the initial shunt estimation is greater than 25%
If used, PEEP is usually set with the minimal positive pressure to maintain
an adequate PaO2 with a safe FiO2. As PEEP increases intrathoracic
pressure, there can be a resulting decrease in venous return and decrease
in cardiac output. A PEEP of less than 10 cmH2O (1 kPa) is usually safe in
adults if intravascular volume depletion is absent. Lower levels are used
for pediatric patients. Older literature recommended routine placement of a
Swan-Ganz catheter if the amount of PEEP used is greater than 10 cmH2
for hemodynamic monitoring. More recent literature has failed to find
outcome benefits with routine PA catheterisation when compared to simple
central venous pressure monitoring.[8] If cardiac output measurement is
required, minimally invasive techniques, such as oesophageal doppler
monitoring or arterial waveform contour monitoring may be sufficient
alternatives.[9][10] PEEP should be withdrawn from a patient until
adequate PaO2 can be maintained with a FiO2 < 40%. When withdrawing,
it is decreased through 1–2 cmH2O decrements while monitoring
haemoglobin-oxygen saturations. Any unacceptable haemoglobin-oxygen
saturation should prompt reinstitution of the last PEEP level that
maintained good saturation.
f. Positioning:
Prone (face down) positioning has been used in patients with ARDS and
severe hypoxemia. It improves FRC, drainage of secretions, and
ventilation-perfusion matching (efficiency of gas exchange). It may improve
oxygenation in > 50% of patients, but no survival benefit has been
documented.
g. Sedation and Paralysis:
Most intubated patients receive intravenous sedation through a
continuous infusion or scheduled dosing to help with anxiety or
psychological stress. Sedation also helps the patient tolerate the constant
irritation of the endotracheal tube in their mouth, pharynx and trachea.
Without some form of sedation and analgesia, it is common for patients to
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\"fight\" the ventilator. This fighting increases work of breathing and may
cause further lung injury. Daily interruption of sedation is commonly helpful
to the patient for reorientation and appropriate weaning. These
interruptions are frequently described as \"sedation vacations\" and have
been shown to reduce the time patients stay on mechanical ventilation.
It is not uncommon for patients on a mechanical ventilator to be given a
muscle relaxant or paralytic to aid in ventilation. These \"neuromuscular
blockades\" prevent skeletal muscle from contracting and thereby stop all
patient movement including respiratory efforts. These types of
pharmaceutical agents must always be given in conjunction with sedation
as the effects of the paralytics is not only uncomfortable but would cause
significant psychological stress and anxiety.
h. Prophylaxis:
 To protect against ventilator-associated pneumonia, patients' beds are
often elevated to about 30°.
 Deep vein thrombosis prophylaxis with heparin or sequential
compression device is important in older children and adults.
 A histamine receptor (H2) blocker or proton-pump inhibitor may be
used to prevent gastrointestinal bleeding, which has been associated
with mechanical ventilation
8. MODIFICATION OF SETTINGS:
In adults when 100% FiO2 is used initially, it is easy to calculate the next
FiO2 to be used and easy to estimate the shunt fraction. The estimated shunt
fraction refers to the amount of oxygen not being absorbed into the circulation.
In normal physiology, gas exchange (oxygen/carbon dioxide) occurs at the
level of the alveoli in the lungs. The existence of a shunt refers to any process
that hinders this gas exchange, leading to wasted oxygen inspired and the flow
of un-oxygenated blood back to the left heart (which ultimately supplies the
rest of the body with unoxygenated blood).
When using 100% FiO2, the degree of shunting is estimated by subtracting
the measured PaO2 (from an arterial blood gas) from 700 mmHg. For each
difference of 100 mmHg, the shunt is 5%. A shunt of more than 25% should
prompt a search for the cause of this hypoxemia, such as mainstem intubation
or pneumothorax, and should be treated accordingly. If such complications are
not present, other causes must be sought after, and PEEP should be used to
treat this intrapulmonary shunt. Other such causes of a shunt include:
 Alveolar collapse from major atelectasis
 Alveolar collection of material other than gas, such as pus from
pneumonia, water and protein from acute respiratory distress syndrome,
water from congestive heart failure, or blood from haemorrhage
9. When to withdraw mechanical ventilation:
Withdrawal from mechanical ventilation—also known as weaning—should not
be delayed unnecessarily, nor should it be done prematurely. Patients should
have their ventilation considered for withdrawal if they are able to support their
own ventilation and oxygenation, and this should be assessed continuously.
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There are several objective parameters to look for when considering
withdrawal, but there is no specific criteria that generalizes to all patients.
Trials of spontaneous breathing have been shown to accurately predict the
success of spontaneous breathing. (Yang K, Tobin MJ. A prospective study of
indexes predicting the outcome of weaning from mechanical ventilation. N Engl
J Med 1991;324:1445-1450).
10. Connection to ventilators:
There are various procedures and mechanical devices that provide protection
against airway collapse, air leakage, and aspiration:
 Facemask - In resuscitation and for minor procedures under anaesthesia,
a facemask is often sufficient to achieve a seal against air leakage. Airway
patency of the unconscious patient is maintained either by manipulation of
the jaw or by the use of nasopharyngeal or oropharyngeal airway. These
are designed to provide a passage of air to the pharynx through the nose
or mouth, respectively. Poorly fitted masks often cause nasal bridge ulcers,
a problem for some patients. Facemasks are also used for non-invasive
ventilation in conscious patients. A full-face mask does not, however,
provide protection against aspiration.
 Laryngeal mask airway - The laryngeal mask airway (LMA) causes less
pain and coughing than a tracheal tube. However, unlike tracheal tubes it
does not seal against aspiration, making careful individualised evaluation
and patient selection mandatory.
Tracheal intubation is often performed for mechanical ventilation of hours
to weeks duration. A tube is inserted through the nose (nasotracheal
intubation) or mouth (orotracheal intubation) and advanced into the
trachea. In most cases tubes with inflatable cuffs are used for protection
against leakage and aspiration. Intubation with a cuffed tube is thought to
provide the best protection against aspiration. Tracheal tubes inevitably
cause pain and coughing. Therefore, unless a patient is unconscious or
anaesthetized for other reasons, sedative drugs are usually given to
provide tolerance of the tube. Other disadvantages of tracheal intubation
include damage to the mucosal lining of the nasopharynx or oropharynx
and subglottic stenosis.
 Oesophageal obturator airway - commonly used by emergency medical
technicians, if they are not authorized to intubate. It is a tube which is
inserted into the oesophagus, past the epiglottis. Once it is inserted, a
bladder at the tip of the airway is inflated, to block (\"obturate\") the
oesophagus, and air or oxygen is delivered through a series of holes in the
side of the tube.
 Cricothyrotomy - Patients who require emergency airway management, in
whom tracheal intubation has been unsuccessful, may require an airway
inserted through a surgical opening in the cricothyroid membrane. This is
similar to a tracheostomy but a cricothyrotomy is reserved for emergency
access.[1]
 Tracheostomy - When patients require mechanical ventilation for several
weeks, a tracheostomy may provide the most suitable access to the
trachea. A tracheostomy is a surgically created passage into the trachea.
Tracheostomy tubes are well tolerated and often do not necessitate any
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use of sedative drugs. Tracheostomy tubes may be inserted early during
treatment in patients with pre-existing severe respiratory disease, or in any
patient who is expected to be difficult to wean from mechanical ventilation,
i.e., patients who have little muscular reserve.
 Mouthpiece - Less common interface, does not provide protection against
aspiration. There are lipseal mouthpieces with flanges to help hold them in
place if patient is unable.
11. TERMINOLOGY
Terminology used in the field of mechanical ventilation and respiratory support:
 APRV Airway pressure release ventilation
 ASB Assisted spontaneous breathing—also ASV = assisted spontaneous
ventilation
 ASV Adaptive support ventilation—a patented technology—closed-loop
mechanical respiration, a further development of MMV. Can also stand for
assisted spontaneous ventilation.
 ATC Automatic tube compensation
 BIPAP Biphasic positive airway pressure
 CMV Continuous mandatory ventilation
 CPAP Continuous positive airway pressure
 CPPV Continuous positive pressure ventilation
 EPAP Expiratory positive airway pressure
 HFV High frequency ventilation
o HFFI High frequency flow interruption
o HFJV High frequency jet ventilation
o HFOV High frequency oscillatory ventilation
o HFPPV High frequency positive pressure ventilation
 ILV Independent lung ventilation—separate sides positive pressure
ventilation.
 IPAP Inspiratory positive airway pressure
 IPPV Intermittent positive pressure ventilation
 IRV Inversed ratio ventilation— mechanical ventilation with switched
respiration phases/time rate.
 LFPPV Low frequency positive pressure ventilation
 MMV Mandatory minute volume
 NAVA Neurally adjusted ventilatory assist
 NIF Negative inspiratory force—amount of force generated by a patient
against a closed valve; greater than 20 cmH2O indicates an adequately
strong diaphragm.
 PAP Positive airway pressure
 PAV and PAV+ Proportional assist ventilation and proportional assist
ventilation plus
 P/F ratio Ratio of PaO2 off an ABG and FiO2 off the ventilator. P/F < 200
indicates ARDS, P/F < 300 indicates ALI
 PC Pressure conrol—pressure-controlled, fully mechanical ventilation.
 PCMV (P-CMV) Pressure controlled mandatory ventilation
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PCV Pressure controlled ventilation—pressure-controlled, fully mechanical
ventilation.
 PEEP Positive end-expiratory pressure
 PNPV Positive negative pressure ventilation—switching pressure
mechanical ventilation
 PPS Proportional pressure support
 PRVC Pressure regulated volume controlled ventilation
 PSV Pressure support ventilation—supported spontaneous respiration,
see also ASB.
 RSBI Rapid shallow breathing index—ratio of breath rate divided by the
tidal volume. RSBI<105 declares a patient can be extubated and maintain
themselves. Also indicates patient has a good chance of staying
extubated.[12]
 (S) IMV (Synchronized) intermittent mandatory ventilation
 S-CPPV Synchronized continuous positive pressure ventilation
 S-IPPV Synchronized intermittent positive pressure ventilation
 TNI Therapy with nasal insufflation—nasal high-flow mechanical ventilation
for respiration support.
 VCMV (V-CMV) Volume controlled mandatory ventilation
 VCV Volume controlled ventilation—volume-controlled, fully mechanical
ventilation.
ZAP Zero airway pressure—spontaneous respiration under atmospheric pressure.
D. EXAMINATION:
This section is intended to capture the minimum data set and identify specific
circumstance(s) that might require additional tests and measures.
I. CHART REVIEW:
1. HPI & PMH
a. Onset and duration of symptoms, nature of dyspnea, previous medical
and/or surgical treatments for pulmonary disorder.
b. Use of home oxygen at rest and with activity
2. HC
a. Ongoing or new medical treatments
b. Pulmonary function tests (PFT), Chest x-rays (CXR), Exercise tolerance test
(ETT)
3. MEDICATIONS:
a. Prolonged, systemic steroid use
b. Inhaler use and schedule
II. SOCIAL HISTORY:
1. Prior functional level, use of assistive devices, history of dyspnea
2. Smoking history
3. Home environment, and current/potential barriers to returning home
4. Family/caregiver support system available
5. Family, professional, social and community roles
6. Patient’s goals and expectations of returning to previous life roles
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
III. PHYSICAL EXAMINATION:
1. Vital signs (HR, BP, RR, SpO2, supplemental oxygen)
2. Range of motion (ROM)
3. Strength
4. Sensation
5. Pain
6. Endurance/ability to monitor fatigue (RPE) and SOB
7. Breathing pattern and cough
8. Posture including chest or spinal deformities
9. Balance
10. Functional mobility
11. Gait
IV. COGNITIVE-PERCEPTUAL AND PSYCHOLOGICAL CONSIDERATIONS:
1. Level of alertness, orientation, and ability to follow commands
2. Safety awareness
3. Assess patient’s coping mechanisms to altered functional status and dyspnea
4. Patient’s goals, motivators and learning style
5. Knowledge of lung disease, breathing techniques, pacing, energy conservation
and relaxation techniques
E. EVALUATION / ASSESSMENT:
The primary goal for inpatient physical therapy for a patient with pulmonary
disease is to maximize his or her functional independence and endurance while
minimizing secondary impairments as a result of their lung disease and hospital
admission.
Potential impairments include but are not limited to: decreased endurance,
strength, ROM, balance, and as well as impaired pulmonary response to low level work
load, breathing pattern, posture, gait and impaired knowledge of pacing, self-
monitoring and home exercises.
The predicted optimal level of improvement for these patients is to maximize their
ability to return to their previous life roles and vocational and/or avocational activities
using an assistive device, adaptive equipment and/or supplemental oxygen, as
needed, over the course of 1-3 months. This prognosis may need to be modified due to
any of the following factors: extent and progression of their lung disease, presence of
co-morbidities, complications or secondary impairments, decreased cognitive status,
barriers to returning to previous living environment and any other factors that may
influence the patient’s ability to achieve functional independence.
Age specific considerations in this population include all the normal physiological
changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach, by
Lewis and Bottomley for more details. The physical therapist will consider all of the
patient’s impairments whether they are disease or age based and will determine a
comprehensive assessment, prognosis and rehabilitation plan for each patient.
Suggested goals may include: (1-2 weeks)
1. Maximize independent functional mobility
2. AROM bilateral UE/LE WFL as appropriate
3. Strength grossly > 3/5 throughout bilateral UE/LE as appropriate
4. Good balance in sitting and standing, with or without assistive device
5. Demonstrate independent pacing and monitoring of fatigue and/or SOB
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6. Demonstrate independent exercise and endurance program
7. Good safety awareness with all functional mobility
8. Improve posture to maximize efficiency of breathing pattern
9. Maintain SpO2 > 95%* at rest and with activities on least supplemental oxygen
(* or SpO2 as indicated by MD orders)
10. Report moderate or less effort (or RPE > 5/10) with all functional activities
F. TREATMENT PLANNING / INTERVENTIONS:
Established Pathway ___ Yes, see attached. _X_ No
Established Protocol ___ Yes, see attached. _X__ No
This section is intended to capture the most commonly used interventions for this case
type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate
interventions.
