PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 1 of 92
NPTE
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-2
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 05/04/2009
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
1

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 2 of 92
NPTE
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
11.0 PHYSICAL AGENTS AND MODALITIES: ....................................................................................................................................................... 6
11.1 THERAPEUTIC MODALITIES: ................................................................................................................................................................. 6
11.1.1 THERMAL AGENTS: ................................................................................................................................................................ 7
A. CRYOTHERAPY: ...................................................................................................................................................................... 7
B. THERMOTHERAPY:................................................................................................................................................................. 8
I. CONTRAINDICATIONS FOR HEAT MODALITIES:......................................................................................................... 8
D. ELECTRICAL MODALITIES: .................................................................................................................................................... 8
I. ELECTRIC STIMULATION: .............................................................................................................................................. 9
II. ELECTRIC STIMULATION / ULTRASOUND COMBO:.................................................................................................. 10
11.1.2 ACROMIOCLAVICULAR SPRAIN REHABILITATION PROGRAM: ....................................................................................... 10
11.1.3 SHOULDER DISLOCATION REHABILITATION PROGRAM:................................................................................................ 14
11.1.4 ADULT WHEELCHAIR MEASUREMENTS: ........................................................................................................................... 20
11.1.5 WOUND STAGING: ................................................................................................................................................................ 21
A. ULCERS:................................................................................................................................................................................. 21
B. PRESSURE ULCERS: ............................................................................................................................................................ 22
I. PREVENTION: ................................................................................................................................................................ 23
II. MAKE SURE: .................................................................................................................................................................. 23
III. TIPS FOR PROPER POSITIONING AND MOVEMENT IN CHAIRS: ............................................................................ 24
C. ORAL ULCER: ........................................................................................................................................................................ 25
I. SYMPTOMS:................................................................................................................................................................... 25
II. CAUSES:......................................................................................................................................................................... 25
III. TREATMENT: ................................................................................................................................................................. 26
D. PEPTIC ULCER: ..................................................................................................................................................................... 26
I. CAUSES:......................................................................................................................................................................... 26
II. PREVENTION: ................................................................................................................................................................ 27
III. DIAGNOSIS: ................................................................................................................................................................... 27
IV. TREATMENT: ................................................................................................................................................................. 28
E. CORNEAL ULCER:................................................................................................................................................................. 28
I. CAUSES:......................................................................................................................................................................... 28
III. DIAGNOSING CORNEAL ULCERS: .............................................................................................................................. 29
IV. TREATMENT FOR CORNEAL ULCERS:....................................................................................................................... 29
F. VENOUS ULCERS:................................................................................................................................................................. 30
I. CAUSES:......................................................................................................................................................................... 30
II. SYMPTOMS:................................................................................................................................................................... 30
III. DIAGNOSIS: ................................................................................................................................................................... 30
IV. TREATMENT: ................................................................................................................................................................. 31
V. RISK FACTORS FOR VENOUS SKIN ULCERS: ........................................................................................................... 31
G. DIABETIC FOOT ULCERS: .................................................................................................................................................... 32
I. PERIPHERAL NEUROPATHY: ...................................................................................................................................... 32
II. CHARCOT FOOT DEFORMITY: .................................................................................................................................... 33
III. MICROVASCULAR DISEASE: ....................................................................................................................................... 33
IV. TREATMENT: ................................................................................................................................................................. 33
H. GENITAL ULCER:................................................................................................................................................................... 33
I. GENITAL HERPES SIMPLEX: ....................................................................................................................................... 33
II. SYPHILIS: ....................................................................................................................................................................... 35
III. CHANCROID:.................................................................................................................................................................. 35
IV. UNCOMMON CONDITIONS:.......................................................................................................................................... 35
I. PREVENTION AND TREATMENT OF PRESSURE ULCERS: .............................................................................................. 35
11.1.6 ELECTRONIC, ELECTRICAL MODALITIES: .............................................................................................................................. 37
A. ULTRASONIC: ........................................................................................................................................................................ 37
I. CONTRAINDICATIONS: ................................................................................................................................................. 37
II. UV RADIATION THERAPY:............................................................................................................................................ 37
III. INDICATIONS: ................................................................................................................................................................ 37
IV. CONTRAINDICATIONS: ................................................................................................................................................. 37
B. SHORT-WAVE DIATHERMY:................................................................................................................................................. 38
C. LASER THERAPY:.................................................................................................................................................................. 38
D. LONGWAVE THERAPY (FOR PAIN RELIEF):....................................................................................................................... 38
E. MFC (Medium Frequency Currents):....................................................................................................................................... 38
F. CONTRAINDICATIONS: ......................................................................................................................................................... 38
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
2

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 3 of 92
NPTE
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.
11.1.7
PHYSIOTHERAPY MODALITIES IN RHEUMATOID ARTHRITIS: ........................................................................................ 39
A.
COLD/HOT APPLICATIONS:.................................................................................................................................................. 39
I. PARAFFIN WAX BATH (P.W.B.): ................................................................................................................................... 40
B ELECTRICAL STIMULATION: ................................................................................................................................................ 40
I. ELECTRICAL CURRENTS: ............................................................................................................................................ 40
II. TENS (TRANSCUTANEOUS NERVE STIMULATOR): .................................................................................................. 40
C. HYDROTHERAPY: ................................................................................................................................................................. 41
I. WHIRLPOOL TREATMENT:........................................................................................................................................... 41
II. TEMPERATURE OF WHIRLPOOL:................................................................................................................................ 41
III. CONTRAINDICATIONS FOR WHIRLPOOL:.................................................................................................................. 41
D. BALNEOTHERAPY:................................................................................................................................................................ 42
I. INDICATIONS FOR BALNEOTHERAPY: ....................................................................................................................... 42
II. CONTRAINDICATIONS: ................................................................................................................................................. 43
III. CAUTIONS:..................................................................................................................................................................... 43
E. VACUUM ASSISTED WOUND CLOSURE:............................................................................................................................ 43
F. HYPERBARIC MEDICINE: ..................................................................................................................................................... 43
G. MASSAGE THERAPY:............................................................................................................................................................ 44
I. MODES OF THERAPEUTIC MASSAGE: ....................................................................................................................... 44
II. ADVANTAGES FROM MASSAGE THERAPY: .............................................................................................................. 45
III. WHERE NOT TO MASSAGE?........................................................................................................................................ 45
12.0 FUNCTIONAL TRAINING AND ORTHOTIC, PROSTHETIC AND SUPPORTIVE DEVICES: ...................................................................... 46
12.1 ADULT UPPER LIMB PROSTHETIC TRAINING:................................................................................................................................... 46
12.1.1 POSTOPERATIVE THERAPY PROGRAM: ........................................................................................................................... 46
A. PROMOTE WOUND HEALING: ............................................................................................................................................. 47
B. CONTROL INCISIONAL AND PHANTOM PAIN: ................................................................................................................... 47
C. MAINTAIN JOINT RANGE OF MOTION:................................................................................................................................ 47
D. EXPLORE THE FEELINGS OF THE PATIENT AND FAMILY: .............................................................................................. 47
E. FINANCIAL SPONSORSHIP: ................................................................................................................................................. 48
12.1.2 PREPROSTHETIC THERAPY PROGRAM: ........................................................................................................................... 48
A. RESIDUAL LIMB SHRINKAGE AND SHAPING: .................................................................................................................... 49
B. RESIDUAL LIMB DESENSITIZATION:................................................................................................................................... 49
C. MAINTENANCE OF JOINT RANGE OF MOTION:................................................................................................................. 49
D. INCREASING MUSCLE STRENGTH: .................................................................................................................................... 49
E. INSTRUCTION IN PROPER HYGIENE OF THE LIMB: ......................................................................................................... 50
F. MAXIMIZING INDEPENDENCE: ............................................................................................................................................ 50
G. MYOELECTRIC SITE TESTING:............................................................................................................................................ 50
H. ORIENTATION TO PROSTHETIC OPTIONS: ....................................................................................................................... 50
12.1.3 DETERMINING THE PROSTHETIC PRESCRIPTION:.......................................................................................................... 51
A. FABRICATION AND TRAINING TIME:................................................................................................................................... 51
12.1.4 ADULT UPPER-LIMB PROSTHETIC TRAINING: .................................................................................................................. 52
A. INITIAL ASSESSMENT:.......................................................................................................................................................... 52
B. STATUS OF THE OPPOSITE UPPER LIMB: ·....................................................................................................................... 52
C. INITIAL VISIT: ......................................................................................................................................................................... 52
D. ORIENTATION TO PROSTHETIC COMPONENT TERMINOLOGY:..................................................................................... 53
E. PROSTHETIC WEARING SCHEDULE: ................................................................................................................................. 53
F. CARE OF THE RESIDUAL LIMB AND PROSTHESIS: .......................................................................................................... 53
G. BODY CONTROL MOTIONS:................................................................................................................................................. 54
H. PROSTHETIC EVALUATION: ................................................................................................................................................ 54
I. PROSTHETIC CONTROLS TRAINING: ................................................................................................................................. 55
J. CONTROLS PRACTICE: ........................................................................................................................................................ 55
K. FUNCTIONAL USE TRAINING:.............................................................................................................................................. 56
I. CUTTING FOOD: ............................................................................................................................................................ 57
II. USING SCISSORS: ........................................................................................................................................................ 57
III. DRESSING:..................................................................................................................................................................... 57
IV. OPENING A JAR OR BOTTLE: ...................................................................................................................................... 57
V. WASHING DISHES:........................................................................................................................................................ 57
VI. HAMMERING A NAIL AND USING TOOLS: .................................................................................................................. 57
VII. DRIVING A CAR: ............................................................................................................................................................ 58
VII. VOCATIONAL ACTIVITIES:............................................................................................................................................ 58
IX. HOME INSTRUCTIONS:................................................................................................................................................. 59
X. FOLLOW-UP ISSUES:.................................................................................................................................................... 59
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
3

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 4 of 92
NPTE
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.
12.2 PHYSIOTHERAPYMANAGEMENT OF ADULT LOWER-LIMB AMPUTEES:........................................................................................ 61
12.2.1. PRESURGICAL MANAGEMENT:........................................................................................................................................... 62
A. INITIAL PATIENT CONTACT:................................................................................................................................................. 62
12.2.2. POSTSURGICAL MANAGEMENT & EVALUATION: ............................................................................................................. 62
A. PAST MEDICAL HISTORY: .................................................................................................................................................... 62
B. MENTAL STATUS:.................................................................................................................................................................. 62
C. RANGE OF MOTION: ............................................................................................................................................................. 62
D STRENGTH:............................................................................................................................................................................ 63
E. SENSATION:........................................................................................................................................................................... 63
F. BED MOBILITY: ...................................................................................................................................................................... 63
G. BALANCE/COORDINATION:.................................................................................................................................................. 63
H. TRANSFERS:.......................................................................................................................................................................... 63
I. WHEELCHAIR PROPULSION:............................................................................................................................................... 63
J. AMBULATION WITH ASSISTIVE DEVICES WITHOUT PROSTHESIS: ............................................................................... 63
K. CARDIAC PRECAUTIONS FOR AMPUTEES:....................................................................................................................... 64
12.2.3 PATIENT EDUCATION: LIMB MANAGEMENT:..................................................................................................................... 65
A. LIMB CARE: ............................................................................................................................................................................ 65
I. PROBLEM DETECTION/SKIN CARE: ........................................................................................................................... 65
II. PROSTHETIC MANAGEMENT: ..................................................................................................................................... 65
III. SOCK REGULATION:..................................................................................................................................................... 65
IV. DONNING AND DOFFING OF THE PROSTHESIS; ...................................................................................................... 65
V. RESIDUAL-LIMB WRAPPING: ....................................................................................................................................... 66
12.2.4 PREPROSTHETIC EXERCISE:.............................................................................................................................................. 69
A. STRENGTHENING: ................................................................................................................................................................ 69
I. RANGE OF MOTION: ..................................................................................................................................................... 70
II. FUNCTIONAL ACTIVITIES:............................................................................................................................................ 71
III. GENERAL CONDITIONING: .......................................................................................................................................... 71
IV. BED MOBILITY: .............................................................................................................................................................. 71
V. TRANSFERS:.................................................................................................................................................................. 71
VI. NOTE FOR THE PT (TRANSFERRING A PATIENT) .................................................................................................... 72
VII. WHEELCHAIR PROPULSION:....................................................................................................................................... 75
VIII. UNSUPPORTED STANDING BALANCE: ...................................................................................................................... 75
IX. AMBULATION WITH ASSISTIVE DEVICES: ................................................................................................................. 76
12.2.5 PREGAIT TRAINING: ............................................................................................................................................................. 76
A. BALANCE AND COORDINATION: ......................................................................................................................................... 76
12.2.6 ORIENTATION TO THE CENTER OF GRAVITY AND BASE OF SUPPORT: ...................................................................... 77
A. SINGLE-LIMB STANDING: ..................................................................................................................................................... 77
12.3 GAIT-TRAINING SKILLS:........................................................................................................................................................................ 79
12.3.1 SOUND LIMB AND PROSTHETIC LIMB TRAINING:............................................................................................................. 79
A. PELVIC MOTIONS:................................................................................................................................................................. 79
12.3.2 VARIATIONS:.......................................................................................................................................................................... 82
12.3.3 ADVANCED GAIT-TRAINING ACTIVITIES: ........................................................................................................................... 83
A. STAIRS: .................................................................................................................................................................................. 83
B. STEP BY STEP:...................................................................................................................................................................... 83
C. STEP OVER STEP: ................................................................................................................................................................ 83
D. TRANSTIBIAL AMPUTEES: STEP OVER STEP: .................................................................................................................. 83
E. CRUTCHES: ........................................................................................................................................................................... 84
F. CURBS:................................................................................................................................................................................... 84
G. UNEVEN SURFACES:............................................................................................................................................................ 84
H. RAMPS AND HILLS: ............................................................................................................................................................... 84
I. SIDESTEPPING:..................................................................................................................................................................... 85
J. BACKWARD WALKING: ......................................................................................................................................................... 85
K. MULTIDIRECTIONAL TURNS: ............................................................................................................................................... 85
L. TANDEM WALKING:............................................................................................................................................................... 86
M. BRAIDING: .............................................................................................................................................................................. 86
N. SINGLE-LIMB SQUATTING:................................................................................................................................................... 86
O. FALLING: ................................................................................................................................................................................ 86
XV. FLOOR TO STANDING: ................................................................................................................................................. 86
P. RUNNING SKILLS: ................................................................................................................................................................. 87
Q. RECREATIONAL ACTIVITIES:............................................................................................................................................... 88
13.0 PROFESSIONAL ROLES AND MANAGEMENT:.......................................................................................................................................... 90
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
4

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 5 of 92
NPTE
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.
13.1 PATIENT CARE ACTIVITIES:................................................................................................................................................................. 90
13.1.1 DIRECT PATIENT CARE:....................................................................................................................................................... 90
13.1.2 INDIRECT PATIENT CARE ACTIVITIES:............................................................................................................................... 90
13.2 NON-PATIENT CARE ACTIVITIES:........................................................................................................................................................ 90
13.3 THE ROLE OF THE PHYSIOTHERAPIST:............................................................................................................................................. 91
13.3.1 EXPECTED PROVISIONS FROM THE PHYSIOTHERAPIST BY THE PATIENT:................................................................ 91
A. RESPONSIBILITIES TO THE CLIENT: .................................................................................................................................. 91
13.3.2 DIFFERENT TYPES OF PHYSIOTHERAPY:......................................................................................................................... 92
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
5

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 6 of 92
NPTE
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.
11.0 PHYSICAL AGENTS AND MODALITIES:
11.1 THERAPEUTIC MODALITIES:
 Contemporary Use of Therapeutic Modalities
 Psychological Aspects of Rehabilitation
 Tissue Injury, Inflammation, and Repair
 Pain and Pain Relief
 Persistent Pain and Chronic Pain
 Impact of Injury and Pain on Neuromuscular Control
 Evidence-Based Application of Therapeutic Modalities
 Cold and Superficial Heat
 Principles of Electrotherapy
 Clinical Uses of Electrical Stimulation
 Ultrasound, Diathermy, and Electromagnetic Fields
 Low Level LASER Therapy
 Mechanical Energy
 Treatment Plans for Acute Musculoskeletal Injuries
 Neuromuscular Control and Biofeedback
 Clinical Management of Persistent and Chronic Pain
Stroking - Relaxation; start and end of session
Kneading - Loosening adhesions and increasing venous return
Tapotement - Nerve stimulation or lung decongestion
Friction - Perpendicular muscle fibbers: stretch scars, loosen adhesions due to inflammation
process
therapeutic_modaliti
es.pdf
Stroking Kneading Tapotement Friction
What are therapeutic modalities? It's the treatment or application of some form of stress to the body for the
purpose of eliciting an adaptive response. The stress must be conducive to the healing process. They fall
into four categories:
 Thermal
 Mechanical
 Electrical
 Chemical
Although modalities from all four categories are used in the training room at Gettysburg College, we will
only be looking at the thermal and electrical modalities.
The goal of therapeutic modalities is to provide an optimal healing environment. Many modalities rely on
the Gate Control Theory. We use therapeutic modalities to override the perception of pain. For example,
when you bang your shin, your first response is to rub it. This is an example of the sensory stimulation
overriding pain perception.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
6

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 7 of 92
NPTE
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.
11.1.1 THERMAL AGENTS:
 Thermal agents are the application of heating or cooling modalities to treat disease and other
traumatic injuries. Its main objective is to produce cellular and vascular changes with
variations in heating and cooling. Cryotherapy is the use of cold, while thermo therapy is the
use of heat.
 To provide an optimal healing environment through the use of thermal agents, one of four
modes can be utilized:
 Conduction is when there is heat loss or gain through direct contact, such as an ice pack.
 Convection is heat loss or gain through the movement of water molecules across the skin,
such as a whirlpool.
 Conversion is changing from one energy form into another, and will be discussed under
ultrasound.
 Evaporation is when thermal energy is removed when there is a change from the liquid state
to the gaseous state, such as a vapocoolant spray.
A. CRYOTHERAPY:
Cold is a relative state characterized by decreased molecular motion. The temperature
ranges from 32 to 65 degrees, and the body reacts with a series of Local and systemic
effects.
Indications to use cold modalities:
1. Acute injuries or inflammation
2. Acute or chronic pain
3. Small, superficial first degree burns
4. Post surgical pain and edema
5. In conjunction with rehabilitation exercises
6. Spasticity accompanying CNS disorders
7. Acute or chronic muscle spasm
Contraindications, when you don't want to use cold modalities:
1. Cardiac or respiratory involvement (because there is a decrease in HR and
respiratory rate)
2. Uncovered open wounds (slows the healing process)
3. Circulatory insufficiency (decrease in metabolic rate - be careful of diabetic patients)
4. Cold allergy
5. Superficial nerves (peroneal/ulnar)
6. Raynaud's Phenomenon
There are a variety of clinical applications for cryotherapy:
1. Ice Packs
2. Ice Massage
3. Ice Immersion
4. Cryostretch
5. Cold Whirlpool
Cryokinetics is the use of cold and exercise together during treatment. The athlete would
exercise while using a cold modality or post modality. The majority is performed in the
whirlpool. An example is an ankle in the whirlpool doing ROM exercises, and post
whirlpool performing manual resistance exercises. The advantage to doing this is there is
decreased pain and spasm leading to improved motion and strength in subacute and
chronic situations. A disadvantage is that the athlete's proprioception is lower, so he is
limited in his selection of exercises. In addition, the athlete may be working through pain
that is performing a protective function.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
7

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 8 of 92
NPTE
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.
B. THERMOTHERAPY:
Heating modalities result in an increase in molecular vibration and cellular metabolic rate.
It is divided into two categories, superficial and deep heating modalities. It is further
divided into chemical, electric, or magnetic. Temperatures range from 105 to 170
degrees. Superficial modalities include infrared lamps, moist heat packs, paraffin baths,
and warm whirlpools. Deep heating modalities include microwave diathermy, short wave
diathermy, and ultrasound. The body reacts with a series of local and systemic effects.
Indications f or heat modalities:
1. Subacute or chronic inflammatory conditions
2. When there is pain at the subacute and chronic levels
3. Chronic muscle spasm
4. When there is decreased ROM
5. Reduction of joint contractures
Circulatory problems
I. CONTRAINDICATIONS FOR HEAT MODALITIES:
1. Acute injuries
2. Circulatory problems
3. Poor thermal circulation
4. Areas of the body that are anesthetic
The following are some of the more commonly used thermo therapy modalities
utilized in the athletic training room:
1. Moist Heat Packs
2. Paraffin Bath
3. Warm Whirlpool
4. Ultrasound
D. ELECTRICAL MODALITIES:
Electrical stimulation is used for acute, subacute, and chronic injuries. There are many
indications and contraindications for electric stimulation. There are three basic set-ups for
pad placement: monopolar, bipolar, and quadripolar. Monopolar is one electrode running
from one channel, bipolar is two electrodes running from one channel, and quadripolar is
four electrodes running from two channels. If you are treating a smaller area, bipolar or
monopolar should be used. If the area being treated is large with more muscle mass
(such as the thigh), the quadripolar set-up should be used.
Some clinical applications of electrical stimulation are for creating muscle contraction
through nerve or muscle stimulation, stimulating sensory nerves to help in treating pain,
creating an electrical field in biological tissues to stimulate or alter the healing process,
and creating an electrical field on the skin surface to drive ions beneficial to the healing
process into or through the skin.
As electricity passes through the body, changes in the physiologic functioning can occur
at various levels:
1) Cellular
2) Tissue
3) Segmental
4) Systematic
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
8