I. INTERVENTION:
Initiate physical therapy intervention, as appropriate, given the patient’s medical
status and activity orders.
1. Therapeutic exercise program
a. Progress from supine, sitting, and standing P/AA/AROM for UE/LE’s, as
appropriate. Progress by adding repetitions and then resistance as
tolerated.
b. Breathing techniques and relaxation exercises including diaphragmatic
breathing, pursed lip breathing and coughing
c. Postural exercises to improve breathing pattern and chest wall flexibility
2. Endurance Training
a. Increase tolerance to sitting in bedside chair
b. Progress time, distance and frequency of ambulation. Recommend activity
schedule to other healthcare providers or family members, as appropriate.
c. Consider interval training using either exercises or gait to increase
respiratory endurance.
d. Initiate stationary bicycle training, as appropriate, according to
departmental guidelines.
3. Functional Mobility Training
a. Bed mobility and supine sit stand activities
b. Transfer training (bed chair wheelchair commode), using
adaptive equipment, as appropriate (e.g. slide board)
4. Gait Training
a. Assistive device prescription and weaning to least restrictive device, as
appropriate, given weight-bearing status
b. Progress to stair training, as appropriate, prior to discharge home
5. Weaning supplemental oxygen
a. Wean oxygen as appropriate given MD orders for SpO2 goal and monitor
SpO2 during treatment.
II. PATIENT/FAMILY EDUCATION:
1. Discuss realistic expectations regarding functional outcomes, benefits of
exercise and mobility training on health status and function, appropriate level
of assist that patient requires from family and their anticipated rehab
progression.
2. Provide emotional support to the patient and family as needed.
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3. Instruct the patient in pacing activities, energy saving and relaxation
techniques, monitoring his/her own level of fatigue, or SOB, and safe activity
progression
4. Instruct the patient and family members in the following and assess their
understanding via return demonstration:
a. Therapeutic exercise and endurance program with prescribed mode,
intensity, duration and frequency guidelines
b. Breathing techniques
c. Safe mobility techniques encouraging maximal independence.
III. AVAILABLE HANDOUTS:
(post in room and/or distribute to patient upon discharge):
1. Home exercise programs (Use Exercise Pro for individualized program)
2. Energy Conservation Pamphlet
3. Relaxation Techniques
IV. FREQUENCY OF TREATMENT:
Patients will have follow-up physical therapy treatments based on individual need.
The frequency of treatment for each patient will be determined by the acuity of his
or her impairments and functional limitations. Refer to the BWH Guidelines for
Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting,
Cardiovascular/Pulmonary Practice Pattern.
V. RECOMMENDED REFERRALS TO OTHER PROVIDERS:
Discuss the patient’s need for additional services with the primary team. A patient
may benefit from the following services if appropriate:
1. Occupational Therapy: For a patient who presents with cognitive or
perceptual impairments, UE weakness or tone, or any other impairment that
affects his or her ability to perform activities of daily living independently and
for a patient who has UE splinting and/or adaptive equipment needs
2. Speech and Swallowing: For a patient who presents with impairments that
affect his or her ability to swallow without difficulty and/or who presents with a
new language impairment. Also consider for patients who have difficulty with
speaking due to breathlessness
3. Respiratory Therapy: For a patient with brochopulmonary hygiene needs and
complicated oxygen delivery needs beyond the typical set-ups available on the
floors. The respiratory therapists are also responsible for all ventilator care.
4. Care Coordination: For a patient who has a complicated discharge situation
and the care coordination team is not involved.
5. Social Work: For a patient who has a complicated social history and he or she
requires additional support or counselling.
G. RE-EVALUATION / ASSESSMENT
Reassessment will occur under the following circumstances: all physical therapy goals
are met, significant change in medical status has occurred, patient has not made the
expected progress with physical therapy intervention, patient is discharged from
services or facility, and/or within 10 days from the previous assessment.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
H. DISCHARGE PLANNING:
Discharge planning will occur on an individual basis depending on the patient’s
medical, physical and social needs and is a coordinated effort that occurs with the
physician, care coordination, therapist(s), the patient and his or her family.
If the patient continues to have significant impairments and functional limitations and/or
complicated medical needs at the time of discharge from the acute hospital, he or she
may be discharged to an alternate inpatient facility (e.g. acute or sub-acute
rehabilitation, inpatient pulmonary rehabilitation, skilled nursing facility (SNF), or
extended care facility). The patient will continue to progress towards their physical
therapy goals with eventual home discharge planning, as appropriate.
If the patient has met all inpatient physical therapy goals, he/she may be discharged
home with or without services. Consider the following resources for continued physical
therapy:
 Home PT (e.g. VNA)
 Outpatient PT
 Outpatient Pulmonary Rehabilitation
I. CHEST PHYSIOTHERAPY (CPT):
Revised 5/03Chest Physiotherapy helps loosen and clear thick secretions from the
lungs. It greatly improves lung function and reduces the amount of lung damage
over time. You will work with a physiotherapist to learn how to do CPT. CPT
usually includes three techniques:
 Postural drainage involves placing your child’s body in positions that allow
mucus to drain.
 Percussion is a clapping technique to loosen secretions. An airway clearance
device, such as a vibrating vest, is an alternative to manual clapping.
 Coughing is used to help remove lung secretions.
There are some injuries or illnesses that percussions and/or vibrations should not
be used with or more damage could be caused. Physiotherapists are
knowledgeable about these risks and perform a full assessment before treatment
in order to avoid any problems from occurring.
2.4.5 MEDICATIONS:
A nebulizer turns medication into a fine mist that your child can breathe in.
Your child may need medications to prevent or treat lung problems. Many are taken with a
nebulizer. This is a device that turns medication into a mist that your child can inhale.
Medications can include:
 Oral or inhaled antibiotics to prevent or treat lung infections.
 Bronchodilators to help open airways.
 Anti-inflammatory medications to decrease airway inflammation.
 Medications, such as dornase alpha or hypertonic saline, to thin secretions.
2.4.6 BENEFITS OF PULMONARY REHABILITATION:
Evidence from systematic review of meta-analysis of randomised controlled trials (level la)
 Improvements in exercise tolerance
 Reduction in the sensation of dyspnoea
 Improvement in health related quality of life (HRQoL).
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to recall by Mullsons Health & Wellness at any time.
Evidence from at least one randomised controlled trial (level lb)
 Improvement in peripheral muscle strength and mass
 Reductions in number of days spent in hospital
 Pulmonary rehabilitation is a cost effective intervention.
Evidence from at least one well designed controlled study without randomisation (level lla) or a
well designed quasi-experimental study (level llb)
 Improvement in the ability to perform routine activities of daily living
 Reductions in exacerbations
 Reduction in anxiety and depression
 Improvements in exercise tolerance are maintained between 6 - 12 months
 Improvements in HRQoL may be maintained for longer.
Obstructive/Restrictive
2.4.7 LUNG DRAINAGE:
Postural drainage is getting in positions that make it easier for mucus to drain. Chest
physiotherapy is gently \"clapping\" parts of the body to remove mucus from the lungs. They
are often used together in conditions such as cystic fibrosis or a spinal cord injury (SCI) to
help loosen and remove mucus from the lungs. When mucus collects in your lungs, it
increases your risk for lung infections, such as pneumonia.
Following are general instructions for chest physiotherapy and postural drainage. Talk to
your health professional about the positions you should use and how long how to do it.
 Be sure your back is covered. Wear a shirt or blouse, or cover your back with a towel.
 Hold each position for 5 minutes to help the mucus drain from your lungs.
 For each position, your caregiver claps your back quickly and rhythmically. Your
caregiver bends his or her hand at the knuckles to form a cup. The handprints in the
above illustrations show where to clap.
 When your caregiver claps, you should hear a hollow sound. If you hear a slapping, the
hand is not cupped enough.
 Do not clap over the spine.
Morning is the best time to do postural drainage, because it helps clear mucus that has
built up during the night. It may also be done just before bed to decrease nighttime
coughing. Do not do it soon after a meal; this may increase the chance of vomiting.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.4.5 LUNG VOLUME CAPACITIES:
IC = Inspiratory capacity
FRC = Functional residual capacity
IRV = Inspiratory reserve volume
TV = Tidal Volume
ERV = Expiratory reserve volume
RV = Residual volume
TLC = Total lung capacity
VC = Vital capacity
REEP = Resting End Expiratory Pressure
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.5 INTEGUMENTARY PHYSICAL THERAPY
2.5.1 DRESSINGS:
Transparent films = Waterproof, breathable, adhesive coated polyurethane film dressing
is permeable to oxygen and moisture vapour, but impermeable to bacteria and fluid. For
superficial wounds or wounds with light exudates. Easy, two step delivery for placement. Sterile
Hydrocolloids = A substance that forms a gel with water. Hydrocolloids come in a variety of
forms including fibrous and sheet form. They provide a moist environment, promoting autolytic
debridements and the stimulation of angiogenesis. Hydrocolloid sheets are occlusive and are
suitable for clean, granulating or necrotic wounds with low to moderate exudates. They are
often used as primary dressings for minor burns and pressure sores. The frequency of
hydrocolloid dressing change is determined by the amount of exudates produced. Although the
average time for redressing is 3-5 days, dressings can sometimes remain in place for up to
seven days. A hydro-colloid which requires changing more often than every three days, may
indicate that a more absorbent product is needed.
Hydro gels = A colloidal gel in which the particles are dispersed in water. Hydro gels are
available either in an amorphous form or as a sheet dressing. Characteristically, they have a
high water content and have hydrophilic sites which enable them to absorb excess exudates
while producing a moist wound environment. Hydro gels are used to debride a wound by
rehydration and promotion of autolysis. Hydro gels can be used in a variety of wounds including
pressure sores and cavity wounds. They are suitable for lightly exuding wounds, necrotic
tissue, slough and also shallow granulating wounds.
Foams = Foam dressings generally provide thermal insulation, maintain a moist wound
environment, are non-adherent and are comfortable to wear. Foam dressings are used in a
variety of wounds including leg ulcers and pressure sores. They may be suitable for light,
moderate or heavily exuding wounds depending on the product. Although there is no evidence
to support it, there is a suggestion that some foam dressings may be useful in the treatment of
over granulation. = derived from seaweed and are highly absorbent dressings. They act via an
ion exchange mechanism, absorbing serous fluid or exudates, which forms a hydrophilic gel
and conforms to the shape of the wound. Alginates are available in sheet form, and also as
cavity dressings. A secondary dressing is needed to occlude the wound.
Gauze dressings = A thin, loosely woven surgical dressing, usually made of cotton.
2.5.2 SKIN DISORDERS:
1. Dermatitis (eczema) Generally, dermatitis describes swollen, reddened and itchy skin.
2.Bacterial infections Prokaryotic cells with a greater surface to volume ratio 3.Viral infections
small cell that cannot live without the use of other living cells 4.Fungal infections a eukaryotic
organism that digests its food externally and absorbs the nutrient molecules into its cells
5.Parasite infections 6.Immune disorders of the skin 7.Skin cancer 8.Skin trauma
Colour changes:
1.Cherry red - Carbon monoxide poisoning
2.Bluish grey - lack of oxygen (cyanosis)
3.Pallor - anaemia/shock/nervousness
4.Yellow - Liver/jaundice
5.Brown liver spots (ouderdomsvlekken)
6.Brown increased pigmentation
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.5.3 BURNS:
1st degree: epidermis only
2nd degree: epidermis + upper dermis or total dermis + nerve ends and sweat glands
3rd degree: complete destruction of epidermis, dermis and subcutaneous tissues
4th degree: destruction of underlying tissues as muscle and bone
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2.6. GI, GU AND METABOLIC/ENDOCRINE AND PSYCHOLOGICAL CONDITIONS:
2.6.1 GASTROINTESTINAL DISEASES:
Achalasia Barrett's Oesophagus
Cancer - see colorectal, gastric and oesophageal Cirrhosis - Liver
Cirrhosis - Primary Biliary Coeliac Disease
Colitis - see Microscopic, Ulcerative, Crohn's Colorectal Cancer
Colorectal Polyps Crohn's Disease
Diverticulosis and Diverticulitis Fatty Liver
Gallstones Gastric Cancer
Gastritis Helicobacter Pylori Infection
Hemochromatosis Hepatitis - Chronic
Hepatitis - Viral Inflammatory Bowel Disease (see Crohn's
Disease, Ulcerative Colitis) Irritable Bowel Syndrome
Liver Failure and Liver Transplantation Ulcerative Colitis
Microscopic Colitis (including collagenous, lymphocytic) Oesophageal Cancer
Pancreatitis Peptic Ulcers
Reflux Oesophagitis Ulcers - Peptic
A. GI CAN CAUSE:
Abdominal pain, Distension, diarrhoea, Jaundice,
Constipation, GI bleeding, Difficulty swallowing, Vomiting (bilious and non-bilious).
B. GASTROINTESTINAL PHYSIOTHERAPY:
 This includes two important aspects:
 Be aware of the warning signs that may indicate malignancy.
 Malignancy should be considered with significant, unintentional weight loss,
progressive dysphasia, chronic blood loss, persistent vomiting and change of bowel
habit in excess of 6 weeks duration especially over the age of 40.
Ooooooo I  Dyspepsia presenting for the first time over 55 or IBS presenting for the first time over
feel good 40 are also warning features.
 Be aware of the many diseases not of the gastro-intestinal tract that need to be
considered.
 In females think of gynecological conditions but they rarely cause pain outside the
pelvis.
 Note the full differential diagnosis of pain in the chest. Both chest pain and epigastria
pain can be cardiac in origin and many a patient with \"indigestion\" has died of heart
disease.
 Abdominal pain can be from the urinary tract or a dissecting abdominal aortic
aneurysm.