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 9 of 92
NPTE
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.
Cellular Level (Five major effects)
1. Excitation of nerve cells
2. Changes in cell membrane permeability
3. Protein synthesis
4. Stimulation of fibroblasts, osteoblasts
5. Modification of microcirculation
Tissue Level (Multiple cellular events)
1. Skeletal muscle contraction
2. Smooth muscle contraction
3. Tissue regeneration
Segmental Level (Regional effect from cellular and tissue levels)
1. Modification of joint mobility
2. Muscle pumping action to change circulation and lymphatic activity
3. Alteration of the micro vascular system to associated with muscle pumping
Systemic Effects
1. Analgesic effects as endogenous pain suppressors are released and act at different
levels to control pain
2. Analgesic effects from the stimulation of certain neurotransmitters to control neural
activity in the presence of pain stimuli
I. ELECTRIC STIMULATION:
Quadripolar When setting up your athlete, you always want to make sure they are in the most
setup comfortable position. When you place the electrodes on the athlete, ask him where
he feels the most pain and place the electrodes accordingly. Keep in mind that the
farther apart the electrodes are, the deeper the penetration.
There are three basic programs that can be used to apply stim to various injuries.
For an acute or subacute injury, the programs used are interferential and
premodulated. These two types of ES are high frequency, sensory level currents that
can be used to override the Gate Control Theory of pain. For chronic pain, you want
to use the Russian Stimulation program. This is a low frequency, motor unit stimulus
that produces a contraction in the muscle. The program can be used for muscle re-
education, muscle strengthening, or to produce a muscle pumping action to reduce
Stim and Ice edema.
If the unit you are using has a dispersive pad to ground the patient that must be
set up. The first thing to do is wet a paper towel to place on the dispersive pad. This
aids as a conductor. Let's say you are treating a quad injury. With the athlete sitting
with his legs straight out on a table, the dispersive pad would be placed underneath
the hamstrings.
When choosing interferential, you want to use the quadripolar set-up. With this,
the electrodes are set up in a diagonal pattern. For this type of setup, you want to
place the red electrodes diagonal of each other and the black electrodes diagonal of
each other. With the premodulated setup, you can choose between monopolar,
bipolar, and quadripolar. You will use the same high frequency setup as the
interferential program.
If you choose interferential, the next step you want to do is to pick the frequency.
For pain control, you should choose 80-150 MHz, for 15 minutes. The premodulated
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
9

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 10 of 92
NPTE
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.
setup for a high frequency program will also give you the choice of 80-150 MHz for
15 minutes. After you select the program, push the start button.
The next step is to turn up the intensity. As you turn up the intensity, tell the
athlete that he will feel a tingling sensation. Ask your athlete to let you know when he
starts to feel the tingling. When they tell you, you can then ask them to let you know
when to stop increasing the intensity as it reaches a comfortable level. Once this is
set, come back every five minutes to check on the athlete and to increase the
intensity if it isn't as strong.
Electrical stimulation can be used in conjunction with other treatments, such as
ice or stim. Both of these treatments work together to override the Gate Control
Theory of pain. Using two treatments at once saves time for both you and the athlete.
II. ELECTRIC STIMULATION / ULTRASOUND COMBO:
Ultrasound and electric stim can be used together to override the Gate Control
Theory. When setting up this treatment, place the electrodes in a bipolar set up. Put
the ultrasound transmission gel over the area of pain, and set up the parameters for
the ultrasound, followed by those for electric stim. The parameters remain the same
as previously explained. Once the treatment has been started and the intensity set at
a comfortable level, tell the athlete that they will feel a motor impulse as the
ultrasound head passes a trigger point within the muscle. Treatment time is set for 5
minutes.
11.1.2 ACROMIOCLAVICULAR SPRAIN REHABILITATION PROGRAM:
Phase I - Control Inflammation (1-2 days for Grade I sprain, 2-3 days for Grade II)
Goals:
Control Inflammation and Pain
Reduce Swelling
Rehab:
1) Cryotherapy
A: Ice for 20 minutes
2) Modalities
A: Interferential Stim (can be used with ice at the same time)
3) NSAIDS
A: Ibuprofen/Advil - 4 times a day for 3 days (only if no allergies)
Phase II - Restore Range of Motion (2-4 days for Grade I sprain, 3-7 days for Grade II sprain)
Goals:
 Passive and active range motion is within 80% of normal in the unaffected arm
 Joint flexibility in affected limb is restored
 Cardiovascular endurance is maintained at preinjury level
 Range of motion exercises performed pain free
Rehab:
1. Heat Therapy
A: Hot pack for 20 minutes
2. Modalities
A: Pulsed ultrasound for 5 minutes
3. Flexibility Exercises
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
10

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 11 of 92
NPTE
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: Hold involved arm across the chest at the involved elbow, pushing slightly posterior until a str
is felt
B: Hold sides of a doorway with hand behind you. Let arms straighten as you lean forward. Rep
with hands in front of you as you lean backward.
4. Codman's Exercises
* Perform without free weights (pain-free)
A: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table with t
involved arm dangling in front of you.
B: Stabilize the scapula with a belt by wrapping it around the upper body and scapula.
C: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging motion
going forwards and backwards, side to side, and in circles.
5. Wall Crawls (Flexion and abduction)
A: Place hand on wall and have fingers crawl up the wall until end of range of motion. Repeat go
down the wall.
B: Start by facing a wall, repeat exercise again by facing sideways to the wall
6. Shoulder Wheel
A: Place hand on grip of shoulder wheel and move wheel around until maximal range of motion i
reached. Repeat going the opposite way.
7. Pulley
A: Place hands on both ends of pulley and have the affected limb pull downward. Repeat again
unaffected limb pulling downward.
8. Cane Exercises
A: Shoulder flexion - hold cane with hands palm down at waist height.
Raise the wand overhead leading with the uninvolved arm until a stretch is felt in the involved
shoulder.
B: Shoulder abduction - hold cane with involved arm palm up, uninvolved arm palm down. Push
cane sideways and upward toward the involved side with the uninvolved arm until a stretch is
in involved shoulder.
C: Shoulder adduction - reverse hand positions from the previous exercise. Pull the cane toward
uninvolved side until a stretch is felt in the involved shoulder.
D: Shoulder internal/external rotation - keep hands palms down on ends of cane at waist level.
Move cane upward toward the head, and then return to the waist level.
9. Cardiovascular Endurance
A: Bike for 20 minutes
10. Cryotherapy
A: Ice after for 20 minutes
Phase III - Strength Training (5-7 days for Grade I sprain, 7-14 days for Grade II sprain)
Goals:
 Range of Motion and flexibility of affected arm equals unaffected arm
 Muscular Strength is equal between affected and unaffected arm
 Cardiovascular endurance maintained at preinjury level
 Range of Motion and Strength Exercises performed without pain
Rehab:
1. Heat Therapy/Flexibility
A: Continue heat and ultrasound therapy
B: Continue flexibility exercises
2. Codman's Exercises with Free Weights
Progress through free weights as tolerated (pain-free)
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
11

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 12 of 92
NPTE
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: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table
with the involved arm dangling in front of you.
B: Stabilize the scapula with a belt by wrapping it around the upper body and scapula.
C: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging
motion, going forwards and backwards, side to side, and in circles.
3. Theraband
A: Flexion - Grip theraband in front of you with the elbow extended. Pull theraband upward
until maximal range of motion is reached and lower downward.
B: Extension - Start in same position as flexion. Pull theraband backward until maximal
range of motion is reached and bring back to starting position.
C: Internal Rotation - Stand in front of theraband board with affected arm facing it. Rotate
arm inward across body while gripping the unattached end of theraband.
D: External Rotation - Stand in front of theraband board with unaffected arm facing It. Rotate
arm outward away from the body while gripping the unattached end of theraband.
E: Abduction - Stand in front of codman with affected arm facing it. Start with arm across the
body and pull away from side.
F: Adduction - Stand in front of codman with affected arm facing it. Grab the theraband and
pull arm toward the buttocks.
G: Horizontal Abduction - Stand in front of theraband board with unaffected arm facing it.
Bring shoulder up to 90 degrees of flexion so that it is parallel to the floor. Pull arm
across body toward the opposite shoulder.
H: Horizontal Adduction - Stand in front of theraband board with affected arm facing it. Bring
shoulder to 90 degrees of flexion so that it is parallel to the floor. Pull arm across body
towards the opposite shoulder.
I: As strength is gained, progress up to different colors of tubing.
4. Proprioception (Cat Stretch-Starting Position)
A: Start in a non-weight bearing position (knees flexed) on a floor
B: As patient gains strength, incorporate the following progressions:
 Body movement - static (still) to dynamic (moving)
 Amount of arms involved - bilateral (2 arms) to unilateral (1 arm) Surface - stable
(floor or wall) to unstable (single and multilane boards)
C: Perform 3-5 stances, holding 15-20 seconds
5. Open Kinetic Chain Exercises
A: Weight Training (Starting position - place weight in affected hand)
 Flexion: Bring it forward and towards the ceiling until maximal range of motion is
reached. Lower downward.
 Extension: Bring weight backward towards the ceiling until maximal range of motion
is reached. Lower downward.
 Abduction/Adduction: Raise weight to the side until maximal range of motion is
reached. Lower downward and continue to lift towards the other side. Lower down
to starting position.
 Horizontal Abduction/Horizontal Adduction: Lift weight up to 90 degrees of flexion.
Bring the weight in front of you towards the other shoulder. Continue in the opposite
direction towards the side until maximal range of motion is reached. Bring weight
back to starting position.
 Internal/External Rotation: Flex elbow of effected limb and bring it close to the side of
the body near the waistline. Bring weight in towards the stomach and continue into
the opposite direction until maximal range of motion is reached.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
12

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 13 of 92
NPTE
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.
6. Closed Kinetic Chain Exercises
A: Wall Presses (push ups against a wall)
B: Standing Shoulder Flexion/Extension
 Stand with hands shoulder width apart on a chair. Rock forward over hands and back.
7. Cardiovascular Endurance
A: Bike or Stairmaster for 30 minutes
8. Cryotherapy
A: Ice for 20 minutes
Phase IV - Return to Activity (approx 14 days)
Goals:
 Normal function and sports specific patterns restored to injured extremity
 Muscular strength, endurance, and power in affected arm is equal to unaffected arm
 Normal coordination and balance
 Cardiovascular endurance is equal to preinjury level
1. Heat therapy/modalities
A: Continue head therapy, ultrasound, and flexibility
2. Strength exercises
A: Perform all exercises with minimal or no pain
3. Sports Specific Exercises
A: Baseball/softball - perform overhand throwing
B: Football - throw a spiral, catch a throw (depending on position)
C: Volleyball/tennis - perform a serve
D: Soccer - practice a throw in
E: Basketball - practice shooting and passing drills
4. Taping/Padding
A: Make an orthroplast pad to prevent further injury and hold in place with an ace wrap
5. Cryotherapy
A: Ice for 20 minutes
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
13

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 14 of 92
NPTE
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.
11.1.3 SHOULDER DISLOCATION REHABILITATION PROGRAM:
Phase I - Control Inflammation (1-2 days)
Goals:
 Control Inflammation and Pain
 Reduce Swelling
Rehab:
Cryotherapy
A: Ice for 20 minutes
Modalities
A: Interferential Stim (can be used with ice at the same time)
NSAIDS
A: Ibuprofen/Advil - 4 times a day for 3 days (only if no allergies)
Phase II - Restore Range of Motion (2-7 days)
Goals:
 Passive and active range motion is within 80% of normal in the unaffected arm
 Joint Flexibility in affected limb is restored
 Cardiovascular Endurance is maintained at preinjury level
 Range of Motion exercises performed pain free
Rehab:
1. Heat Therapy
A: Hot pack for 20 minutes
2. Modalities
A: Pulsed ultrasound for 5 minutes
3. Flexibility Exercises
A: Hold involved arm across chest at the involved elbow, pushing slightly posterior until a
stretch is felt
B: Hold sides of a doorway with hand behind you. Let arms straighten as you lean
forward. Repeat with hands in front of you as you lean backward.
4. Codman's Exercises without a Free Weight
A: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table
with the involved arm dangling in front of you.
B: Stabilize the scapula with a belt by wrapping it around the upper body and scapula.
C: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging
motion, going forwards and backwards, side to side, and in circles.
5. Wall Crawls (Flexion and abduction)
A: Place hand on wall and have fingers crawl up the wall until end of range of motion.
Repeat going down the wall.
B: Start by facing a wall, repeat exercise again by facing sideways to the wall
6. Shoulder Wheel
A: Place hand on grip of shoulder wheel and move wheel around until maximal range of
motion is reached. Repeat going the opposite way.
7. Pulley
A: Place hands on both ends of pulley and have the affected limb pull downward. Repeat
again with unaffected limb pulling downward.
8. Cane Exercises
A: Shoulder flexion - hold cane with hands palm down at waist height.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
14