 Thyrotoxicosis can cause weight loss.
 Congestive heart failure can cause engorgement of the liver.
 Metabolic disease such as porphyria can cause abdominal pain.
 Depression or psychotic illness can cause hypochondriacal or bizarre symptoms.
Recognition of depression is not always easy but remember that depression can
result from somatic illness and is not necessarily the cause.
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to recall by Mullsons Health & Wellness at any time.
 The key to GI cure is a prescribed diet and rest. Postoperative conditions for GI
surgery patients may be jaundice and hence Chest physiotherapy is done to drain
the fluids from lungs. Light physiotherapy is done to strengthen stomach muscles.
Light aerobic exercise is recommended to strengthen the abdominal muscles.
C. PHYSIOTHERAPY FOR ACTIVE LIFESTYLE:
Food as Medicine for the Mind and Body
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2.6.2 GU/RENAL (DISEASES OF THE GENITOURINARY (GU) TRACT):
 Bloody or discolored urine, edema, decreased or increased urination, dysuria, groin or
scrotal mass or pain, urinary frequency or urgency.
 Physiotherapy will not be able to return the prolapsed pelvic organ(s) to their original
position, but it can help improve the strength of the pelvic floor muscles, so that they
provide more support to the pelvic organs to prevent further slippage.
 Physiotherapy can also play an important part in teaching you how to avoid certain
activities and helping you make simple lifestyle changes which will prevent you from
causing further damage and stretching of your pelvic floor muscles. It can also teach you
how to improve your bladder control.
 Physiotherapy is always carried out in a private treatment room, always with the same
Physiotherapist, providing sensitive, professional treatment. It starts with a thorough
assessment. You will be asked detailed questions about your symptoms, your bladder
and bowel control, your medical and surgical history, pregnancies and births, your diet
and lifestyle. A physical examination will then follow, which may include looking at your
posture, back, abdominal muscles and likely an internal examination.
 Once the examination is complete, a discussion follows, explaining the findings and
exploring treatment options. It is a good opportunity for you to ask questions to gain a
better understanding of your problems.
 The goals of Physiotherapy are to reduce the symptoms caused by the prolapse and to
improve your pelvic floor support. Treatment will always involve a lot of education, to
teach you simple measures, which can make a big impact on your comfort and control,
for instance instructions on how to pass bowel movements without straining.
 Treatment is often focused around the pelvic floor muscles – the sling of muscles which
help to support and control the bladder. You will be taught how to identify them, how to
tighten them (Kegel exercises) and how to use them functionally to help support your
pelvic organs during daily activities.
 Treatment techniques may include computerized biofeedback, to teach pelvic floor
muscle awareness, bladder retraining, posture re-education, exercises for the abdominal
and other ‘core’ muscles. A home exercise program will always be an important part of
your treatment.
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A. INCONTINENCE:
Urinary incontinence may be complete, partial, \"urgency\" or \"stress.\" Causes and
characteristics of incontinence in patients include the following:
 Over-sedation (especially from opioids or tranquilizers): Incontinence primarily at
night or while asleep
 Diuretics: Incontinence primarily following administration of diuretics. Characterized
by frequency, urgency, and large volume of urine.
 Other medications that may affect continence include: Anticholinergics such as
antihistamines, antianxiety or sleeping medications, antidepressants, antipsychotics
(often used to treat nausea), blood pressure medications, and decongestants.
 Alcohol may also affect continence.
 Urinary tract infection: Incontinence accompanied by dysuria (pain or burning with
urination), frequency, urgency, or difficult urination.
 Stress incontinence: Incontinence resulting from movement, lifting, coughing,
laughing, etc.
 Problems of access complicated by weakness, tremors, etc.: Incontinence as the
result of urgency coupled with inability to reach the toilet or manage buttons, zippers,
etc.
 \"Irritable bladder\" (detrusor overactivity): Incontinence with sudden urge and partial
loss of urine. Detrusor overactivity is common among older people. In patients with
cancer, incontinence may be related to irritation to bladder from tumor, medications,
other agents.
 Frequency due primarily to urinary frequency can result from problems of diabetes,
hypercalcemia, and other physical causes.
 Retention (bladder unable to empty) or atonic bladder (no muscle tone): Incontinence
with no awareness of full bladder or urgency. Among the causes are pelvic lesions,
spinal cord injury, diabetic neuropathy, other neurological damage.
 Effects of treatment: Incontinence following radiation and/or surgery.
 Mechanical problems such as bladder or other obstruction from tumor; fecal
impaction; prostrate enlargement: Incontinence unexplained by the above, especially
leaking of urine.
 Fistula: Urine leaking from areas other than urethra.
 Related to heart failure: Incontinence especially at night, presence of edema, chest
pain, cough, and other signs of heart failure.
I. MANAGING INCONTINENCE:
 Give emotional support to the person having the problem.
 Address the cause of, or contributing factor to incontinence. In some cases,
incontinence is reduced by actions such as decreasing sleep medications,
decreasing evening fluids, giving diuretics in the morning only or decreasing
diuretic dose.
 Kegel’s exercises
 Medications:
 Tolterodine (Detrol), a muscarinic antagonist is indicated for overactive bladder
with symptoms of urinary frequency, urgency, or urge incontinence.
 Oxybutin (Ditropan, Oxytrol), an antispasmodic/anticholinergic is indicated for
uninhibited neurogenic or reflex neurogenic bladder, e.g., urinary urgency,
frequency, leakage, urge incontinence, dysuria.
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use adult incontinence pants (Attends) or towels to catch and soak up the urine. If
this attempted, scrupulous attention must be paid to skin care and frequent changes
of towels, etc. A barrier (such as Vaseline) between skin and urine is necessary.
Behavioral programs such as those used for bladder training are seldom appropriate
for patients who are terminally ill. More often, a urinary catheter is used.
II. CATHETER CARE:
Types of catheter:
1. Indwelling (a tube passing through the urethra into the bladder)
2. Condom (occasionally used for men when there is no retention)
3. Suprapubic catheters (surgically implanted through the abdominal wall) - less
frequently used.
Complications involved in catherization:
 Frequent urinary tract infections
 Encrustation at the insertion site, bladder spasms,
 And in the case of condom catheters, circulation may be cut off if too tight around
the penis.
Catheter insertion is usually done by an RN on a sterile field (included in the
catheter kit). Because of the presence of the catheter in the urethra (the passage
from the bladder to outside the body), many people feel like they need to urinate for
several hours to days after initial catheterization. Increasing fluid intake helps to
minimize the discomfort. Indeed, fluids should be increased throughout the time the
catheter is in place since the resulting increased flow of urine helps decrease urinary
tract infections and/or blockage. Water is the best fluid to take. Cranberry juice is
often recommended as a means of acidifying the urine, but it is difficult people in
good health to take in large enough quantity to actually affect urine acidity. Limited
sweet fluids, e.g., sodas, apple juice, etc., are not harmful in most cases.
Usually the catheter (with some slack) is kept taped to the inner thigh.
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B. URINARY TRACT INFECTION:
Urinary tract infection or cystitis (UTI) is a common complication of catheterization. UTI is
always a consideration in a person with an indwelling catheter and new onset of
confusion, discomfort, fever, or other signs of infection. Some bacteria are nearly always
found in the urine of a person with a catheter. UTIs are prevented or minimized by:
 Careful handwashing on the part of caregivers before and after cleaning around the
insertion site or otherwise giving catheter care - including any part of the drainage
system.
 Keeping the perineal area (genitals) clean - usually once or twice daily or more often
if there is fecal or other waste contamination. Frequent cleaning around the insertion
site is not necessary other than during other bathing times. Topical antibiotics are
sometimes used at the insertion site.
 Maintaining adequate fluid intake.
 Preventing backflow of urine from the drainage system back into the bladder. Thus
the catheter and drainage system allow for downward flow of urine. Be sure that
there are no kinks in any of the tubing.
 Keeping the drainage system closed except when draining the bag.
 Draining the bag regularly at about eight hourly intervals.
 Giving medications that acidify the urine or have an antiseptic affect on the urine.
Some medications may be taken orally and some instilled via the catheter into the
bladder. Antibiotics are used to treat and sometimes to prevent UTIs.
 Changing the catheter when indicated, i.e., (usually) when the catheter is obstructed
and cannot be irrigated or when there is sediment in the catheter.
 Bladder spasms may also occur and cause pain or discomfort and leaking around the
catheter. In some cases, spasms can be relieved by manipulating the catheter
slightly so the its' position in the bladder changes. Increasing fluids may also help. A
variety of medications are effective in relieving bladder spasms.
 Preventing damage to internal urethral tissue. Common causes are traction (pulling)
on the catheter and movement of the catheter in and out of the opening of the urethra
(urinary meatus).
 Irrigating the catheter is sometimes necessary to flush out the tubing and relieve a
partial or complete blockage of the catheter. Maintaining a high fluid intake usually
eliminates the need for mechanical irrigation. The primary indications for irrigation are
decreased or stopped urine flow in a person taking adequate fluids. Always check to
be sure there are no kinks or other blockages in the drainage system. A sterile
solution (often normal saline) and sterile equipment are required for irrigation. For
adults, a large syringe (30-50cc) is used to gently push 30-50cc of solution into the
catheter. If the patient has a closed system, the lumen port is cleaned with the
prescribed antiseptic, the needle inserted into the port, and the prescribed amount of
solution is gently introduced and allowed to drain into the bag. If an open system, the
juncture of the catheter and tubing is cleaned with the prescribed antiseptic, then
separated. Without touching or setting down (except on a sterile field) either end of
catheter or tubing a sterile cap is placed over the end of the tubing. The tip of the
sterilized syringe (without needle) is introduced into the end of the catheter and the
solution infused. The solution is then allowed to drain into the urine bag or
receptacle.
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C. OBSTRUCTIVE UROPATHY:
Obstruction in the urinary tract is marked by changes in urinary habits, either gradual or
rapid.
SYMPTOMS:
1. Urinary retention or the absence of urine - primary symptom.
2. Frequent urination of smaller amounts,
3. Increased nighttime urination,
4. Urgency to urinate,
5. Difficulty starting urination,
6. Decreased force of stream,
7. Abdominal or flank pain,
8. Blood in the urine (hematuria),
9. Frequent urinary tract infections.
Rapid obstruction of the tubes between bladder and kidneys (ureters) results in severe
pain. Partial kidney obstruction often results in alternating large amounts of urine
(polyuria) and small amounts (oliguria), infection, kidney stones, and decreased renal
function.
I. CAUSES OF OBSTRUCTION:
1. Primary or metastatic regional (pelvic or lower abdominal) tumors or regional
lymph involvement;
2. Enlargement of the prostate gland;
3. Urethral stricture.
II. MANAGING OBSTRUCTIVE UROPATHY:
1. Indwelling catheter.
2. Surgery - may be necessary for lower (below the bladder) obstruction, and
almost always necessary for higher obstruction (above the bladder). The only
exception to surgery is when the patient has advanced disease or is otherwise
unable to tolerate surgery.
D. BLOOD IN THE URINE (HEMATURIA):
Blood in the urine ranges from tiny flecks of blood to pinkish urine to large amounts of
red or brown-colored urine. Clots may cause obstruction in the bladder (and subsequent
pain). Causes include side effects of drugs (especially chemotherapeutic), infection and
lesions in the urinary tract system (including prostate) due to cancer.
Managing blood in the urine:
1. Insertion of an irrigating catheter to flush any clots
2. Instillation of medications
3. Treatment or surgical resection of the affected area
4. Radiation is sometimes used, but has a high potential for troublesome side effects.
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E. PELVIC FLOOR MUSCLE TRAINING FOR MEN:
 The physiotherapist will educate you to correctly identify the pelvic floor muscles and
train you to exercise your pelvic floor muscles.
 Relaxing techniques of your thighs, buttocks and tummy muscles is a key to the
exercises. Lift and squeeze inside as if you are trying to hold back urine, or wind from
the back passage.
 If you are unable to feel a definite squeeze and lift action of your pelvic floor, don't
worry. Even people with very weak muscles can be taught these exercises.
 If you feel unsure whether you have identified the correct muscles, try to stop your
flow when passing urine, then restart it. Only do this to identify the correct muscles to
use - this is a test, NOT an exercise.
 If you are unable to feel a definite tighten and lift action in your pelvic floor muscles
you should seek professional advice.
 At first you may need to perform these exercises while sitting. As the muscles
strengthen you can progress to exercise standing up. Like any activity, start with what
you can achieve and progress from there. Remember to use your muscles whenever
you exert yourself during your daily activities.
If you can feel the muscles working, exercise them by:
1. Squeezing/ tightening and drawing in and up around both your anus (back passage)
and urethra (bladder outlet). Lift up inside and try to hold this contraction strongly for
as long as you can (1 - 10 seconds). Keep breathing! Now release and relax. You
should have a definite feeling of letting go.
2. Rest 10 - 20 seconds - repeat Step 1, and remember it is important to rest. If you find
it easy to hold, try to hold longer and repeat as many as you are able. Work towards
12 long, strong holds.
3. Now try 5 - 10 short, fast strong contractions.
 Do NOT hold your breath
 Do NOT push down instead of squeeze and lift
 Do NOT pull your tummy in tightly
 Do NOT tighten your buttocks and thighs.
 Try to set aside 5 - 10 minutes in your day for this exercise routine, and
remember, quality is important. A few good contractions are more beneficial than
many half-hearted ones and good results take time and effort.
 Remember to use the muscles when you need them most. That is, always
tighten before you cough, sneeze, lift, bend, get up out of a chair, etc.
 Increase the length of time and number of holds you do in succession before
experiencing muscle fatigue. Work towards 12 long, strong holds. Increase the
number of short, fast contractions - always do your maximum number of quality
contractions.
Some helpful hints
 Keep your weight within a healthy range for your height and age
 Seek medical advice for chronic cough
 Develop good bowel habits
 You should anticipate that improvement in pelvic floor muscle strength will take 3
- 6 months of regular training of the muscles.