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 15 of 92
NPTE
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.
Raise the cane to 90 degrees, leading with the uninvolved arm until a stretch is felt in
the involved shoulder.
B: Shoulder abduction - hold cane with involved arm palm up, uninvolved arm palm down.
Push cane sideways and upward toward the involved side with the uninvolved arm until
a stretch is felt in involved shoulder.
C: Shoulder adduction - reverse hand positions from the previous exercise.
Pull the cane toward uninvolved side until a stretch is felt in the involved shoulder.
D: Shoulder internal/external rotation - keep hands on ends of the cane, elbows flexed at
90 degrees. Keep elbows at your side while keeping upper arms still. Move the cane
side to side using only the forearms.
9. Cardiovascular Endurance
A: Bike for 20 minutes
10. Cryotherapy
A: Ice after for 20 minutes
Shoulder Exercise:
Extension from 45°
Shoulder
Exercise:
Extension to Shoulder Exercise: Shoulder
Hyperextension External Rotation in Exercise:
overhead Horizontal \"Rotator Cuff\" External
overhead Rotation in
Neutral
overhead
Shoulder Exercise: Shoulder Exercise:
Extension from 90° Extension from full
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
15

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 16 of 92
NPTE
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.
Shoulder Exercise: Shoulder Exercise:
Flexion from Neutral Horizontal Abduction
Shoulder
Exercise:
Flexion from
135°
overhead
Shoulder Exercise: Shoulder Exercise: Shoulder Exercise: Shoulder Exercise:
Horizontal Flexion Abduction Internal Rotation from Neutral Internal Rotation from Neutral Neutral Abduction
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
16

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 17 of 92
NPTE
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.
Phase III - Strength Training (1-3 weeks)
Goals:
 Range of motion and flexibility of affected arm equals unaffected arm
 Muscular strength is equal between affected and unaffected arm
 Cardiovascular endurance maintained at preinjury level
 Range of motion and strength exercises performed without pain
 Mobility upon stability
Rehab:
1. Heat Therapy/Flexibility
A: Continue heat and ultrasound therapy
B: Continue flexibility exercises
2. Scapular Stabilizations / Strengthening
A: Depression - minidips or provide manual resistance while the athlete pushes his fist
towards the ground
B: Elevation - shoulder shrugs either against manual resistance or while holding a weight
C: Protraction - manual resistance while the athlete rolls his shoulders towards the front
D: Retraction - rows
3. Isometric Resistance
A: Stay below 90 degrees, and pain-free ROM
B: In each of the following positions, push your fist against a wall, desk, or any other
stationary item every 15 degrees throughout the range of motion.
 Push arm straight up in front of you
 Push arm straight out to the side
C: With elbow flexed at 90 degrees, push the outside of your fist against a wall every 15
degrees up to 45/50 degrees, and do the same with the inside of the fist
4. Codman's Exercises
Progress through free weights as tolerated (pain-free)
A: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table
with the involved arm dangling in front of you.
B: Stabilize the scapula with a belt by wrapping it around the upper body and scapula.
C: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging
motion, going forwards and backwards, side to side, and in circles.
5. Theraband
A: Flexion - Grip theraband in front of you with the elbow extended. Pull the theraband
upward until maximal range of motion is reached and lower downward.
B: Extension - Start in same position as flexion. Pull theraband backward until maximal
range of motion is reached and bring back to starting position.
C: Internal Rotation - Stand in front of theraband board with affected arm facing it.
Rotate arm inward across body while gripping the unattached end of theraband.
D: External Rotation - Stand in front of theraband board with unaffected arm facing it.
Rotate arm outward away from the body while gripping the unattached end of
theraband.
E: Abduction - Stand in front of codman with affected arm facing it. Start with arm across
the body and pull away from side.
F: Adduction - Stand in front of codman with affected arm facing it. Grab the theraband
and pull arm toward the buttocks.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
17

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 18 of 92
NPTE
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: Horizontal Abduction - Stand in front of theraband board with unaffected arm facing it.
Bring shoulder up to 90 degrees of flexion so that it is parallel to the floor. Pull arm
across body toward the opposite shoulder.
H: Horizontal Adduction - Stand in front of theraband board with affected arm facing it.
Bring shoulder to 90 degrees of flexion so that it is parallel to the floor. Pull arm across
body towards the opposite shoulder.
I: As strength is gained, progress up to different colors of tubing.
6. Proprioception (Cat Stretch-Starting Position)
A: Start in a non-weight bearing position (knees flexed) on a floor
B: As patient gains strength, incorporate the following progressions:
 Body movement - static (still) to dynamic (moving)
 Amount of arms involved - bilateral (2 arms) to unilateral (1 arm)
 Surface - stable (floor or wall) to unstable (single and multiplane boards)
C: Perform 3-5 stances, holding 15-20 seconds
7. Open Kinetic Chain Exercises
A: Weight Training (Starting position - place weight in affected hand)
 Flexion: Bring it forward and towards the ceiling until maximal range of motion is
reached. Lower downward.
 Extension: Bring weight backward towards the ceiling until maximal range of
motion is reached. Lower downward.
 Abduction/Adduction: Raise weight to the side until maximal range of motion is
reached. Lower downward and continue to lift towards the other side. Lower down
to starting position.
 Horizontal Abduction/Horizontal Adduction: Lift weight up to 90 degrees of flexion.
Bring the weight in front of you towards the other shoulder. Continue in the
opposite direction towards the side until maximal range of motion is reached. Bring
weight back to starting position.
 Internal/External Rotation: Flex elbow of effected limb and bring it close to the side
of the body near the waistline. Bring weight in towards the stomach and continue
into the opposite direction until maximal range of motion is reached.
8. Closed Kinetic Chain Exercises
A: Wall Presses (push ups against a wall)
B: Standing Shoulder Flexion/Extension
Closed Kinetic Chain Exercises
 Stand with hands shoulder width apart on a chair. Rock forward over hands and back.
9. Cardiovascular Endurance
A: Bike or Stairmaster for 30 minutes
10. Cryotherapy
A: Ice for 20 minutes
Phase IV - Return to Activity (approx 14 days)
Goals:
 Normal function and sports specific patterns restored to injured extremity
 Muscular strength, endurance, and power in affected arm is equal to unaffected arm
 Normal coordination and balance
 Cardiovascular endurance is equal to preinjury level
1. Heat therapy/modalities
A: Continue head therapy, ultrasound, and flexibility
2. Strength exercises
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
18

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 19 of 92
NPTE
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: Perform all exercises with minimal or no pain
3. Sports Specific Exercises
A: Baseball/softball - perform overhand throwing
B: Football - throws a spiral, catch a throw (depending on position)
C: Volleyball/tennis - perform a serve
D: Soccer - practice a throw in
E: Basketball - practice shooting and passing drills
4. Taping/Padding
A: Make an orthroplast pad to prevent further injury and hold in place with an ace wrap
5. Cryotherapy
A: Ice for 20 minutes
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
19

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 20 of 92
NPTE
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.
11.1.4 ADULT WHEELCHAIR MEASUREMENTS:
15\" - Low forward reach, minimum from floor
24\" to 26\" - Width chair, from rim to rim
24\" - Maximum side reach
29\" to 30\" - height armrest to floor
32\" - Minimum clear width for doorways and halls
36\" - Height push handles to floor
36\" Turning space (90degr)
36\" - Ideal clear width for doorways and halls
42\" to 43\" - Chair length
48\" - High forward reach maximum
Ramp ratio 1:12 2.2.2 Skin disorders and colour changes
Graphic Conventions
Minimum Clear Width for
Single Wheelchair
Fore more info on the dimensions, visit
http://www.access-board.gov/ufas/ufas-html/figures.htm
Minimum Clear Width for Two Wheelchairs
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
20

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 21 of 92
NPTE
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.
11.1.5 WOUND STAGING:
Stage I: Redness, heat and edema involving the epidermis (non-blanchable erythema of
intact skin), reversible with decreased pressure, dermis is not involved
Stage II: Partial thickness skin loss with tear in epidermis, both epidermis/dermis are
involved, infection and/or necrosis may be present
Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that
may extend down to but not through underlying fascia, infection and/or necrosis may be
present
Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to
muscle, bone and supporting structures
A. ULCERS:
 Pressure Ulcer (dermatology), a discontinuity of the skin
 Oral ulcer, an open sore inside the mouth
 Peptic ulcer, a discontinuity of the gastrointestinal mucosa (stomach ulcer)
 Corneal ulcer, an inflammatory or infective condition of the cornea
 Venous ulcer, a wound thought to occur due to improper functioning of valves in the
veins
 Diabetic foot ulcers
 Genital ulcer, an ulcer located on the genital area
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
21

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 22 of 92
NPTE
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.
B. PRESSURE ULCERS:
 A pressure ulcer is an injury to the skin as a result of constant pressure due to
impaired mobility. The pressure results in reduced blood flow and eventually causes
cell death, skin breakdown and the development of an open wound. Pressure ulcers
can occur in persons who are wheelchair-bound or bed-bound, sometimes even after
a short time (two to six hours). If the conditions leading to the pressure sore are not
rapidly corrected, the localized skin damage will spread to deeper tissue layers
affecting muscle, tendon and bone. Common sites include the sacrum (tailbone),
back, buttocks, heels, back of the head and elbows. If not adequately treated, open
ulcers can become a source of pain, disability and infection.
 People at greater risk of getting pressure ulcers are those who spend a lot of time in
a bed, chair, or wheelchair. Others at risk include:
 People who cannot move or change positions without someone else’s help, including
those who are in a coma, paralyzed, or have had a hip fracture
 People who have problems controlling their bowel or bladder functions
 People who do not eat a balanced diet
 People who have a lowered mental awareness caused by a medical condition,
medicines or anesthesia. (When mental awareness is lowered, a person might not be
able to act to prevent the development of pressure ulcers.)
 People who have a lowered overall health status
 Where on the body do pressure ulcers usually form?
 Pressure ulcers occur more often over bony parts of the body because there is more
pressure on the skin over these bony areas and less fat to cushion the area. The
illustrations on the right show these most common body sites. You and your
caregiver should pay attention to these areas when inspecting your skin for signs of
pressure ulcers.
Pressure Ulcers
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
22