 The best results will be achieved by seeking help from a physiotherapist (with
training in continence) who will design an individual training programme
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especially suited to you. Pelvic floor exercises may also be useful for people on a
bladder-training programme.
F. PELVIC FLOOR MUSCLE TRAINING FOR WOMEN:
Four Phases of Pelvic Muscle Exercise
1. Awareness of the function and co-ordination of the PFM muscle.
For older adults and persons whose pelvic muscle is severely relaxed, this may take
several weeks.
2. Gains over muscle identification, control and strength.
Muscle strength is the maximal force that can be generated by the PFM. Although the
PRM is not flexible, the muscle must adapt to different or changing requirements so
the PFM must have contractibility and build force quickly when contracting.
3. Firming, thickening, broadening and bulking of the muscles to increase muscle
endurance.
Muscle endurance is a performance characteristic of the ability of the PFM to execute
repeated contractions to an initial level of strength often called a \"sub maximum\"
contraction.
4. Improvements of the symptoms indicate that the muscles are strengthening,
especially as the ability to feel the muscle contract and relax increases.
The ability to contract the muscle during the time of leakage (when coughing,
sneezing, laughing, on the way to the bathroom) prevents urine loss. At this point some
people feel that their incontinence is so improved that regular exercising is no longer
needed.
I. IDENTIFYING THE PELVIC FLOOR MUSCLE:
Individuals have a difficult time identifying and isolating this muscle. Without sufficient
information, many men and women may mistakenly bear down or exercise
ineffectively. Specifically, women should \"draw in\" and \"lift up\" the perivaginal and
rectal/anal sphincter muscles. Men should just draw in or tighten the rectal sphincter.
Once the person is able to identify the muscle, he or she is instructed to perform a
series of \"quick flicks\" or 2-second contractions followed by sustained (endurance
contractions) contractions of 5 seconds and longer as part of a daily exercise
regimen. At least 10 seconds of relaxation is recommended between contractions.
The individual should aim for a high level of concentrated effort with each pelvic
muscle contraction, as greater contraction intensity is associated with improvement in
pelvic muscle strength.
II. FREQUENCY OF PELVIC MUSCLE EXERCISES:
Individuals are instructed to do the pelvic muscle exercises three times daily and,
optimally, to perform the exercises in 3 positions -- lying, sitting and standing. A
minimum of 50-60 PMEs per day is recommended. A gradual increase in number of
contractions over a period of PME practice has been shown to increase muscle
strength significantly and decrease urine loss. The person should be instructed to
contract the muscle at the time of the UI episode. Contracting it before sneezing,
coughing, lifting, standing or swinging a golf club can prevent stress UI from
occurring. The muscle also can be contracted when he or she feels a strong urge to
void. Results may not occur until after 6-8 weeks of exercise, and optimal results
usually take longer.
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A large body of medical research has demonstrated the efficacy of behavioral
intervention that includes PMEs. Pelvic floor re-education has proven to be effective
in women with sphincter deficiency and detrusor instability
Practice of PME's in primiparas (women who have given birth to one child) results in
fewer UI symptoms during late pregnancy and the postpartum period. Behavioral
modifications, pelvic muscle rehabilitation and bladder retraining programs have
successfully decreased UI in homebound elders. A study of men with urinary
incontinence following radical prostate surgery showed that 88% of the treatment
group achieved continence in 3 months compared to 56% of the control group. In
addition, a more recent study examined the effects of combining behavioral treatment
and drug treatment for urge UI in ambulatory women. The subjects' reduction of
incontinence went from a mean 57.5% with behavioral therapy to a mean 88.5%
overall reduction with combined behavioral and drug (anticholinergic) treatment. The
majority of the PME research used some type of device to teach and train the PFM.
In general, both men and women may experience improvements in continence from a
Kegel exercise program.
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2.6.3 RENAL DISEASE:
Renal failure or kidney failure is a situation in which the kidneys fail to function
adequately. It is divided in acute and chronic forms; either form may be due to a large
number of other medical problems.
Bio chemically, it is typically detected by an elevated serum creatinine. In the science
of physiology, renal failure is described as a decrease in the glomerular filtration rate.
When the kidneys malfunction, problems frequently encountered are abnormal fluid levels
in the body, deranged acid levels, abnormal levels of potassium, calcium, phosphate,
hematuria (blood in the urine) and (in the longer term) anaemia. Long-term kidney
problems have significant repercussions on other diseases, such as cardiovascular
disease.
A. ROLE OF PHYSIOTHERAPY IN RENAL REHABILITATION:
I. THE NEED FOR EXERCISE:
Patients with renal disease require different treatment to maintain normal body
functions. Dialysis is important in regulating the body homeostasis and thus the
general well-being of the patients. Furthermore a normal physical fitness is essential
for the patients to perform independent daily activities and self care tasks.
Cardiopulmonary fitness level in dialysis patients is reported to be low in many
studies It is seen that that over 80% of dialysis patients were limited in vigorous
activities and 62% to 79% in tasks requiring only minimal energy expenditure, such
as walking for several blocks or climbing stairs. Even after transplant, 40% of patient
reported limitation in these simple physical tasks. The symptoms of easy tiring and
fatigue were prevalent (67% to 82% of dialysis patients and 43% of transplant
recipients).
The limitation of exercise capacity is multi-factorial. Cardiac and muscle
dysfunction may impair delivery and utilization of oxygenated blood thus their
exercise capacity. High level of uraemic toxins and anaemia affect the physical
activity of renal patients in general. Autonomic dysfunction also limits the cardiac
performance. Finally, muscle fatigue can lead to physical inactivity. Muscle weakness
explains the impaired exercise tolerance for end stage renal failure patients with
anemia. It is also reported that the VO2 max (maximal oxygen consumption) of
dialysis patients was only half of the expected for the same age. Various studies
showed that conditioning exercise program was beneficial and could increase the
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exercise capacity in dialysis patients. It is reported that exercise training performed
either during or in between haemodialysis sessions improved VO2 max.
Exercise training can also increase skeletal muscle strength, increase joint
flexibility and improve sense of balance and decrease risk of fall. Regular exercise
increases the functional capacity, thus enhancing independence of the patients,
which is one important component in rehabilitation. Regular exercise also helps in
reducing the cardiovascular risks, improving the haematocrit and better controlling
the blood pressure. With regular exercise, most patients experience sense of
increased energy, feeling of well-being and improvement in psychological profiles
such as anxiety, hostility and depression. The quality of life is, as a result, improved.
A well-designed exercise regime with multidisciplinary contribution is ideal for the
rehabilitation of dialysis patients.
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II. PLANNING OF EXERCISE:
Planning of exercise program depends on the patients' medical condition and
ambulatory status. For those patients with satisfactory ambulatory ability,
independent exercise with regular follow-up is appropriate. Home exercise or
community-based programs are all possible choices. Education is an important
component for an effective program. It should include information on how to start, the
expected progress and the signs and symptoms of discomfort during exercise. An
effective communicating channel must be established with the medical team. Follow-
up on the progress, response and symptoms should be included in any independent
exercise program.
The exercise program for the non-ambulatory patients must be planned and
designed carefully according to the change in efforts and physical ability. Exercise is
not recommended for patients immediately after dialysis. It is because fluid lost may
produce extra stress to the cardiovascular system and upset the stability of blood
pressure. Excessive exercise may produce undesirable effects on the cardiovascular
system.
Flexibility Exercise
1. TYPES OF EXERCISE:
Several types of exercise are suitable for dialysis patients, including flexibility,
strengthening, and cardiovascular exercises.
a. Flexibility exercise :
Gentle muscle stretching improves the range of motion of the body and major
joints. Increased flexibility improves functional performance and prevents
musculo-skeletal injury. The combination of flexibility and strengthening
exercises improve patients' ability to perform activities of daily living, such as
reaching, fending and carrying.
b. Strengthening exercises:
Specific muscle groups strengthening exercise increases muscle mass and
muscle strength. Muscle strength is increased or maintained with two to three
sessions of exercise per week. Cuff weights, sandbags or elastic bands can
be used to train the muscle. Exercise with low resistance but high number of
repetition is recommended but not for high resistance. Simple and easily
available equipment is more appropriate for patient training.
III. CARDIOVASCULAR EXERCISE TRAINING:
Cardiovascular activities require the movement of large muscle groups in rhythmic
manner. The goal of cardiovascular exercise training is to achieve and sustain an
activity of increased energy requirements (approximately 40% to 85% of peak
capacity) for increasing periods of time. Cardiovascular benefits can also be obtained
from short periods of sustained aerobic activity (10 minutes) several times a day. For
optimal cardiovascular conditioning, it is recommended to build up the sustained
activity gradually with close monitoring by the physiotherapist. Unaccustomed
exercise type and unsupervised progress may be more harmful and should be
avoided. Careful screening and evaluation of risk factors by the physician is essential
prior implementation of any exercise program. Patients should always be advised to
start slowly and proceed gradually.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
IV. ASSESSMENT:
Assessment is important in the planning and adjustment of exercise program and the
monitoring of patient's progress. An assessment includes the medical history, social
history and physical examination.
 Medical History: It includes the diagnosis of the renal disease and other
concomitant medical conditions such as hypertension, heart disease or anemia.
The effect of medications like Erythropoietin or Beta-blocker must be taken into
account.
 Social History: A detail assessment of the social background including the
occupation, education level, family support is vital for planning a tailor-made
rehabilitation program.
 Physical Examination: Musculo-skeletal assessment: Muscle strength can be
measured by Oxford manual muscle testing and hand held dynamometer. Hand
held dynamometer provides more objective outcome measurement.
 Cardio-pulmonary Assessment: Six-minute walk test is an universal accepted
field test. It is safe, simple and well tolerated by most patients, even frail elderly.
Patients are instructed to 'walk continuously as quickly as possible' up and down
one of two hallways (at least 100 feet). Pace should be adjusted but running is
not allowed. Perceived exertion (PE) ratio scale developed by Borg can be used
to assess the subjective effort of the patient during exercise. Six-minute walk test
in addition to PE measurement reinforce the assessment on the effort domain. It
is reliable and feasible for many patient populations including the renal patients.
Criteria for terminating the test include dizziness, angina, fatigue, severe
musculoskeletal pain as in leg claudication, signs of vascular insufficiency,
progressive fall in systolic blood pressure of 20 mmHg or more in the presence of
increasing heart rate and workload.
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to recall by Mullsons Health & Wellness at any time.
VI. EXERCISE APPROACH:
Department Based Exercise Program:
It is more flexibility in time allocation, space and equipment resources utilization.
The professional advice can be given to all patients in the initial phase of the program
by the physiotherapists. The exercise program is conducted under supervision. The
proper program should include the warm-up exercise, the graded strengthening,
aerobic exercise depending on the individual and the cooling down exercise. The
utilization of upper and lower limb ergo meters can provide appropriate loading to
individual patient.
Home Based Exercise Program:
It is a continuum of the department-based training program. Without succession
of home exercise regime, the benefits of physical training will decrease soon. In order
to have an effective home based program, encouragement and support from both the
therapist and family members are essential. Patient's motivation is also a vital
successful factor. Utilization of simple exercise equipment such as sand bag, cuff
weight, light resistance rubber band or cycle exerciser enhances the training effect
and maintain the patient's motivation. Home based program shall include a warm-up
component, both strengthening and aerobic training and cool down exercise as in the
department based program. Clear instructions on self-monitoring the exercise
intensity and regular follow-up on the changes in physical parameters by the
physiotherapist will make the program a success. The use of exercise logbook can
facilitate the monitoring of exercise effect both by the physiotherapist and patient.
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to recall by Mullsons Health & Wellness at any time.
2.6.4 PSYCHIATRIC PHYSIOTHERAPY:
(BODY PAIN ALWAYS AFFECTS YOU PSYCHOLOGICALLY.):
“Did you know that? You live your feelings through your body… We hold our breath, we grit
our teeth and we swallow the lump in our throat, while the heart is beating in the chest.”
“Did you know that? The body’s alarm system reacts when we are exposed to danger. But
whenever constant threat occurs, we are always in a state of alertness.”
“The alertness of the body might be reduced simultaneously as you become aware of your
body’s resources and your psychological resources, and these are liberated.”
“Did you know that? Recent researches on the brain show that the brain’s network learns and
has a large capacity for learning throughout the whole life. The brain does not separate body
and mind.”
“Natural functions such as the appetite, sleeping, digestion and temperature regulation are
deranged when we are in alertness.”
A. PSYCHIATRIC AND PSYCHOSOMATIC PHYSIOTHERAPY:
Also known as psychomotor physiotherapy and basic body knowledge.The main
thought is that the body, the thoughts and the feelings function as a whole in a
continuous interaction with the surroundings. The body is thought of as a carrier of
important experience and is thus an important source of «self-knowledge». Our thoughts
and feelings are experienced and expressed in the body. But life may demand «bad
things” to be put aside. When the breath is held and the muscles are strained, stress, fear
and unrest are rejected for a certain time. Tensions that are held over time have an effect
upon the balance, the breath and the availability of thoughts and feelings. When tensions
are not regulated with release, an accustomed tension is developed. This accustomed
tension may develop to chronic pain that alters the experience of the body and affects the
self-esteem and the body. During psychological disorders, problems with the body are
often parts of the symptoms. There is also a lot of research within psychological illnesses
that shows that adapted physical activity together with other treatment reduces the
symptoms and encourages rehabilitation. In the event of a disease difficult feelings and
body changes may be important issues, and the treatment may contribute to a better
body- and emotional balance.
B. PHYSIOTHERAPIST’S OFFER:
 Explore the body’s attitude, the musculature, the way of moving and the breathing
pattern.
 Explore the balance, the capacity of release and the contact and the trust with one’s
own body.
 Issues concerning natural functions such as sleeping, the appetite and the digestion.
 The exploration of the body is lead by reflection and conversation.
 The examination may be carried out with the clothes on.
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to recall by Mullsons Health & Wellness at any time.