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 23 of 92
NPTE
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.
I. PREVENTION:
 Keep the skin clean: Use a gentle cleanser made for this purpose (not soaps,
which dry the skin). Dry the skin by patting — not rubbing — Before anyone
treats or touches the skin/wound area, make sure the person washes his or her
hands.
 Keep the skin from drying out: Apply a cream moisturizer (for example, Eucerin,
Neutrogena) immediately after a bath or shower to seal in the moisture from
bathing.
 Eat healthy foods: Proper nutrition is vital to healing. Poor eating habits result
in delayed healing, increased length of hospital stay, and increased risk of
infection. Your body, in fact, requires extra calories to help heal wounds. Eating
foods high in calories and protein — such as cheese, peanut butter, chicken,
beef, and fish — is important. In addition to a balanced diet, talk with your health
care providers (doctors, nurse, dietitian) about the need for vitamins, extra
minerals, or other nutritional supplements.
 Protect the skin from too much moisture: When skin gets too wet — a condition
called maceration — it is more likely to break down. Skin can become too moist
when sweat, urine, feces, or wound drainage remain in direct contact with the
skin. If your moisture problem is caused by a bowel or bladder control problem,
II. MAKE SURE:
The skin is cleaned as soon as it becomes soiled with urine or stool
A moisture barrier cream is used to protect the skin from body fluids
Absorbent pads or underwear with a quick-drying surface are used to help keep
moisture away from the skin
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
23

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 24 of 92
NPTE
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.
 If pressure ulcers do form, they do not have to get worse. Treatment of pressure
ulcers consists of relieving the pressure that caused the sore, treating the sore
itself, and improving eating habits and other conditions to help the sore heal.
 Tips for proper positioning and movement in bed
 If you must stay in bed:
 Inspect your skin at least once a day.
 Change position at least every two hours. (If you are unable to change positions
by yourself, ask for assistance.)
 Keep a written \"turning schedule\" to record when your body position was last
changed as well as a note of your last position.
 Shift your weight slightly every 15 minutes, if you can.
 Use your arms to lift yourself rather than dragging yourself onto the bed or chair.
If in a hospital bed, use the trapeze bar to help lift your body to reposition.
 Avoid lying directly on your hipbone when lying on your side. A 30 degree side-
lying position is best. To accomplish this, tuck pillows under one side so that your
weight rests on the fleshy part of your buttock instead of your hip bone.
 Raise the head of the bed as little as possible (no more than 30 degrees from
horizontal) for as short a time as possible to avoid sliding down in the bed. The
head of the bed can be raised during meals to prevent choking. Return the head
of the bed to a horizontal or semi-reclining position one hour after eating.)
 When lying on your back, keep your heels up off the bed by placing a thin foam
pad or pillow under your legs from the middle of your calf to your ankle.
 Position the pillow length-wise, as shown.
 Do NOT place the pad or pillow directly–and only–under the knees because this
could reduce blood flow to the lower leg.
 Use pillows or small foam wedge pads to keep knees and ankles from touching
each other.
 Keep linens as wrinkle-free as possible.
 Let your health care provider know if the bed linens are soiled so that they can be
changed.
III. TIPS FOR PROPER POSITIONING AND MOVEMENT IN CHAIRS:
If you must stay in a chair or wheelchair:
Inspect your skin at least once a day.
Always use a seat cushion designed to relieve pressure on sitting surfaces. Ask your
health care provider about proper foam or air cushion product(s) to use. (Avoid
donut-shaped cushions, since these reduce blood flow to the tissue, causing tissue to
swell.)
Change position every hour. (If you are unable to change positions by yourself, ask
for assistance or have someone help you back to bed so you can change positions.)
Lift yourself up off the chair every 15 minutes. Depending on your strength, use one
of the three methods described below (listed from most to least preferred) and holds
the position for at least a slow count of five to 10 seconds:
1. Place your hands on the arm rest and lift your body off the chair.
2. Press your elbow on the arm rest to lift that side of your body off the chair; repeat
on opposite side, or do both sides at the same time.
3. Shift your weight by leaning far over to one side and repeat on the opposite side.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
24

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 25 of 92
NPTE
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.
Keep the top of your thighs slightly sloping forward and use pillows or foam cushions
to keep knees and ankles from touching each other.
Rest your feet comfortably on the floor or on the footrest.
Rest your elbows, forearms, and wrists on the chair arm supports.
If a pressure ulcer forms, how long does it last?
Pressure ulcers should always be treated by trained health care personnel. With
proper care and treatment, a pressure ulcer should begin healing within two weeks.
Where can I get more information about pressure ulcers?
The skin around the area will be red and shiny or dark purple. (In dark-skinned
people, the area might simply become darker than normal.)
The skin might be warm to the touch compared with nearby tissue.
The area might also be swollen or hard, and might lack feeling
Note: Skin reddening that disappears after pressure is removed is normal and is not
a pressure ulcer. Discoloration of the skin that is constant might be a pressure ulcer.)
C. ORAL ULCER:
An oral ulcer (/ˈʌl-sɚ/, from Latin ulcus) is the name for the appearance of an open sore
inside the mouth caused by a break in the mucous membrane or the epithelium on the
lips or surrounding the mouth. The types of oral ulcers are diverse, with a multitude of
associated causes including: physical or chemical trauma, infection from microorganisms,
medical conditions or medications, cancerous and nonspecific processes. Once formed,
the ulcer may be maintained by inflammation and/or secondary infection. Two common
oral ulcer types are aphthous ulcers (canker sores) and cold sores (aka fever blisters).
Cold sores around the lip are caused by the herpes simplex virus
I. SYMPTOMS:
 The symptoms preceding the ulcer may vary according to the cause of the
ulcerative process.
 Some oral ulcers may begin with a sharp stinging or burning sensation at the site
of the future mouth ulcer. In a few days, they often progress to form a red spot or
bump, followed by an open ulcer. Sometimes this takes a little bit longer,
depending on the cause of the ulcer.
 The oral ulcer appears as a white or yellow oval with an inflamed red border.
Sometimes a white circle or halo around the lesion can be observed. The gray,
white, or yellow colored area within the red boundary is due to the formation of
layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is
often extremely painful, especially when agitated, may be accompanied by a
painful swelling of the lymph nodes below the jaw, which can be mistaken for
toothache.
II. CAUSES:
There are many processes, which can lead to ulceration of the oral tissues. In some
cases they are caused by an overreaction by the body's own immune system.
Factors that appear to provoke mouth ulcers include stress, fatigue, illness, injury
from accidental biting, hormonal changes, menstruation, sudden weight loss, food
allergies and deficiencies in vitamin B12, iron and folic acid.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
25

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 26 of 92
NPTE
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.
III. TREATMENT:
Treatments based on antibiotics and steroids are reserved for severe cases, and
should be used only under medical supervision.
Some doctors may also prescribe local anesthetic, such as lidocaine, for cases of
multiple or severe oral ulcers.
Some people benefit from using the over-the-counter topical gel Bonjela, which
contains choline salicylate -- choline salicylate is a local analgesic that helps to
reduce the pain and inflammation associated with oral ulcers.
D. PEPTIC ULCER:
Peptic ulcers are raw spots or sores that can occur anywhere on the lining of the
stomach (where they are called gastric ulcers) or the duodenum (where they are called
duodenal ulcers).
Peptic ulcers are craterlike erosions in the lining of the stomach, the duodenum (the part
of the small intestine just past the stomach), and rarely, the esophagus. Duodenal ulcers
are about three times more common than stomach (gastric) ulcers. Normally, glands in
the stomach secrete acid and the enzyme pepsin (hence the name peptic ulcer) that help
to break down foods in the digestive process. The stomach and duodenum meanwhile
secrete mucus to protect them against harm from pepsin and gastric acid. In peptic ulcer
disease the digestive tract's defensive mechanisms break down, often as a result of
infection with the bacterium Helicobacter pylori. Consequently, even small amounts of
stomach acid can cause corrosion. Each year, about 1 percent of Americans develop
peptic ulcers, and overall, up to 10 percent of the population will have an ulcer at some
point during their lives. All ages may be affected (including children), although ulcers
most often affect those over 30. Ulcers commonly recur: even after an ulcer has healed,
new ones often arise throughout the patient's lifetime, either in the original location or
elsewhere. Therefore, current ulcer drugs, which mostly act to reduce levels of stomach
acids, must often be taken on a long-term basis. The development of newer, short-term
drug regimens directed against H. pylori may significantly lower the high rate of ulcer
recurrence. Although peptic ulcers are rarely a major health threat, they sometimes lead
to serious complications, such as bleeding, obstruction of the digestive tract due to
scarring, or the creation of a hole or tear (perforation) in the digestive tract, which can
lead to severe, life-threatening infection of the abdominal cavity (peritonitis). In addition,
in a small percentage of cases a persistent stomach ulcer may be cancerous. The same
is not true for duodenal ulcers. For most ulcers, treatment is highly effective in controlling
symptoms and preventing serious complications.
I. CAUSES:
At least 80 percent of ulcers are believed to be caused by infection of the digestive
tract with H. pylori bacteria. It's not known how the infection spreads, although it may
be transmitted orally. H. pylori infests about 60 percent of Americans by age 60, but
most of those infected do not develop ulcers. Rather, the bacteria merely increase
the chances of developing an ulcer by weakening the stomach's protective
mechanisms and making the lining of the digestive tract susceptible to erosion by
stomach acids. Once an ulcer has developed, various secondary factors can
aggravate it, including alcohol, caffeine, dietary factors, smoking, and stress.
In the past, excessive production of stomach acid was thought to be the primary
cause of ulcers. It is now recognized that many people with ulcers actually have
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
26

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 27 of 92
NPTE
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.
normal or even slightly less-than-normal amounts of stomach acid. However,
because mechanisms that protect the digestive tract lining are weakened, even small
amounts of stomach acid can cause (or delay the healing of ) ulcers. The exception is
ulcers caused by certain kinds of pancreatic or duodenal tumors, which secrete the
hormone gastrin and cause massive amounts of acid secretion (Zollinger-Ellison
syndrome).
Long-term use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs),
such as ibuprofen or naproxen, can lead to ulcers primarily in the stomach by
irritating its lining.
Hereditary factors also appear to play a role.
STOMACH ULCER
II. PREVENTION:
Avoid long-term use of aspirin or nonsteroidal anti-inflammatory drugs if possible.
Anyone who must take these drugs on a long-term basis, such as those with arthritis,
may benefit from the prescription drug misoprostol. Or your doctor may recommend
one of the newer anti-inflammatory drugs called cylooxygenase-2 (COX-2) inhibitors,
such as celecoxib and rofecoxib, which have been shown to have decreased
gastrointestinal side effects compared to other nonsteroidal drugs.
Taking ulcer medications as prescribed, and avoiding smoking and foods or drinks
that have aggravated ulcers in the past, can help prevent ulcer recurrence.
III. DIAGNOSIS:
Patient history and physical examination are needed.
An upper GI series (which involves swallowing a solution containing barium to create
a clear image of the digestive tract on x-ray) may show active ulcers or scarring
caused by past ulcers.
Endoscopy (in which a flexible scope is guided down the throat and into the stomach
and duodenum) allows ulcers to be viewed directly. Endoscopy also allows the doctor
to take a small sample of the ulcer (biopsy); this sample is then tested for cancer.
Biopsies can also detect the presence of H. pylori, but this method is invasive and
expensive. Quick office tests for the detection of this bacterium are becoming
available.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
27

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 28 of 92
NPTE
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. TREATMENT:
 For those with mild disease (one or two periods of symptoms a year),
prescription drugs that reduce secretion of stomach acid (cimetidine, ranitidine,
famotidine, nizatidine, or omeprazole) or that coat the lining of the stomach
(sucralfate) usually relieve pain within a week, although ulcers take about eight
weeks to heal. Antacids may also help, although they may interfere with the
actions of the prescription drugs if both are taken in close succession.
 Antibiotics directed against H. pylori bacteria are generally reserved for those
with more serious disease who do not respond to other ulcer medications, as the
long-term effectiveness and side effects of this approach are still being
evaluated. A combination of two antibiotics (usually metronidazole and
tetracycline) is usually taken for at least two weeks, along with a bismuth-
containing antacid (such as Pepto- Bismol). Antacids or medications that reduce
acid secretion may also be given. Combination antibiotic regimens prevent ulcer
recurrences in about 90 percent of cases.
 Surgery may be needed for bleeding, obstruction or perforation of the digestive
tract, or intractable pain from ulcers.
 Eat a well-balanced diet rich in fiber. Many dietary measures advocated in the
past—such as eating bland foods, eating many small meals a day, or drinking
milk—do not appear to help. Indeed, milk may actually increase stomach acid
production, although one or two glasses a day is usually not harmful. Coffee, tea,
and caffeinated sodas can increase acid secretion. Avoid excessive alcohol
consumption.
E. CORNEAL ULCER:
The front portion of the eye is covered with a thin, transparent membrane called the
cornea, which protects the interior of the eye. If there is a break or defect in the surface
layer of the cornea, called the epithelium, and damage to the underlying stroma, a
corneal ulcer results. The ulcer is usually caused by microorganisms, which gain access
to the stroma through the break in the epithelium.
Corneal ulcers generally heal well if treated early and aggressively. However if neglected,
corneal clouding and even perforation (a hole in the cornea) may develop, resulting in
serious loss of vision and possibly loss of the eye. Corneal ulcers are a serious vision-
threatening condition and require prompt medical attention.
Symptoms of corneal ulcers:
 Watery eyes
 Acute pain
 Sensitivity to light
 Blurry vision
 The feeling that there's something in your eye
 Discharge from the eye
I. CAUSES:
 Infection
 Wearing contact lenses for excessive periods of time
 Inadequate contact lens sterilization
 Eye injury
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
28

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 29 of 92
NPTE
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.
 Lack of tear production
 Complications of herpes simplex keratitis, neurotrophic keratitis, chronic
blepharitis, conjunctivitis, trachoma, bullous keratopathy and cicatricial
pemphigoid
 Vitamin A deficiency or protein malnutrition
 Eyelid abnormalities
III. DIAGNOSING CORNEAL ULCERS:
Corneal ulcers are a serious vision-threatening condition and require prompt medical
attention. If left unattended, corneal ulcers may penetrate the cornea allowing
infection to enter the eyeball, which can cause permanent loss of vision and possible
loss of the eye. Your eye doctor can identify corneal ulcers by examining your eyes
with magnifying instruments and performing a culture study to identify infection. Your
doctor will check your eye, including under your eyelid, to make sure there are no
foreign materials present. Depending on the initial exam, fluorescein dye may be
used to identify the corneal defects. A test called the Seidel test (painting the wound
with dye and observing for leakage) may be performed to uncover possible deeper
injuries.
IV. TREATMENT FOR CORNEAL ULCERS:
If treated early, corneal ulcers are usually curable in two to three weeks. They are
typically treated with antibiotic eye drops. Sometimes, topical steroids will also be
used to decrease the risk of scarring and inflammation.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
29

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 30 of 92
NPTE
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.
F. VENOUS ULCERS:
A venous skin ulcer, also called a stasis leg ulcer, is a shallow wound that develops when
the leg veins do not move blood back toward the heart normally (venous insufficiency).
Venous skin ulcers typically develop on either side of the lower leg, above the ankle and
below the calf. See a picture of areas affected by venous skin ulcers.
I. CAUSES:
 The veins in the body have valves that keep blood flowing toward the heart. In a
condition called venous insufficiency, the valves are damaged and allow some
blood to back up in the vein. The slowed circulation causes fluid to seep out of
the overfilled veins into surrounding tissues, causing tissue breakdown and
ulcers. See a picture of abnormal blood flow caused by venous insufficiency.
 Less frequently, blocked veins are a contributing factor in the development of
venous skin ulcers.
II. SYMPTOMS:
 The first sign of a venous skin ulcer is the appearance of dark red or purple skin
over the affected area. The skin may also become thickened and dry and itchy.
Contact your doctor when you first notice the signs of a venous ulcer because
you may be able to prevent an open wound (ulcer) from forming.
 Without treatment, an ulcer may form. The wound may be painful, and you may
also have swollen and achy legs. You may get rashes, such as contact
dermatitis, on the skin around the ulcer.
 Because venous skin ulcers are a result of poor blood circulation, these wounds
are often slow to heal. If an ulcer becomes infected, there may be an odor, pus
draining from the wound, and increased tenderness and redness.
III. DIAGNOSIS:
Venous skin ulcers can usually be diagnosed with a health history and physical
exam. Your doctor may also use duplex Doppler ultrasound. This shows how well
your blood is moving up through the lower leg.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
30

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 31 of 92
NPTE
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. TREATMENT:
 Improving circulation is critical in the treatment of venous skin ulcers. You can
accomplish this by elevating your legs above the level of your heart when you
can and, during your waking hours, using specially fitted stockings called
compression stockings, designed to help prevent blood from pooling in your legs.
See a picture of how to put on compression stockings.
 More aggressive medical treatments, such as skin grafting and vein surgery, are
available for venous skin ulcers that take longer than 6 months of treatment to
heal or that become infected.
V. RISK FACTORS FOR VENOUS SKIN ULCERS:
 Factors that contribute to venous insufficiency and increase your risk of
developing venous skin ulcers include:
 Deep vein thrombosis, which can result from a severe leg injury (such as a
broken or crushed bone) or leg surgery (including knee replacement and
varicose vein procedures). Deep vein thrombosis can also develop when you
don't move around for long periods (for example, if you are paralyzed or
bedridden).
 Obesity.
 Pregnancies, which may aggravate an existing venous problem.
 A family history of varicose veins, especially if you also have reverse blood flow
in a saphenous vein, which runs up the inner thigh.
 A blood-clotting disorder.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
31

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 32 of 92
NPTE
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. DIABETIC FOOT ULCERS:
Diabetic ulcers are the most common foot injuries leading to lower extremity amputation.
Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot
complications. Management of the diabetic foot requires a thorough knowledge of the
major risk factors for amputation, frequent routine evaluation and meticulous preventive
maintenance. The most common risk factors for ulcer formation include diabetic
neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful
physical examination, buttressed by monofilament testing for neuropathy and noninvasive
testing for arterial insufficiency, can identify patients at risk for foot ulcers and
appropriately classify patients who already have ulcers or other diabetic foot
complications. Patient education regarding foot hygiene, nail care and proper footwear is
crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a
systematic regimen of diagnosis and classification can improve communication between
family physicians and diabetes subspecialists and facilitate appropriate treatment of
complications. This team approach may ultimately lead to a reduction in lower extremity
amputations related to diabetes.
I. PERIPHERAL NEUROPATHY:
Peripheral Neuropathy is not a distinct disease, but the manifestation of many
conditions that damage the peripheral nerves (nervous tissue other than the brain
and spinal cord). Symptoms depend on whether sensory nerves (the nerves that
transmit sensory information from the body to the brain and spinal cord) or motor
nerves (the nerves that transmit impulses from the brain and spinal cord to the body)
are affected. If the sensory nerves are damaged, sensation may be diminished,
lacking or abnormal. Damaged motor nerves impair movement or function. Peripheral
neuropathy may be caused by direct or indirect injury, or by a systemic cause such
as a metabolic disorder.
Can cause altered or complete loss of sensation in the foot and /or leg. Similar to the
feeling of a \"fat lip\" after a dentist's anesthetic injection, the diabetic with advanced
neuropathy looses all sharp-dull discrimination. Any cuts or trauma to the foot can go
completely unnoticed for days or weeks in a patient with neuropathy. It's not
uncommon to have a patient with neuropathy tell you that the ulcer \"just appeared\"
when, in fact, the ulcer has been present for quite some time. There is no known cure
for neuropathy, but strict glucose control has been shown to slow the progression of
the neuropathy.
Diabetes can damage the nerves and
cause a complication called neuropathy.
This generally begins as loss of sensation
in the toes, and possibly fingers.
Eventually, the neuropathy can move up
the person's legs or arms.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
32

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 33 of 92
NPTE
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.
II. CHARCOT FOOT DEFORMITY:
Occurs as a result of decreased sensation. People with \"normal\" feeling in their feet
automatically determine when too much pressure is being placed on an area of the
foot. Once identified, our bodies instinctively shift position to relieve this stress. A
patient with advanced neuropathy looses this important mechanism. As a result,
tissue ischemia and necrosis may occur leading to plantar ulcerations. Micro
fractures in the bones of the foot go unnoticed and untreated, resulting in
disfigurement, chronic swelling and additional bony prominences.
III. MICROVASCULAR DISEASE:
CHARCOT FOOT DEFORMITY Is a significant problem for diabetics and can lead to ulcerations. It is well known that
diabetes is called a small vessel disease. Most of the problems caused by narrowing
of the small arteries cannot be resolved surgically. It is critical that diabetics maintain
close control on their glucose level, maintain a good body weight and avoid smoking
in an attempt to reduce the onset of small vessel disease.
IV. TREATMENT:
First, you must determine the cause of this ulcer. Is it neuropathic, ischemic or a
combination? Base your treatment protocol on the etiology of the ulcer. Assuming
that there is adequate perfusion to heal a plantar ulcer, one should have appropriate
shoe modifications made to disperse weight away from the ulcerative area. Absorb
any excess discharge and maintain a moist wound environment with appropriate
product selection. Keep the wound edges dry. Make sure no sinus tracking occurs.
Watch for infection. Debride necrotic debris and the hyperkeratotic rim as they are
niduses of for infection.
H. GENITAL ULCER:
Genital ulcer: The occurrence of an ulcer located on the genitals. More detailed
information about the symptoms, causes, and treatments of Genital ulcer is available
below. In the world today, the majority of young, sexually active patients who have genital
ulcers have genital herpes, syphilis, or chancroid. The frequency of each condition differs
by geographic area and patient population; however, genital herpes is the most prevalent
of these diseases. More than one of these diseases can be present in a patient who has
genital ulcers. All three of these diseases has been associated with an increased risk for
HIV infection. Not all genital ulcers are caused by sexually transmitted infections.
I. GENITAL HERPES SIMPLEX:
It is estimated that 50 million people in the United States have genital herpes
infection. Most people with herpes simplex virus (HSV) type 2 have not been
diagnosed and those who transmit the virus are often unaware they are infected.
Multiple, painful vesicular ulcers are absent in many patients. Viral culture sensitivity
diminishes quickly as lesions begin to heal. Serologic testing for HSV-2 is available
but requires careful interpretation and application.
Antiviral therapy does not eradicate latent virus. Topical antiviral medication offers
minimal clinical benefit. Patients with initial genital herpes infections should receive
acyclovir 400 mg t.i.d., famciclovir 250 mg t.i.d., or valacyclovir 1 g b.i.d for 7-10
days.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
33