C. PHYSIOTHERAPY TREATMENT:
 The treatment involves that you get in touch with muscular tensions and with your
breathing and might help you regaining your spontaneous and natural relaxation
abilities.
 The treatment requires a good cooperation between the physiotherapist and the
patient.
 The goal is to become more familiar with body’s signals and what they might express.
 The contact with own needs and limits enhance and might help you developing a
more reasonable psychological defense.
 The treatment might be demanding, but you gain in body and emotional security. The
relation to others is often altered.
 Body pain and symptoms are reduced or disappear.
D. METHODS IN THE TREATMENT:
 The treatment involves different forms of massage, touching and movement.
 Touching and body experience might carry forward memories and new reflections
and words.
 Reflection and conversation concerning relevant issues and patterns of interaction
are thus of main importance.
 The handling of difficult feelings is a part of the treatment.
E. TREATMENT OF CHILDREN:
 Coordinated movements oriented towards mastering and playing are essential during
the treatment of children.
 The aim is for the children in the examination to feel respected, to make them believe
in the abilities of their bodies, to make them experience that the body might feel
painful, but also strong, supple, easy to move, and good to be in!
 The physiotherapist helps the child to understand the relation between breathing,
strained muscles and for example head-aches.
F. BENEFICIARIES OF THE TREATMENT:
 The treatment suits people who feel stressed at work or in their private lives, for
which this has had an effect upon the body. The treatment might be considerable for
people suffering from anxiety, depression, eating disorder, or other psychological
problems. There is no age limit to profiting from the treatment.
 Your health condition, your symptoms, your estimations and your life story will be
decisive for the aim of the treatment and the choosing of methods.
Reflection and conversation
concerning relevant issues
d tt
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.7 PEDIATRIC PHYSICAL THERAPY:
 Paediatric physical therapy assists in early detection of health problems and uses a wide variety of
modalities to treat disorders in the paediatric population.
 Children are not just miniature adults. Throughout development from babies to teenagers, children are
constantly growing and developing, physically, and psychologically. Only a highly experienced clinician
is sufficiently qualified to care competently and compassionately for children.
 Paediatric Physical therapists are specialized in the diagnosis, treatment, and management of infants,
children, and adolescents with a variety of congenital, developmental, neuromuscular, skeletal, or
acquired disorders/diseases.
 Treatments focus on improving gross and fine motor skills, balance and coordination, strength and
endurance as well as cognitive and sensory processing/integration. Children with developmental
delays, cerebral palsy, spina bifida, and torticollis are a few of the patients treated by paediatric
physical therapists.
 Paediatric Physical Therapists provide treatment for children who have delayed gross motor skills
and/or lack flexibility, strength or endurance. Physical therapy program is on a one-on-one basis with a
licensed physical therapist. Each session is individualized to meet both the child and parent's needs.
Treatments may include exercises and or therapeutic activities that are specifically geared toward
improving strength, balance, coordination, and endurance. Therapy goals are established with the
parents to focus on helping children improve their function, mobility, relieve pain and prevent or limit
permanent physical disabilities.
 Therapists teach parents and children to use adaptive equipment, such as crutches, walkers and
wheelchairs and also evaluate and make recommendations for orthotics.
CHILDHOOD CONDITIONS:
The list is endless but can be divided into:
 System & Lungs
 Brain & Nervous System
 Development Disorders
 Bones, Joints and Muscles
 Sports or traumatic injuries on a child are managed differently to similar injuries seen on an adult.
Healing times and mechanical forces vary throughout each stage of a child's development.
 Similarly, developmental problems and conditions such as cerebral palsy, spina bifida, muscular
dystrophy, scoliosis and cystic fibrosis amongst others, call for particular care, sometimes with
intensive treatment, at various stages of the child's life.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.7.1 BONES, JOINTS AND MUSCLES:
 Conditions affecting bones, joints and the tissues around them are described as ‘musculo-
skeletal’ or ‘orthopaedic’.
 Because there are many physiological and anatomical differences between children and
adults, children require a specialised approach to their orthopaedic management. The
physiotherapists at Kids Physio always consider these differences when assessing and
treating children.
 Some of the more common musculo-skeletal problems that affect children and teenagers
include:
 Trauma injuries: For example fractures, sprains or strains resulting from sports, falls, car
accidents and other injuries.
 When children’s bones break they look similar to a broken green branch from a tree, hence
the name \"greenstick fractures\". Adult’s bones tend to have a well-defined break. The bones of
children and young adolescents contain \"growing zones\" called growth plates or epiphyses.
Special care needs to be taken if the fracture site is near to one of these growth plates.
Children often need physiotherapy after breaking a bone to help to restore mobility and
strength to the affected limb.
 Strains occur when a muscle is over-stretched, often following inadequate warming up before
sport or if the muscle is not used to a particular activity.
 Sprains are an overstretching or a partial tear of the ligaments or tendons, and are usually the
result of an injury, such as twisting an ankle or knee.
A. GAIT PROBLEMS:
When children first start walking they will often walk on their toes or with their feet turned in.
This is quite normal, but usually improves by the time they are 6 or 7. Sometimes, as children
grow, they develop an uneven walking pattern which can be improved with physiotherapy.
 Flat Feet are feet with a flattened arch. Flat feet can contribute to other problems such as
knee and hip pain and balance difficulties.
 Scoliosis is a name given to an abnormal ‘s’ shaped curve of the spine.
 Talipes is also called ‘club foot’. The ligaments and tendons around the foot and ankle are
Flat tight when the baby is born, making the foot stiff to move. Physiotherapy stretches can
help to restore the movement in the foot.
 Erbs Palsy is also known as Brachial Plexus Paralysis. The primary nerves, that supply
the movement and sensation to the arm, are partially or completely paralysed causing
weakness and limitation in movement. Physiotherapy helps to maximise the range of
movement, strength and function of the affected arm.
 Torticollis or ‘Wry Neck’ describes a condition where a tight sterno-mastoid muscle in
one side of the neck limits a child’s neck movements. Positioning and physiotherapy
stretches can help to gain full neck movements.
 Hyper mobility: describes when a child has an increased range of movement in joints.
 Arthritis is a disease involving the immune system. It causes inflammation of joints,
causing weakness and stiffness.
 Knee Problems are common in adolescents. Osgood-Schlatter disease is an
inflammation of the bone, cartilage, and/or tendon at the top of the shinbone.
Chondromalacia Patella is characterised by pain under the knee cap.
 Growing Pains are pains, generally in children’s or adolescent’s legs, often attributed to
rapid growth.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
B. MUSCULAR DYSTROPHY (MD):
Is a genetic disorder that gradually weakens the body's muscles. It's caused by incorrect or
missing genetic information that prevents the body from making the proteins it needs to build
and maintain healthy muscles.
 A child who is diagnosed with MD gradually loses the ability to do things like walk, sit
upright, breathe easily, and move the arms and hands. This increasing weakness can lead
to other health problems.
 There are several major forms of muscular dystrophy, which can affect a child's muscles in
different levels of severity. In some cases, MD starts causing muscle problems in infancy,
while in others, symptoms don't appear until adulthood.
 There is no cure for MD, but researchers are quickly learning more about how to prevent
and treat the condition. Doctors are also working on improving muscle and joint function,
and slowing muscle deterioration so that kids, teens, and adults with MD can live as
actively and independently as possible.
I. WHAT ARE THE FIRST SYMPTOMS OF MUSCULAR DYSTROPHY?
 Many kids with muscular dystrophy follow a normal pattern of development during
their first few years of life.
 But in time common symptoms begin to appear. A child who has MD may start to
stumble, waddle, have difficulty going up stairs, and toe walk (walk on the toes without
the heels hitting the floor). A child may start to struggle to get up from a sitting position
or have a hard time pushing things, like a wagon or a tricycle. It is also common for a
young child with MD to develop enlarged calf muscles, a condition called calf
pseudohypertrophy, as muscle tissue is destroyed and replaced by fat.
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to recall by Mullsons Health & Wellness at any time.
II. HOW IS MUSCULAR DYSTROPHY DIAGNOSED?
 When a doctor first suspects that a child has muscular dystrophy, he or she probably
will do a physical exam, take a family history, and ask about any problems -
particularly those affecting the muscles - that the child might be experiencing.
 In addition, the doctor may perform a series of tests to determine what type of MD a
child may have and to rule out any other diseases that may be causing a problem.
This might include a blood test to measure levels of serum creatine kinase, an enzyme
that's released into the bloodstream when muscle fibers are deteriorating. Elevated
levels of this enzyme indicate that something is causing muscle damage.
 The doctor also may do a blood test to check a child's DNA for gene abnormalities, or
a muscle biopsy to examine a muscle tissue sample for patterns of deterioration and
abnormal levels of dystrophin, a protein that helps muscle cells keep their shape and
length. Without dystrophin, the muscles break down.
III. TYPES OF MUSCULAR DYSTROPHY:
 Duchenne muscular dystrophy - the most common and the most severe form of the
disease. It affects about 1 out of every 3,500 boys. (Girls can carry the gene that
causes the disease, but they usually have no symptoms.) This form of MD occurs
because of a problem with the gene that makes dystrophin. Without this protein, the
muscles break down and a child becomes weaker.
In cases of Duchenne muscular dystrophy, symptoms usually begin to appear
around age 5, as the pelvic muscles begin to weaken. Most kids with this form of MD
need to use a wheelchair by age 12. Over time, their muscles weaken in the
shoulders, back, arms, and legs. Eventually, the respiratory muscles are affected, and
a ventilator is required to assist breathing. Kids who have Duchenne muscular
dystrophy typically have a life span of about 20 years.
Although most kids with Duchenne muscular dystrophy have average intelligence,
about one-third of them experience learning disabilities and a small number of them
have mental retardation.
While the incidence of Duchenne is known, it's unclear how common other forms
of MD are because the symptoms can vary so widely between individuals. In fact, in
some people the symptoms are so mild that the disease goes undiagnosed.
 Becker muscular dystrophy - similar to Duchenne, but it is less common and
progresses more slowly. This form of MD affects approximately 1 in 30,000 boys. It
too is caused by insufficient production of dystrophin.
With this form of MD, symptoms typically begin during the teen years, then follow a
pattern similar to Duchenne muscular dystrophy. Muscle weakness first begins in the
pelvic muscles, then moves into the shoulders and back. Many children with Becker
have a normal life span and can lead long, active lives without the use of a wheelchair.
 Myotonic dystrophy - also known as Steinert's disease, is the most common adult
form of muscular dystrophy, although half of all cases are diagnosed in people who
are younger than 20 years old. It is caused by a portion of a particular gene that is
larger than it should be. The symptoms can appear at any time during a child's life.
The main symptoms include muscle weakness, myotonia (in which the muscles have
trouble relaxing once they contract), and muscle wasting, where the muscles shrink
over time. Kids with myotonic dystrophy also can experience cataracts and heart
problems.
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 Limb-girdle muscular dystrophy - affects boys and girls equally. Typically,
symptoms begin when kids are between 8 and 15 years old. This form of MD
progresses slowly, affecting the pelvic, shoulder, and back muscles. The severity of
muscle weakness varies from person to person. Some kids develop only mild
Limb-girdle muscular weakness while others develop severe disabilities and as adults need a wheelchair to
get around.
 Facioscapulohumeral muscular dystrophy - affects both boys and girls, and the
symptoms usually first appear during the teen years. This form of muscular dystrophy
tends to progress slowly.
Muscle weakness first develops in the face, making it difficult for a child to close the
eyes, whistle, or puff out the cheeks. The shoulder and back muscles gradually
become weak, and kids who are affected have difficulty lifting objects or raising their
hands overhead. Over time, the legs and pelvic muscles also may lose strength.
 Other types of muscular dystrophy, which are rare, include distal, ocular,
oculopharyngeal, and Emery-Dreifuss.
IV. CARING FOR A CHILD WITH MUSCULAR DYSTROPHY:
Though there's no cure for MD yet, doctors are working to improve muscle and joint
function, and slow muscle deterioration in kids who are living with the condition. Muscular
dystrophy is often degenerative, so kids may pass through different stages as the disease
progresses and require different kinds of treatment. During the early stages, physical
therapy, joint bracing, and the medication prednisone are often used. During the later
stages, doctors may use assistive devices such as:
 physical therapy and bracing to improve your child's flexibility
 power wheelchairs and scooters to improve your child's mobility
 a ventilator to support your child's breathing
 robotics to help your child perform routine daily tasks
1. PHYSICAL THERAPY AND BRACING:
 Physical therapy can help a child to maintain muscle tone and reduce the severity
of joint contractures with exercises that keep the muscles strong and the joints
flexible.
 A physical therapist also uses bracing to help prevent joint contractures, a
stiffening of the muscles near the joints that can make it harder to move and can
lock the joints in painful positions.
2. PREDNISONE:
 If a child has Duchenne muscular dystrophy, the doctor may prescribe the steroid
prednisone to help slow the rate of muscle deterioration. By doing so, a child with
muscular dystrophy may be able to walk longer and live a more active life.
 There is some debate over the best time to begin treating a child with prednisone,
but most doctors prescribe it when a child with MD is 5 or 6 years old, or when
the child's strength begins to show a significant decline. Prednisone does have
side effects, though. It can cause weight gain, which can put even greater strain
on a child's already-weak muscles. It also can cause a loss of bone density and,
possibly, lead to fractures. If your doctor prescribes prednisone, he or she will
closely monitor your child.
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to recall by Mullsons Health & Wellness at any time.
3. SPINAL FUSION:
Many children who have the Duchenne and Becker forms of muscular dystrophy
develop severe scoliosis - an S- or C-shaped curvature of the spine that develops
when the back muscles are too weak to hold the spine erect. Some kids who have
severe cases of scoliosis undergo spinal fusion, a surgery that can reduce pain,
lessen the severity of the spine curvature so that a child can sit upright and
comfortably in a chair, and ensure that the spine curvature doesn't have an effect on
the child's breathing. Typically, spinal fusion surgery only requires a short hospital
stay.
4. RESPIRATORY CARE:
Many kids with muscular dystrophy also have weakened heart and respiratory
muscles. As a result, they can't cough out phlegm and sometimes develop respiratory
infections that can quickly become serious. Good general health care and regular
vaccinations are especially important for children with muscular dystrophy to help
prevent these infections.
5. ASSISTIVE DEVICES:
 A variety of new technologies are available to create independence and mobility
for kids with muscular dystrophy.
 Some kids with Duchenne muscular dystrophy may use a manual wheelchair
once it becomes difficult to walk. Others go directly to a motorized wheelchair,
which can be equipped to meet their needs as muscle deterioration advances.
 Robotic technologies also are under development to help kids move their arms
and perform activities of daily living.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
Talipes
·Arthritis
Hyper mobility
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.7.2 BRAIN & NERVOUS SYSTEM:
The nervous system is extremely complicated. The brain has often been likened to a central
computer within a vast, complicated network of wiring (the nervous system). The brain works at
lightening speed making infinite decisions that affect the outcome of everything we do. It allows us
to breathe, feel, talk, learn and remember, and enables us to move our bones and muscles in
complicated yet coordinated ways. The brain allows us to perform all of these things and more,
often without any conscious effort on our part, and even while we are asleep.
Unfortunately, such an amazing and complex system can go wrong. Damage can happen to
the brain and nervous system before, during and after birth. Physiotherapy can help when damage
occurs by helping the brain learn or relearn patterns of movement. Some of the children’s
conditions treated by physiotherapists include:
 Cerebral palsy(CP) is a condition primarily affecting a child’s motor development. It is caused
by damage to the brain before, during or shortly after birth.
 Meningitis and Encephalitis are inflammatory conditions affecting the brain and spinal cord,
usually caused by bacteria or viruses. Meningitis is the inflammation of the coverings
(‘meninges’) of the brain and spinal cord. Encephalitis is an inflammation of the brain tissue
itself. Both conditions can result in permanent damage to the brain.
 Spinal Cord Injury is caused by damage to the spinal cord. It can be caused from a direct
injury to the cord itself or from an indirect injury from damage to the bones, soft tissues, and
blood vessels surrounding the spinal cord. Only about 5% of spinal cord injuries occur in
CEREBRAL children. Symptoms of a spinal cord injury vary depending on the location and severity of the
PALSY injury. The main problem is weakness of muscles and loss of sensation at and below the level
of the injury.
 Spina bifida is a congenital disorder affecting the formation of the spine. About 75% of cases
are called ‘Myelomeningocele’. The backbone and spinal canal do not completely form before
birth causing a decrease or lack of function of the parts of the body controlled from or below
MENINGITIS the defect. Most defects occur in the lower lumbar or sacral areas of the back (the lowest
areas of the spine) because this area is normally the last part of the spine to close during inter-
utero development.
 Head Injuries are injuries to the brain caused by the head being hit by something or shaken
violently. Head injuries are also called traumatic head or brain injury (TBI) and acquired brain
injury (ABI). They can change how the person acts, moves and thinks. The signs of head
injury can be very different depending on which part of the brain has been injured and how
severely.
 Microcephaly is a neurological disorder where the baby’s head is much smaller than normal
for an infant of the same age and sex. It may be associated with other conditions or
SPINAL CORD syndromes. Children with microcephaly may have learning difficulties and delayed
INJURY development.
Spin
a
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.7.3 SYSTEM & LUNG:
Conditions that affect the whole body are called ‘systemic conditions’. Examples include chronic
fatigue syndrome, lupus and systemic juvenile arthritis. Specific and graded exercise programmes
have been shown to help the recovery of such problemsRespiratory conditions effect the lungs
and air passages. Physiotherapist offers assessment, treatment and advice on respiratory
conditions including asthma and cystic fibrosis.
A. ASTHMA:
Asthma is a common problem for infants and children. It is also called ‘Reactive Airway
Disease’. People with asthma have sensitive airways, which become inflamed and swollen
and produce more mucus. The muscles surrounding the airways (bronchial tubes) contract
more than they should, narrowing the air passages (bronchoconstriction).
Common symptoms of asthma include:
Recurrent episodes of coughing Difficulty breathing Rapid and/or noisy breathing
Wheezing Shortness of breath
Asthma symptoms tend to worsen at night or after with exposure to certain triggers, such as
smoke, dust, pet hairs, weather changes, exercise, and colds and flu.
Whilst there is no cure for asthma, with the right management, most children's asthma can be
kept under control. They will be able to participate in physical activities and sports and keep
up with the other children. Many health authorities have dedicated asthma clinics, where your
child can see a doctor, nurse and physiotherapist regularly for check-ups and to offer advice
on keeping your child’s asthma under control.
Physiotherapist will assess:
 Child’s medication
 Child’s peak flow rate
 The warning signs for when your child is likely to have an asthma attack .
 Child’s exercise tolerance . We will advise you and your child on any specific
WHEEZING exercises or activities to help build up strength and offer general advice on sports.
 Child’s breathing technique and their ability to clear secretions. Your physiotherapist
will advise on breathing games for younger children and specific breathing techniques
for older children. These may include the active cycle of breathing technique and
autogenic drainage.
 Physiotherapist will discuss what to do if the child has an asthma attack, including
breathing control, relaxation, and positions that can help during an attack.
B. CYSTIC FIBROSIS:
Cystic Fibrosis (CF) is a condition where the glands in the body produce abnormally thick,
sticky mucus and the sweat glands produce excess salt. The two main areas of the body
involved are the lungs and the pancreas. This increased production of mucus causes most of
the problems seen in cystic fibrosis.
The lung problems of cystic fibrosis are caused by the thick sticky mucus, which makes them
susceptible to infection and damage. The thick mucus collects in the lungs blocking some
airways and resulting in damage caused by the infection. Much of this damage can be
prevented through adequate treatment of infections.
Physiotherapy and medication help to keep the lungs clear of the mucus.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.7.4 EQUIPMENT USED WHILE UNDERGOING PHYSIOTHERAPY:
There are different types of equipment that may be used with children who are going through
physical therapy. An example is a safety belt that prevents the child from falling down or stumbling
when they are learning how to walk. Crutches may also be used and the child and parents will be
instructed on how to use them when the child encounters such obstacles as stairs. Children may
also be required to wear a safety belt while learning how to walk on crutches so they do not injure
themselves further.
Other types of equipment include:
 Walkers made just for children that help them learn to walk.
 Toys such as balls, swing, benches, and slides. Toys are an important tool because it
encourages the child to work their muscles through fun.
 Ultrasound devices that are used in controlling pain and inflammation.
 Therapy balls are kind of like exercise balls, but they are made in smaller sizes for children
 Therapy rolls are like long noodle type objects that the child can lean on, roll on, and
simply have fun with.
 Steps incline mats, and hurdles can create a great physical environment for a child
because these objects encourage them to climb and jump.
 Many of the different types of Physiotherapy equipment that is used promote physical
activity in some way. Then there are others types of equipment that is used in reducing
pain and inflammation and helps restore a balance within the injured area. There seems to
be a little something for every situation for every single age, whether it be devices to help
a child walk or to rehabilitate a muscle that has been torn. With sports becoming so
intense nowadays, sports injuries are very prevalent and a physiotherapist is required for
the healing process. Then again, children are born with conditions that Physiotherapy
equipment can provide relief for. That is why it is important that the proper equipment be
available to help these children.
2.7.5 ERICKSON STAGES:
1. 0-18 months >> Trust vs. Mistrust
2. 18 months - 3 years >> Autonomy vs. Shame
3. 3 years - 5 years >> Initiative vs. Guilt
4. 6 years - 12 years >> Industry vs. Inferiority
5. 12 years - 18 years >> Identity vs. Role confusion
6. 18 years - 35 years >> Intimacy and Solidarity vs. Isolation
7. 35 years - 55-65 years >> Generativity vs. Self Absorption
8. 55-65 years to Death >> Integrity vs. Despair
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.7.6 GRASPS:
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.8 GERIATRIC PHYSICAL THERAPY:
kal mera haath
pakadna jab main
boodha ho jaoon
Geriatric Physiotherapy covers a wide area of issues concerning people as they go through normal adult
aging, but is usually focused on the older adult. Conditions that may be treated through the use of geriatric
Physiotherapy are arthritis, osteoporosis, cancer, Alzheimer’s disease, hip replacement, joint replacement,
and more. It is used to help restore mobility, reduce pain, and increase fitness levels and more.
2.8.1 PHYSICAL ACTIVITY IN GERIATRICS:
Age involves a reduction in the muscle tone and in the movement amplitude, degradation in
the motor coordination, and a reduction in the respiratory capacities. Therefore, at 60, it is already
seen a reduction in the heart yield and in the respiratory movements (mostly inspiratory) of the
thoracic cage. In order to slow down the exhaustion of the reserve potential of the different organic
systems (in short, of the ability to adapt to the increasing needs), the central axis of every
treatment must be physical exercise, mostly aerobic; it is also very important to control the dietetic
habits, hygiene, etc. It is basic to start from the correct clinical exam, which will allow us to value
any possible alteration that could be a contraindication. The therapeutic physical activity
(preventive, healing, palliative, or recovery) is a professional medical act, which starts from a
medical diagnosis, preferentially by a geriatrician, from which a physiotherapeutic diagnosis of
functional evaluation is done. The physiotherapist is the one who does the functional valoration the
development of the treatment program and its application. The program’s follow up is an
interdisciplinary job between the geriatrician, the family practice physician, the A.P. nurse, the
physiotherapist and even the social worker. It is important to look for sanitarian professionals and
to run away from other figures (gym instructors, massagers, “cultural healers”), due to the risks
that acting on an ill person or on a reduced capacity person may bring (liability).
This, my dear is the best
therapy. Let them care
for your children.
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to recall by Mullsons Health & Wellness at any time.
A. FUNCTIONAL DIAGNOSIS:
 Anamnesis: Personal and familiar health history (e.g. Sudden death in close relatives).
 Apparatus examination:
 Cardiorespiratory Apparatus: T.A.; rest and effort E.C.G.(Step test: going up/down a 40
cm step during 3 minutes, measure F.C, he must be near to the rest frequency 60ppm-).
 Locomotor Ap: Atrophies, joint mobility, force, resistance, arthralgias, etc.
 Nervous System: Highly related to the latter: value skills, coordination, reflexes,
sensitivity, proprioception and kinaesthesia.
 General somatic control: Stature, weight, body mass index (BMI). In case any important
alteration is found, the patient will be forwarded to a specialist.
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to recall by Mullsons Health & Wellness at any time.
B. PROGRAM DEVELOPMENT:
 The following points will support it:
 Duration: between 15 to 60 m.
 Frequency: 3 to 5 times per week.
 Rising difficulty workout (it starts with low intensity, and progresses within 3 to 4 weeks to
achieve the maximum workout).
 A low intensity workout during an extended duration is chosen, better than the opposite
option (same benefit in long term with lower risk).
 The session will have warm-up, muscle conditioning (strength), aerobic exercise and
cooling.
 The C.F. will oscillate between 75% of the theoretical maximum (C.F. max = 225-age) and
a minimum value under which there is no benefit (C.F. min = C.F. rest + 0,6 (fc max-fc
rest)). NB: To be applied in non-cardiopat subjects, you must observe the existence of
musculoesketal pathologies.
 To do the workout, if possible, in group (10/15 people in semi-circle) adapting when
possible the program to an individual level.
 Exercises must be changed from time to time and not very repetitive (they bore and loose
attention). Wait 2 hours after the main meals.
 The more intensive the workout is, the more effect it will have. But also the greater the
risk. Below 15m/session, 3 times/week and C.F. lower than 45% maximum: It is inefficient.
C. EXAMPLE OF EXERCISE PROGRAM:
 Warm-up: 5 m (e.g.. to walk quickly).
 Flexibility and coordination exercises: 10 m (e.g.. dancing steps, symmetrical an
asymmetrical).
 Strength: 10 m (e.g.. use of small gadgets. Avoid isommetrics).
 Pure aerobics: 30 m (e.g.. Cycloergonometer. Avoid contact/stressful sports).
 Cooling: 5 m (e.g.. to walk slowly).
D. SELECTION OF THE DIFFERENT EXERCISES:
 Flexibility and coordination:
 Stretching: mild stretching. Do not copy other subject’s positions, but pay attention to his
own.
 Bilateral exercises: Symmetrical and asymmetrical, in order to integrate both brain
hemispheres.
E. MUSCLE STRENGTH:
 They must produce mostly isotonic contractions. Isometrical contractions produce a strong
increase in the T.A. Deben producer contracciones fundamentalmente isotónicas, las
isométricas producen un aumento brusco de la T.A and in the C.F.; if isometric exercises
were used (e.g. in post surgical recovery), it should not be passed the 40% of the
maximum strength. If the subject is cardio path, the 15 or 20%.
 General exercises (maintenance) should be more requested in LEGS more than in
ARMS, due to the fewer muscles and resistance of the latter.
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F. AEROBIC EXERCISE:
They will be the central axis of the session. They allow to improve the cardiorespiratory and
musculoskeletal resistance of the subject.
Advises: To walk, swim, cycloergometer, etc. always without doing competition and avoiding
shock sports (Footbal, footing, skydiving...).
G. FOR ALL TYPES OF EXERCISES:
Due to the fact that the old people’s metabolism lasts longer in activating itself and in reaching
its maximum performance, you should avoid the extreme hours in the day. We recommend the
last hours in the morning or in the afternoon.
H. THE EXERCISES:
May be different and may vary from time to time. You must mix and alternate them along the
session to make it funny and amusing; you can use balls, strings, broomsticks, musical
rhythms, etc.
When you combine the exercises with simple order like “up”, “forwards”, you stimulate
orientation and attention, combining physical activity with mental activity.
Abdominal respiration is specially important: They must learn to breath according a abdominal
standard and separate the abdominal/thoracic standard, using the nose filter in the inspiration,
and the reeducatory expiration (pursed lips: rise in the equal pressure point) in order to
achieve the most efficient respiration.