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 34 of 92
NPTE
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.
HSV-2 virus causes most recurrent genital herpes. Oral antiviral therapy can
ameliorate acute recurrences. Treatment of recurrences requires therapy within 1 day
of onset or during the prodrome.
Antiviral drugs during recurrences are typically given for 5 days. Suppressive therapy
can substantially reduce attacks in patients with more than six recurrences a year.
Suppressive antiviral therapy does not eliminate asymptomatic viral shedding.
HSV infection alone does not cause cancer, but HSV-2 may be a cofactor in the
development of cervical cancer.
Patients with asymptomatic genital herpes should be aware that sexual transmission
is common in the first 12 months after acquisition of HSV-2.
The CDC National STD/HIV hotline (800-227-8922) and the American Social Health
Association (www.ashastd.org) offer printed materials to assist clinicians in
counseling patients.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
34

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 35 of 92
NPTE
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.
II. SYPHILIS:
Dark field examination and direct fluorescent antibody testing of exudates are core
methods for diagnosing early syphilis. Although no comparative trials provide data for
optimal dosing, adults with primary and secondary syphilis should receive a single
dose of 2.4 million units IM of benzathine penicillin. Patients with HIV and primary or
secondary syphilis are at higher risk for neurosyphilis, but should be treated with the
same single dose of IM benzathine penicillin. Some specialists, however, recommend
2.4 million units IM weekly for 3 weeks.
CSF pleocytosis and elevated protein levels are common in patients with early
syphilis or HIV. Patients with concomitant syphilis and HIV need careful follow-up to
determine if therapy for neurosyphilis is warranted.
Only 10% of patients with a history of severe penicillin allergy remain allergic. Most
patients stop expressing penicillin-specific IgE over time and can be treated safely
with penicillin. Skin testing can reliably identify patients at high risk for severe
reactions.
III. CHANCROID:
Chancroid should be considered in patients with one or more painful genital ulcers,
regional lymphadenopathy, negative dark field or serologic testing for syphilis, and
negative testing for herpes simplex virus. Commercial culture media are not widely
available and no Food and Drug Administration-approved polymerase chain reaction
test is marketed.
Single-dose treatment with 1 g azithromycin or 250 mg ceftriaxone is preferred over
500 mg ciprofloxacin b.i.d. for 3 days or 500 mg erythromycin t.i.d. for 7 days. Some
cases are resistant to Cipro or erythromycin.
Most chancroid lesions respond within 3-7 days of therapy. Large ulcers may require
2 weeks to heal. Slow clinical response may indicate incorrect diagnosis, coinfection
with HIM or resistant organisms.
Lymph nodes may need drainage.
Ten percent of patients with chancroid also are infected with syphilis or herpes
simplex virus. Patients should be retested for syphilis and HIV at 3 months after
therapy.
IV. UNCOMMON CONDITIONS:
Granuloma inguinale presents as a painless, progressive ulcer without
lymphadenopathy. The lesions are erythematous and bleed easily on contact. It is
rare in the United States.
Lymphogranuloma venereum features tender, usually unilateral inguinal
lymphadenopathy and is rarely seen in the United States. Genital ulcers are usually
healed at the time of patient presentation.
I. PREVENTION AND TREATMENT OF PRESSURE ULCERS:
Prevention of pressure ulcers is key because treatment can be difficult. Prevention plans
require the skin to be kept clean and moisturized, frequent careful changing of body
position (with proper lifting, not rubbing across surfaces), use of special mattresses or
supports, management of other contributing illnesses and implementation of a healthy
diet. Relieving or reducing the pressure on the area is essential. Once an ulcer appears,
additional treatment options can include:
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
35

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 36 of 92
NPTE
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.
Local ulcers care, including maintaining proper moisture balance and use of anti-bacterial
dressings
Debridements (removing dead tissue)
Keeping unaffected tissue around the pressure ulcer clean and lightly moisturized
Surgical intervention to provide muscle flaps and skin grafts for some patients
MUSCLE FLAPS
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
36

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 37 of 92
NPTE
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.
11.1.6 ELECTRONIC, ELECTRICAL MODALITIES:
Short-wave Diathermy LASER Therapy
Electrical Currents MFC (Medium Frequency Currents)
UltraSonic Longwave Therapy (For Pain Relief)
Paraffin Wax Bath (P.W.B.) Exercises
TENS (Transcutaneous Nerve Stimulator)
A. ULTRASONIC:
 Ultrasound is one intervention-type physiotherapy that helps to decrease the pain, swelling
and scarring.
 Ultrasonic involves the use of sound waves. It is useful for localized pain and helps to
reduce pain, muscle spasm, and loosens adhesions.
 It is also useful in Neuralgic pain eg. post-herpatic neuralga. Care should be taken for the
dosage.
 Degranulation of mast cells
 Thermal US: Increases tissue temperature
 Nonthermal US: chemical alterations
 Causes release of histamine
 Cause fibroblast to secrete collagen
 Increase wound contraction
 Improve tensile strength of tissue
I. CONTRAINDICATIONS:
 Infection
 Bleeding Ultrasound is one intervention-
 Pregnancy type physiotherapy that helps
to decrease the pain, swelling
II. UV RADIATION THERAPY: and scarring.
 UVA- Longest wavelength, (melanoma)
 UVB- Sunburn
 UVC- Bactericidial effect
III. INDICATIONS:
 Psoriasis
 Chronic Wounds
 Atopic dermatitis
 Eczema
 Acne vulgaris
IV. CONTRAINDICATIONS:
 Acute herpes simplex
 Sensitizing drugs
 Precancerous conditions
 Acute psoriasis
 Acute erythematous
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
37

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 38 of 92
NPTE
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.
B. SHORT-WAVE DIATHERMY:
It is a high frequency alternating current which helps to reduce muscle spasm, relieves pain,
increases circulation of the painful area. Mainly used for arthritis, backpain, neck pain,
shoulder pain, sprain etc.
C. LASER THERAPY:
This was the first of its kind in India. An acronym of the term 'Light Amplification of Stimulated
Emission of Radiation'. It is a non-invasive modality for the pain relief; it is a low power laser
class 1, which is safe to use, as they do not destroy tissue. It has a unique physiological effect
that gives immediate pain relief in certain cases. Its indications are arthritis, tennis elbow, heel
pain, neck pain, backpain, sciatica, healing of wounds, knee injuries etc.
D. LONGWAVE THERAPY (FOR PAIN RELIEF):
First of its kind in India. The Equipment generates a high frequency current. It is manufactured
in Norway. It is based on the capacitor field method. Patient feels mild comfortable heat, which
has long lasting pain relief and in some cases immediate 30% to 40% relief is obtained.
Indications: Calf muscles pain, Ankle sprain, Backache, Arthritis, Frozen Shoulder, Tennis
Elbow, Heel pain etc.
E. MFC (Medium Frequency Currents):
MFC is found effective for pain modulating and has even nerve block effect, and has long
lasting pain relief. It's programmable computerized unit, where relaxation and contraction of
the muscles can be controlled in 1:1 or 2:4 ratio. It gives good relief in post-operative pain.
F. CONTRAINDICATIONS:
 A contraindication is a specific situation in which a drug, procedure, or surgery should
NOT be used, because it may be harmful to the patient.
 Some treatments may cause unwanted or dangerous reactions in people with allergies,
high blood pressure, or pregnancy. For example, certain decongestants are
contraindicated for people with high blood pressure.
 Many medications interact and should not be used together by the same person. For
instance, a person who takes blood-thinning medication to thin the blood should not take
aspirin.
 The information provided herein should not be used during any medical emergency or for
the diagnosis or treatment of any medical condition. A licensed physician should be
consulted for diagnosis and treatment of any and all medical conditions.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
38

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 39 of 92
NPTE
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.
11.1.7 PHYSIOTHERAPY MODALITIES IN RHEUMATOID ARTHRITIS:
Physiotherapy modalities are commonly used in the treatment of RA. These include
cold/hot applications, electrical stimulation, and hydrotherapy.
Controlled studies performed with adequate numbers of cases and using validated
objective measures to evaluate various physiotherapy and rehabilitation methods in RA are
quite rare. This is because the disease process may be affected by various factors, and the
actual effectiveness of the investigated agents is difficult to determine. However, various
physiotherapy agents are commonly used in daily practice; most often, their use is based
on personal experiences.
A. COLD/HOT APPLICATIONS:
 Cold/hot modalities are the most commonly used physical agents in arthritis
treatment. It is well known that cold application is mostly used in acute stages
whereas hot is used in chronic stages of RA.
 By using heat, analgesia is accomplished, muscle spasm relieved, and elasticity of
periarticular structures obtained. Heat can be used before exercise for maximum
benefit. Thermo therapy may be applied as a superficial hot-pack, infrared
radiation, paraffin, fluid therapy, or hydrotherapy. Applications are recommended
for 10-20 minutes once or twice a day. Caution is necessary in patients with
sensorial deficits and impaired vascular circulation in hands and feet because of
burn risk. Cold application is preferred in active joints where intra-articular heat
increase is undesired. Cold pack, ice, nitrogen spray, and cryotherapy are different
methods of applying cold-therapy.
 Cartilage-destroying enzymes are produced within the inflamed joints of patients
with RA. The temperature of local joints affects levels of destructive enzymes such
as collagenase, elastase, hyaluronidase, and protease. With temperatures of 30°
Celsius or lower, effects of these enzymes are negligibly small. Normal intra-
articular temperature is 33° Celsius, whereas it may rise up to 36° Celsius in
patients with RA. Increasing intra-articular temperature is also related to an
increase in collagenase activity and cartilage damage. Despite the inhibition of cell
proliferation and metabolic activation within the synovial fluid at 41-42° Celsius, it
cannot be used as a therapeutic method because of irreversible joint damage.
Various studies have investigated the changes within joints upon application of
heat. Intra-articular temperature increased by superficial heat application. In the
first 5 minutes, the joint temperature decreased but subsequently, as expected, it
began to rise. It has been suggested that within the first few minutes, superficial
vessels become dilated and circulation moves away from the inflamed synovial
tissue. The opposite of this occurs during the cold application. Effects of heat
application change between normal healthy subjects and patients with inflamed
joints. Accordingly, skin temperature rises with paraffin at the most and intra-
articular joint temperature with diathermy application. Temperature increase with
short-wave diathermy application continues for 40 minutes. However, it has been
observed that increased intra-articular temperature has no beneficial effect on
clinical prognosis or radiologic progression. Skin temperature decreases the most
by cold air application, whereas intra-articular temperature decreases the most by
ice application. Increased intra-articular temperature by cold-pack application may
be explained by react ional temperature rise with short-term application, which was
previously mentioned.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
39