I. CONTINUITY IN THE EXERCISE PROGRAM:
In order to see the cardiovascular benefit, around 4 weeks are required. Remarkable results
are seen within 3 months. If the program is abandoned, in 4 weeks time most of the benefit is
lost, and in 8 weeks the patient goes back to his original state.
Make your parents feel
that you care. This will
give them the energy to
work with us.
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any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
2.9 THERAPEUTIC EXERCISE FOUNDATIONS:
2.9.1 STRETCHING:
Flexibility: the ability to move a joint through a series of articulations in a full non-
restricted,
 Pain-free range of motion (ROM).
 Stretching: techniques used to lengthen shortened soft tissues at the musculotendinous
units to facilitate an increase in ROM.
 Stretching has an impact on both contractile and non-contractile soft tissues. Passive
stretching to the elastic limit can allow these tissues to resume the original resting
length. Passive stretching beyond the elastic limit into plasticity will lead to a greater
soft tissue length compared to the original resting length when the stretch is removed.
Prolonged lengthening of the contractile units of muscle, the sarcomeres, into the
plastic ROM progressively leads to increased soft tissue length due to an increased
number of sarcomeres in series. Non-contractile units of muscle are ligaments, joint
capsule, and fascia which all consist of collagen and elastin fibbers. Prolonged
lengthening of collagen up to its yield point leads to tissue lengthening due to
permanent tissue deformation. Elastin fails without deformation with high loads. The
more elastin the tissues contain, the more flexible the tissues. To avoid damaging soft
tissues, healing and remodelling time must be allowed between periods of stretching.
Indications:
 Essential for establishing normal ROM of joints and soft tissue
 Important decreasing risk of injury to the musculotendinous unit
 Prevent contractures and adaptive shortening
 Combats the effects of prolonged immobilization
 Optimal flexibility will reduce stresses to surrounding joints and tissues
Contraindications: Do not stretch…
 Around acutely inflamed or infected joints
 Patients who are already hyper mobile
 Patients when shortened muscles are providing stability if normal joint stability is
decreased or assists with functional abilities such as in persons with par paresis
 Across a joint when a bony block prevents motion
A. PROCEDURE: MUSCLE FLEXIBILITY AND STRETCHING:
 It is optimal to warm up before stretching vigorously
 To increase flexibility, the muscle must be overloaded or stretched beyond its
elastic ROM, but not to the point of pain
 Exercise caution when stretching muscles around painful joints
 Avoid over-stretching ligaments and capsules that surround joints
 Use caution if history of steroid use
 Use caution-stretching patients with known or suspected osteoporosis, or who
have been on prolonged bed rest
 Only patients who are already flexible should do ballistic stretching
 Stretching should be performed at least 3 times per week, but between 5 and 6 will
yield maximal results
 Use caution-stretching patients with frail integument
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 Use caution stretching older patients because their collagen loses its elasticity and
they have reduced capillary blood supply.
B. EQUIPMENT / SUPPLIES NEEDED:
Occasionally towels, buttress material, or straps are used to fixate or position a body
part.
I. STRETCHING METHODS:
Static Stretch: involves stretching a muscle to the point of discomfort and then
holding it at that point for an extended period of time. Can be held between 3 and
60 seconds. Optimal stretch time is between 15 and 30 seconds.
II. ADVANTAGES:
 Prolonged low load will best facilitate a long lasting change in ROM
 Least likely to exceed the limits of the tissue extensibility
 Requires less energy expenditure
 Produces minimal muscle soreness
 Ballistic Stretch: dynamic, rapid action of repetitive bouncing motions applied to
the muscle being stretched. The antagonistic muscle group of the muscle being
stretched initiates the motion. It is an effective technique for athletes but
creates increased chance of muscle soreness and injury. Uncontrolled force
and proposed neurologic inhibitory influences of rapid stretch may cause injury.
III. PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF) STRETCHING
TECHNIQUES:
The first three of the following techniques incorporate use of the stretch reflex. All
muscles contain mechanoreceptors that when stimulated, stimulate the central
nervous system. The muscle spindles and the Golgi tendon organs are sensitive to
changes in length. Muscle spindles immediately increase muscle tension in
response to an increase in length and fire for at least 6 seconds. The Golgi tendon
organs over-ride the muscle spindles after 6 seconds and cause reflex relaxation of
the antagonistic muscle allowing extensibility limits to be extended.
1. Hold Relax (HR):
a. Passively move limb until the comfortable end range
b. 6-10 sec sub-maximal isometric contraction of the antagonist (muscle to be
stretched) against resistance
c. This is followed by a concentric contraction of the agonist combined with
light pressure from the therapist for a maximal stretch on the antagonist for
6-10 sec
d. Repeat b. and c.
2. Contract Relax (CR):
a. Passively move limb until the comfortable end-range
b. 6-10 sec sub-maximal contraction of the antagonist (muscle to be
stretched) isotonically against the resistance of the therapist
c. The antagonist relaxes as the therapist moves the limb passively through
as much ROM as possible returning to end-range for 6-10 sec
d. Repeat b. and c.
3. Slow Reversal-Hold-Relax (SRHR), Contract-Relax-Agonist-Contraction
(CRAC):
a. Passively move limb until the comfortable end range
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b. Isotonic contraction of the agonist
c. Followed by isometric contraction of the antagonist (muscle to be
stretched) for 6-10s
d. Repeat b. and c.
4. Rhythmic Initiation: indicated when tone or muscle spasm is sensitive to
stretch.
a. Full PROM into the direction desired
b. Commands are given “Relax let me move you,” followed by “now you do it
with me.”
5. Rhythmic rotation: indicated when tone or muscle spasm is sensitive to stretch.
a. Supported full PROM into the direction desired
b. Rotation of the body part alternately in both directions in a slow rhythmic
manner around a longitudinal axis for 10 sec
c. The command to “Relax and let me move you.” is given
d. Once relaxation is achieved, the limb is moved passively or actively into
the newly gained range.
IV. PATIENT EDUCATION:
 Pt should be instructed in proper techniques for self-stretching.
Documentation:
 Name of muscle(s) to be stretched
 Method of stretching
 Position
 Length of time stretch maintained
 Frequency stretch is performed
Alternatives:
Stretching is more effective when the intramuscular temperature is increased.
Tissue heated to 103 degrees Fahrenheit is optimal and can be achieved through
either therapeutic modalities or low-intensity warm-up exercises.
2.9.2 THERAPEUTIC EXERCISE:
 Therapeutic exercises are the exercises used during a rehabilitation program. When
developing a program, it is important to remember the following steps:
 Do a good evaluation and assessment of the patient.
 Establish goals.
 Get the athlete involved in goal setting.
 Develop a good treatment protocol.
 Supervise and reassess the progression of the program.
 If these steps are followed, then the athlete will have a successful rehabilitation and will
be returned to activity as soon as possible.
A. CONTROL INFLAMMATION:
 Inflammation is the first process of healing that happens immediately following an
injury. This process can be divided into 3 phases:
 Phase I
 Acute Phase This phase starts off with vasoconstriction of the blood vessels to
prevent blood loss to the injured area.
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 Vasodilation immediately follows to help phagocytes come into the area, resulting
in serotonin being produced along the chemical heparin.
 Swelling occurs due to the arrival of leukocytes and mast cells. Mast cells consist
of white blood cells, heparin, and histamine.
 The enzyme bradykinin is released, which stimulates nerve endings and pain.
 Between 24 to 48 hours, phagocytosis begins to remove waste products and the
swelling decreases.
Phase II - Subacute phase
This phase lasts from 48 to 72 hours but could last up to 6 weeks. The hematoma is in
top formation and there is growth of a new tissue. This is referred to as scar tissue. It is
made up of dead cells (exudate) and is high in proteins.
Phase III - Remodelling phase
This phase lasts from 3 to 6 weeks but can last up to a year or more. The collagen
content is deficient but can adapt to the stresses placed on it.
The treatment protocol for controlling inflammation is known as RICE application. RICE
stands for:
 Rest
 Ice
 Compression
 Elevation
Another type of inflammation is known as chronic inflammation. This occurs when the
acute healing process does not follow its normal course. The primary cells present
during this phase are lymphocytes, plasma cells, and monocytes. There is no
regeneration or phagocytosis. The result of this is constant pain to the injured area
when stress is being placed on it.
B. STRETCHING AND FLEXIBILITY:
Flexibility is total range of motion of a joint that depends on normal joint mechanics,
mobility of soft tissues, and muscle extensibility. The amount of flexibility is dependent
on the two primary proprioceptors: the muscle spindles and golgi tendons. \"When
stimulated, the spindle sensory fibbers discharge and through reflex action in the spinal
cord initiate impulses to cause the muscle to contract reflexively, thus inhibiting the
stretch.\" (Prentice)The muscle performing the movement is known as the agonist. The
muscle that moves in opposition of the agonist is the antagonist. If a stretch is held for
an extended period of time, the golgi tendons are stimulated which causes a reflex
inhibition of the antagonist muscle.
There are 2 types of stretches:
 Ballistic stretches: this type of stretching includes using repetitive bouncing at the
end of motion, therefore stimulating the muscle spindles.
 Static stretches: this type of stretching includes slow movement through the range
of motion, therefore stimulating the golgi tendons.
Another important type of stretch is called PNF stretching, which is a pattern of agonist
and antagonist contractions moving a limb. These stretches are promoted through the
stimulation of the proprioceptors. They also help in elongating muscle tissue. There are
2 different techniques of PNF stretches:
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 Active Inhibition - when the muscle group relaxes prior to the stretch while the
trainer stabilizes the limb. This stimulates the golgi tendons to stretch, which
causes the relaxation. Methods include contract-relax, hold-relax, and slow
reversal hold-relax.
 Reciprocal Inhibition - using agonist contractions to stretch antagonist muscle. This
type of stretching is beneficial when a muscle is very tight due to the early stage of
healing.
When using stretching, it is important to use the following precautions:
 Do a warm-up to increase muscle temperature.
 Stretch beyond normal ROM.
 Stretch until you feel tightness.
 Be cautious when stretching with pain.
 Avoid overstretching ligaments and capsules around joints.
 Stretch while seated or lying down so there will be less stress on lower back.
 Make sure athlete can breathe normally.
 Stretch 3 times a week to see benefits.
C. RESTORE RANGE OF MOTION:
This phase includes restoring range of motion and flexibility to the injured area. An
instrument that can be used to assess this is a goniometer.
Prior to these exercises, it is recommended that cryotherapy or thermo therapy be used
along with friction massage or joint mobs.
Active Range of Motion (AROM):
Active ROM exercises are when the athlete moves a limb by himself causing a
contraction and relaxation of the muscle fibbers. These exercises should be painless.
During the early phases of rehabilitation, these exercises can be performed in a cold
whirlpool (cryokinetics). For example, an athlete with a sprained ankle may spell out the
alphabet while having their foot is a warm whirlpool.
Passive ROM (PROM):
Passive ROM exercises are performed when the athletic trainer moves the limb
through its range instead of the individual. This type of range of motion prevents joint
changes and promotes healing by preventing scar tissue from adhering to the fibrils.
Limited passive ROM, also known as hypo mobility can be restored through joint
mobilizations. Passive ROM can also be done by machine by as well. An example of
this would be a CMU machine, which is used for post-surgery ROM.
Active Assisted ROM (AAROM):
Active Assisted ROM exercises are performed when the athlete needs some
assistance from a trainer or machine in order to attain full range of motion.
Resistive ROM (RROM):
This type of ROM is performed when the trainer applies resistance to the body part as
the athlete moves it. You can learn more about this type of ROM through the Muscular
Strength section.
When applying ROM exercises, it is important for the trainer to remember the following
techniques:
 Place athlete in a comfortable position to move body through a ROM.
 Make sure athlete has proper alignment.
 Free area from restrictive items. (i.e. braces)
 Position yourself so that proper body mechanics can be used.
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 Make sure the trainer controls the movement - stabilize distal area of the joint.
 If joints are painful, you might modify ROM.
 Stabilize joints with poor structure integrity.
 Always move segment through its complete pain free ROM.
 Do the motions very smoothly.
 Do ROM in anatomical ranges.
D. JOINT MOBILIZATION:
Joint Mobilization is a technique used to increase the range of motion of an injured
limb. It is also used to align the articulating surfaces of a joint and to reduce joint play.
To understand the concept of joint mobilization, it is important to understand the types
RADIOULNAR JOINT
of movements a joint can perform. The first types are called physiological movements
such as flexion, extension, abduction and adduction. The second type of movements,
which is the principle on which joint mobilization is based, are accessory movements
such as spins, rolls, and glides. Here are their definitions:
 Spins- rotation of a segment around a stationary axis. An example of this is the
radioulnar joint
 Glides- specific point on one articulating surface comes in contact with many points
on another
 Roll - Many points on one articulating surface comes in contact with many points
on another
The key principle of joint mobilization is known as the concave-convex rule. The rule
states: If a concave surface is moving on a convex surface, then the glide will occur in
the same direction as the roll. If a convex surface is moving on a concave, then the
Joint mobilization of the
patella to increase ROM glide is in the opposite direction of the roll.
after ACL reconstructive
surgery.
For example, let's talk about the knee. The femur is a convex surface and the tibial
plateau is a concave surface. If you are moving the tibia and the femur is fixed, then the
role and glide are in the same direction. If you are moving the femur and the tibia are
fixed, the glide will in the opposite direction of the roll.
Some guidelines when performing joint mobilization:
 Start with slow, small amplitude movements.
 If the pain worsens, perform joint motivation in the wrong direction until proper
technique can be tolerated.
 Perform 3 to 6 sets lasting 20-60 seconds each.
E. DEVELOPING MUSCULAR STRENGTH, ENDURANCE, AND POWER:
After pain free range of motion is reached, the next thing you should develop is the
strength of the muscles in the injured area. First, let's start with the definitions of
muscular conditioning. Muscular Strength is the ability of a muscle to generate force
against a resistance. Muscular Endurance is the ability of muscles to perform
repetitions against resistance for a period of time. Muscular Power is the ability for a
muscle to produce a force over a period of time.
There are 2 principles that are important in the increasing of muscular strength: the
overload principle and the \"specific adaptation to imposed demands\" (or SAID)
principle. The overload principle states that a person will see improvement in strength if
they demand more from their muscles than required. The SAID principle states that a
\"body responds to a given demand with a specific and predictable adaptation.\"
(Prentice) In order to achieve overload of the muscles, the intensity, duration, and
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frequency must be adjusted. Frequency refers to the amount of times per week a
person exercises. Duration is the amount of time of each exercise session. Intensity
refers to the amount of use of the energy systems of the body. It is important to develop
frequency, followed by duration, then intensity.
There are 3 types of exercises that can be done to develop muscular strength. The
first type of exercises is called isometrics. This is when a muscle contracts without a
change in the length of the muscle. An example of this would be placing your hand
under a table and trying to bring the arm up towards you. You will feel the isometric
contraction in the front of the arm at the biceps muscle. This exercise should be
performed early in the rehabilitation program because it helps in the decrease of
swelling and the re-education of the muscle. Each contraction should be performed 10
times and held for 5-10 seconds each.
The second type of strength exercises is called isotónicas. This type of exercise is
defined as moving a resistance through a range of motion. An example with the biceps
muscle would be flexing and extending the elbow. Two types of isotonic exercise are
concentric in which the limb is moving against gravity and eccentric, which is moving a
limb with gravity. A concentric exercise for the biceps muscle would be to bring your
hand towards your head. To perform an eccentric exercise with the elbow, extend the
elbow downward towards the ground.
The third type of strength exercises is called isokinetics. This type of exercise is
defined as a limb moving against a resistance to a set speed. Also, the resistance will
vary throughout the range of motion. To perform isokinetic exercises a certain type of
machine must be used. Three examples of machines include the Biodex, Cybex, and
Orthotron.
upper extremity movement F. PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION:
pattern moving into flexion. Proprioceptive Neuromuscular Facilitation, or otherwise known as PNF, is a
Starting position. strengthening technique used in therapeutic exercise that is based on human anatomy
and neurophysiology. It is used to increase strength, flexibility, and ROM.
 Physiology - PNF exercises are based on the stretch reflex, which is caused by
stimulation of the golgi tendon and muscle spindles. This stimulation results in
impulses being sent to the brain, which leads to the contraction and relaxation of
muscles. When a body part is injured, there is a delay in the stimulation of the
muscle spindles and golgi tendons resulting in weakness of the muscle. PNF
exercises help to re-educate the motor units, which are lost due to the injury. These
upper extremity movement pattern
also overflow.
moving into flexion. Ending position. To perform PNF exercises, it is important to remember the following principles:
Ending position. Ending position.  Patient must be taught the pattern.
 Have the patient watch the moving limb moved passively.
 The athletic trainer must give proper verbal cues.
 Manual contact with appropriate pressure is very important.
 Contraction of the muscle group is facilitated by hand placement.
 Apply maximal resistance throughout ROM.
 Resistance will change.
 Rotation of movement will change throughout ROM.
 Distal movement should occur first and before halfway through movement.
upper extremity movement
pattern moving into flexion.  Use maximal contraction to promote overflow of strength.
Starting position. Starting Four types of PNF Strengthening:
position. Ending position. Ending
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 Rhythmic initiation: includes progression from passive to active-resistive, then
followed by active movement. This is used when a patient cannot start a range of
motion, and to teach the patient the movement.
 Repeated contraction: Patient moves limb isotonically through resistance until
fatigue is present.
 Slow reversal: isotonic contraction of agonist and immediate contraction of
antagonist. It helps to develop AROM and coordination between agonist and
antagonist. This helps to increase strength of a specific ROM.
upper extremity movement  Rhythmic stabilization: isometric contraction of agonist followed by isometric
moving into extension. contraction of antagonist. It increases the holding power of a specific ROM.
Ending position. Starting
position. Ending position. G. PLYOMETRICS:
Plyometrics is a form of muscular strength training that is specific to jumps and leaping.
It was developed in the 1970's by Donald Chu and has become popular over the last
20 years. Today, most research is being done on lower extremity plyometrics. These
exercises are used to increase the excitability of the nervous system.
Physiology - Plyometrics is based on the concept of the amortization phase, which is
the time between the concentric contraction and an eccentric contraction. It consists of
a rapid eccentric contraction of the muscle prior to a powerful concentric contraction.
The greater the eccentric contraction, the more force that is generated within the
muscle.
Plyometrics can be divided into the following categories:
 In-place jumps
 Standing jumps
 Multiple jumps
 In-depth jumping
 Bounding
Before starting a plyometrics program, the athlete should be adequately tested. The
first group of tests are called static. An example of this is the single leg stance. Start
with the eyes open and progress on to eyes closed. You can add more difficulty to this
exercise by adding a squat.
The next set of testing exercises is dynamic testing. An example of these is vertical
jumps. Progression can go from two leg jumps to a single leg jump.
When designing a plyometrics program, it is important to keep the following factors in
mind:
 Direction of body movement
 Weight of the athlete
 Speed of the movement
 External load
 Intensity
 Volume
 Frequency
 Training age
 Recovery time
To minimize injury, make sure you follow these guidelines:
 Specific to the athlete's needs
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 Break skill down into small components
 Quality of work is more important than quantity
 Higher the intensity, the greater the recovery time
 Perform plyometrics after a normal practice session
 When proper technique cannot be accomplished, maximal volume has been
reached
 Exercises should be progressive done no more than 3 times a week, more volume
during preseason, nothing during in season
 Do dynamic testing to motivate the athlete
H. RETURN TO SPORT ACTIVITY:
This phase is the final one of the rehabilitation program. Before the athlete goes back
to activity, they should be functionally tested by sport and pain free. The testing should
be as specific to the athlete's sport.
Some examples of functional activities by sport are:
 Baseball/Softball/Cricket/Hockey
o Lower Extremity: running/cutting around the bases
o Upper Extremity: performing overhand throwing
 Football:
o Lower Extremity: Cutting, getting up from a stance
o Upper Extremity: throwing a spiral, catching a throw
 Volleyball:
o Lower Extremity: jumping up over net to perform a spike
o Upper Extremity: perform a serve
 Soccer:
o Lower Extremity: passing the ball, running
o Upper Extremity: practice a throw-in
 Basketball:
o Lower Extremity: Rebounding drills, cutting
o Upper Extremity: practice shooting and passing drills
If the athlete has pain-free during the testing, you should wait another day before
returning them to the sport. Start the athlete practicing on lighter drills and work up
slowly to full participation.
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2.9.3 EFFECTS OF JOINT MOBILIZATION:
A. NEUROPHYSIOLOGICAL EFFECTS:
 Stimulates mechanoreceptors to Ô pain
 Affect muscle spasm & muscle guarding – nociceptive stimulation
 Increase in awareness of position & motion because of afferent nerve impulses
B. NUTRITIONAL EFFECTS:
 Distraction or small gliding movements – cause synovial fluid movement
 Movement can improve nutrient exchange due to joint swelling & immobilization
Inflammatory arthritis C. MECHANICAL EFFECT:
 Improve mobility of hypo mobile joints (adhesions & thickened CT from
immobilization – loosens)
 Maintains extensibility & tensile strength of articular tissues
D. CRACKING NOISE MAY SOMETIMES OCCUR:
I. CONTRAINDICATIONS FOR MOBILIZATION:
 Should not be used haphazardly
Malignancy Avoid the following:
 Inflammatory arthritis
 Malignancy
 Tuberculosis
 Osteoporosis
 Ligamentous rupture
Bone disease
 Herniated disks with nerve compression
 Bone disease
 Neurological involvement
 Bone fracture
 Congenital bone deformities
 Vascular disorders
 Joint effusion
 May use I & II mobilizations to relieve pain
Precautions:
 Osteoarthritis
 Pregnancy
 Flu
Osteoporosis  Total joint replacement
 Severe scoliosis
 Poor general health Herniated disks with nerve
compression
 Patient’s inability to relax
Vascular disorders
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E. MAITLAND JOINT MOBILIZATION GRADING SCALE:
Grading based on amplitude of movement & where within available ROM the force is
applied.
hypomobile joints Grade I
 Small amplitude rhythmic oscillating movement at the beginning of range of
movement
 Manage pain and spasm
Grade II
 Large amplitude rhythmic oscillating movement within midrange of movement
 Manage pain and spasm
Note: Grades I & II – often used before & after treatment with grades III & IV
Grade III
 Large amplitude rhythmic oscillating movement up to point of limitation (PL) in
range of movement
 Used to gain motion within the joint
 Stretches capsule & CT structures
Grade IV
 Small amplitude rhythmic oscillating movement at very end range of movement
 Used to gain motion within the joint
 Used when resistance limits movement in absence of pain
Grade V – (thrust technique) - Manipulation
 Small amplitude, quick thrust at end of range
 Accompanied by popping sound (manipulation)
 Velocity vs. force
 Requires training
Indications for Mobilization:
Grades I and II - primarily used for pain
 Pain must be treated prior to stiffness
 Painful conditions can be treated daily
 Small amplitude oscillations stimulate mechanoreceptors - limit pain perception
Grades III and IV - primarily used to increase motion
 Stiff or should be treated 3-4 times per week – alternate with active motion
exercises
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F. ALWAYS EXAMINE PRIOR TO TREATMENT:
 If limited or painful ROM, examine & decide which tissues are limiting function
 Determine whether treatment will be directed primarily toward relieving pain or
stretching a joint or soft tissue limitation
 Quality of pain when testing ROM helps determine stage of recovery & dosage of
techniques:
1. If pain is experienced BEFORE tissue limitation, gentle pain-inhibiting joint
techniques may be used. Stretching under these circumstances is
contraindicated
2. If pain is experienced CONCURRENTLY with tissue limitation (e.g. pain &
limitation that occur when damaged tissue begins to heal) the limitation is
treated cautiously – gentle stretching techniques used
3. If pain is experienced AFTER tissue limitation is met because of stretching of
tight capsular tissue, the joint can be stretched aggressively
G. JOINT MOBILIZATION APPLICATION:
 All joint mobilizations follow the convex-concave rule
 Patient should be relaxed
 Explain purpose of treatment & sensations to expect to patient
 Evaluate BEFORE & AFTER treatment
 Stop the treatment if it is too painful for the patient
 Use proper body mechanics
 Use gravity to assist the mobilization technique if possible
 Begin & end treatments with Grade I or II oscillations
Positioning & Stabilization
 Patient & extremity should be positioned so that the patient can RELAX
 Initial mobilization is performed in a loose-packed position
 In some cases, the position to use is the one in which the joint is least painful
 Firmly & comfortably stabilize one joint segment, usually the proximal bone
 Hand, belt, assistant
 Prevents unwanted stress & makes the stretch force more specific & effective
H. TREATMENT FORCE & DIRECTION OF MOVEMENT:
 Treatment force is applied as close to the opposing joint surface as possible. The
larger the contact surface is, the more comfortable the procedure will be (use flat
surface of hand vs. thumb)
 Direction of movement during treatment is either PARALLEL or PERENDICULAR
to the treatment plane
 Treatment plane lies on the concave articulating surface, perpendicular to a line
from the centre of the convex articulating surface
 Joint traction techniques are applied perpendicular to the treatment plane. Entire
bone is moved so that the joint surfaces are separated
 Gliding techniques are applied parallel to the treatment plane
 Glide in the direction in which the slide would normally occur for the desired motion
 Direction of sliding is easily determined by using the convex-concave rule
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 The entire bone is moved so that there is gliding of one joint surface on the other
 When using grade III gliding techniques, a grade I distraction should be used
 If gliding in the restricted direction is too painful, begin gliding mobilizations in the
painless direction then progress to gliding in restricted direction when not as painful
* Revaluate the joint response the next day or have the patient report at the next visit
 If increased pain, reduce amplitude of oscillations
 If joint is the same or better, perform either of the following:
** Repeat the same manoeuvre if goal is to maintain joint play
 Progress to sustained grade III traction or glides if the goal is to increase joint play
Speed, Rhythm, & Duration of Movements
1. Joint mobilization sessions usually involve:
o 3-6 sets of oscillations
o Perform 2-3 oscillations per second
o Lasting 20-60 seconds for tightness
o Lasting 1-2 minutes for pain 2-3 oscillations per second
2. Apply smooth, regular oscillations
3. Vary speed of oscillations for different effects
4. For painful joints, apply intermittent distraction for 7-10 seconds with a few seconds
of rest in between for several cycles
5. For restricted joints, apply a minimum of a 6-second stretch force, followed by
partial release then repeat with slow, intermittent stretches at 3-4 second intervals
Patient Response
 May cause soreness
 Perform joint mobilizations on alternate days to allow soreness to decrease &
tissue healing to occur
 Patient should perform ROM techniques
 Patient’s joint & ROM should be reassessed after treatment, & again before the
next treatment
 Pain is always the guide
Joint Traction Techniques
 Technique involving pulling one articulating surface away from another – creating
separation
 Performed perpendicular to treatment plane
 Used to decrease pain or reduce joint hypo mobility
 Kaltenborn classification system
=Combines traction and mobilization
= Joint looseness => slack
Kaltenborn Traction Grading
Grade I (loosen)
 Neutralizes pressure in joint without actual surface separation
 Produce pain relief by reducing compressive forces]
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NATIONAL PHYSIOTHERAPY EXAM PREP GUIDE
NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of
Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for
any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject
to recall by Mullsons Health & Wellness at any time.
Grade II (tighten or take up slack)
 Separates articulating surfaces, taking up slack or eliminating play within joint
capsule
 Used initially to determine joint sensitivity
Grade III (stretch)
 Involves stretching of soft tissue surrounding joint
 Incr