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 40 of 92
NPTE
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.
I. PARAFFIN WAX BATH (P.W.B.):
Has a low melting point, a special wax is used for small joints of hands and feet.
Skin acts as a insulator. It is used for stiff joints (post-plaster, fracture of hands,
feet) Arthritic cases of small joints. It should not be given in certain skin
conditions.
B ELECTRICAL STIMULATION:
Electro stimulation is used in patients with RA to relieve pain. Transcutaneous
electrical nerve stimulation (TENS) therapy is the most commonly used method.
Mannheimer and Carlsson applied TENS at various frequencies and reported that the
highest frequency TENS was the most beneficial, with an analgesia that persisted up to
18 hours. Various studies have reported an increase in handgrip strength after daily
application of 15 minutes of TENS and a decrease in pain after using TENS once a
week for 3 weeks. Levy and colleagues observed reduction of synovial fluid and
inflammatory exudate following TENS application in acute arthritis and suggested that
pain relief might be partially explained by this effect. Postoperative pain control by
TENS therapy following knee joint arthroplasty reduces need for analgesic drugs and
hospital stays. Due to the variations between the materials and methods of the studies,
it is difficult to interpret TENS applications. Nevertheless, TENS is generally a short-
acting therapy (6-24 hours), and the most beneficial frequency is 70 Hz. It also has a
high placebo effect. It cannot be used in every painful joint simultaneously, which is a
disadvantage in patients with polyarticular involvement. Interferential current can also
be used for analgesia. Studies have shown its efficacy on pain relief, swelling, and
improvement in ROM. Also, no difference was found between interferential current and
TENS in the magnitude of analgesia.
I. ELECTRICAL CURRENTS:
 Galvanic: Can be used for Diagnostic and Therapeutic purposes, Direct
Galvanic current is mainly used for Ionisation i.e. transference of ions of drugs
into the tissues through the skin for pain relief. It is also used for stimulation of
weak muscles.
 Faradic: Can be surged with different wave forms. It is used for pain &
Swelling. eg. post operative knee surgery-it is given to improve muscle
strength, prevent atrophy, & reduction of muscle swelling.
II. TENS (TRANSCUTANEOUS NERVE STIMULATOR):
 This is a small battery operated instrument. It has a simple theory \"gate control\" i.e.
Pain can be blocked by non destructive means.
 A gentle application of electrical stimulation (with special rate, width, & voltage control)
helps to close the gate, thereby blocking the pain message to the brain at the spinal
cord level giving immediate pain relief in certain conditions. Author is using T.E.N.S.
since 1979, she has found good results in chronic backpain and neckpain. It is
biologically safe to use. (Except when pacemaker is implanted)
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
40

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 41 of 92
NPTE
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. HYDROTHERAPY:
There has been widespread use of Balneotherapy by patients with rheumatic diseases
since the old times in search of a cure for their ailment. Therefore, there are some
suggestions that the science of rheumatology has been developed in balneotherapy.
Initially, the term \"balneotherapy\" was used to discriminate thermal and mineral water
therapy from hydrotherapy, but today these terms are often used interchangeably. In
recent years, balneotherapy has served as one of the therapeutic alternatives in other
rheumatoid diseases, particularly in chronic degenerative diseases. Objectives of
balneotherapy are to increase ROM, to strengthen muscles, to relieve painful muscle
spasms, and to improve the patient's well being.
I. WHIRLPOOL TREATMENT:
Use for the following types of wounds:
 Moderate to heavy draining wounds
 Necrotic
 Tissue, which can tolerate moderate to heavy increased circulatory perfusion
 Ischemic wounds where vigorous perfusion to wound and surrounding tissues
is desired
II. TEMPERATURE OF WHIRLPOOL:
 Water temperature range from 33.5 °C to 35.5 0C = 92 °F to 96 °F
 Water temperature should not exceed 1 °C above skin temperature in
presence of PVD.
 Inflammatory phase- (90-95) degrees [standard 5-20 minutes]
 Proliferation phase- (96-98) degrees [standard 20 minutes]
 Water temperature should not exceed 38 °C in presence of cardiopulmonary
disease
 Water temperature of 32 °C blood flow of 2.3cc/100 cc of limb volume. Higher
temperature gives greater blood flow volume.
 When using lower temperatures, avoid chilling by maintaining warm room
temperature and use only for single limb, not whole body.
III. CONTRAINDICATIONS FOR WHIRLPOOL:
 Clean granulating wounds - are easily traumatized by the force of even a mild
agitation
 Epithelializing wounds
 DVT, Lethargy, Maceration
 Migrating epidermal cells may be damaged by even minimal force
Physiotherapy treatments  New skin grafts - skin grafts will not tolerate the high shearing forces and
such as hydrotherapy turbulence
(seen here) helps reduce  New tissue flaps - tissue flaps are very sensitive to shearing forces and
pain and improves the vasoconstriction which may occur if the water or air temperature cause chilling
patient's ability to exercise.
 Cardiopulmonary deficits
 Lower Extremity edema
 Venous ulcers - it is undesirable to increase blood volume to an area where
blood volume is already a problem - will complicate the problem; in addition, a
dependent position will produce more dependent edema and stasis; the hard
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
41

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 42 of 92
NPTE
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.
necrotic fibrin found in a venous ulcer are not effectively debrided by
hydrotherapy.
 Non-necrotic diabetic ulcers - callus will be softened leading to maceration,
macerated tissue will not tolerate pressure and wound will be enlarged
D. BALNEOTHERAPY:
One of the most important activities that takes place at a traditional spa is
balneotherapy, a natural approach to health and healing that uses hot spring water,
gases, mud, and climatic factors (such as heat) as therapeutic elements.
1. Bathing in hot springs gradually increases the temperature of the body, thus killing
harmful germs and viruses.
2. Thermal bathing increases hydrostatic pressure on the body, thus increasing blood
circulation and cell oxygenation. The increase in blood flow also helps dissolve and
eliminate toxins from the body.
3. Hot springs bathing increases the flow of oxygen-rich blood throughout the body,
bringing improved nourishment to vital organs and tissues.
4. Bathing in thermal water increases body metabolism, including stimulating the
secretions of the intestinal tract and the liver, aiding digestion.
5. Repeated hot springs bathing (especially over three- to four-week period) can help
normalize the functions of the endocrine glands as well as the functioning of the
body’s autonomic nervous system.
6. Trace amounts of minerals such as carbon dioxide, sulfur, calcium, magnesium,
and lithium are absorbed by the body and provide healing effects to various body
organs and system. These healing effects can include stimulation of the immune
system, leading to enhanced immunity; physical and mental relaxation; the
production of endorphins; and normalized gland function.
7. Mineral springs contain high amounts of negative ions, which can help promote
feelings of physical and psychological well-being.
8. The direct application of mineralised thermal waters (especially those containing
sulphur) can have a therapeutic effect on diseases of the skin, including psoriasis,
dermatitis, and fungal infections. Some mineral waters are also used to help the
healing of wounds and other skin injuries.
I. INDICATIONS FOR BALNEOTHERAPY:
Over the several hundred years during which the science of medical balneology
has developed, physicians have been able to identify the health conditions that can
best be treated by healing springs.
CHRONIC DISEASES
 Chronic rheumatic diseases
 Functional recovery of central and peripheral neuroparalysis
 Metabolic diseases, especially diabetes, obesity, and gout
 Chronic gastrointestinal diseases
 Chronic mild respiratory diseases
 Circulatory diseases, especially moderate or mild hypertension
 Peripheral circulatory diseases (affecting the hands and feet)
 Chronic skin diseases
 Psychosomatic and stress-related diseases
 Autonomic nervous system dysfunction
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
42

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 43 of 92
NPTE
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.
 Vibration disorder (a middle ear disorder affecting balance)
 Sequela of (conditions resulting from) trauma
 Chronic gynaecological diseases
II. CONTRAINDICATIONS:
If you have any illnesses or diseases, or are pregnant, consult with your physician
before using spa therapy.
III. CAUTIONS:
Avoid soaking in a hot spring alone and the elderly should use with caution. Don’t
use a spa if you are under the influence of alcohol or drugs, especially heart
medications. Don’t overheat, drink plenty of cool water and use private pools if you
have a skin disease.
E. VACUUM ASSISTED WOUND CLOSURE:
Use of negative pressure for wound closure with stage III or IV pressure ulcers. Also used on
arterial, venous, flaps, diabetic ulcers and non-surgical patients.
Benefits: Increases granulation tissue, blood flow, fills cavity of wound, limited dressing
changes, and is portable.
Protocol: 125 mmHg for flaps and pressure sores 50-75 for chronic wounds, neuropathies,
and venous stasis
Contraindications:
Necrotic tissue
Malignancy
Fistulas
Untreated osteomylitis
F. HYPERBARIC MEDICINE:
Hyperbaric medicine, also known as hyperbaric oxygen therapy (HBOT), is the medical
use of oxygen at a level higher than atmospheric pressure.
Some of the benefits of hyperbaric medicine include: improved bacterial clearance,
angtiogenesis, and collagen deposition.
Hyperbaric treatment of diabetic and pressure ulcers are commonplace. Hyperbaric use with
arterial and venous ulcers is limited. Standard treatment is approximately 90-120 minutes at
2.0-2.5 ATA. Some treatments may be twice a day.
Systemic hyperbaric:
Osteoradionecrosis Gas Gangrene
Crush Injuries Decompression sickness
Smoke Inhalation Air/Gas Embolism
Topical hyperbaric:
Diabetic ulcers Burns
Pyroderma gangranosum Necrotizing fascitis
Osteomyelitis Refractory ulcers
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
43

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 44 of 92
NPTE
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. MASSAGE THERAPY:
Massage is one of the oldest of the Health sciences and has been used for curative purposes
since time immemorial. Massage treatment uses \"TOUCH\" to apply pressure to the body's
skin, muscles, tendons, and ligaments.
The Idea of Massage is to ease disorders by;
1. Relieving tension, 2. Promoting blood flow, 3. Calming nerves, 4. Loosening muscle
I. MODES OF THERAPEUTIC MASSAGE:
 Stroking: Stroking is performed with the whole hand or fingers. It comprises the
usage of relaxed hand over the patient's skin with a rhythm and pressure that produce
a relaxing effect.
 Effleurage: spreading and moving the hands with pressure and speed, to gain
relaxation and lymph drainage, perform Effleurage.
 Kneading: Kneading involves alternate compression and release of the part to be
manipulated.
 Picking up: Picking up involves lifting up of tissue from underlying bone, releasing it
after squeezing it.
 Wringing: Wringing technique lifts up the tissue and applies a twist to enhance
stretching effect.
 Friction: Friction is a small movement applied with thumb or finger where pressure is
applied from superficial to depth of the tissue.
 Hacking: Hacking is performed with extended forearm and striking the skin using the
side of the hand .
 Clapping: Clapping is done by striking the skin with cupped hands.
 Shaking and Vibration: Shaking and vibration involves gentle strokes of shakes and
vibrations respectively
 Traction: Traction is a device used for reducing the fractures and dislocations of a
bone.
Types:
 Continuous - applied over period of few days or weeks
 Intermittent - repeated application for a short duration
Indications:
 Myalgia
 Arthritis
 Fibrositis
 Scar Tissue
 Lymphedema
Contraindications:
 Circulatoryt disorder
 Abnormal sensation
 Metastatic Cancer
 Bacterial infection
 Bleeding
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
44

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 45 of 92
NPTE
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.
II. ADVANTAGES FROM MASSAGE THERAPY:
Relief of pain Relieves tension
Muscle tightness is relieved Skin is toned
General relaxation Drainage of oedema or swelling
Induce sleep in insomnia Loosens secretion in the Lungs
III. WHERE NOT TO MASSAGE?
If the treatment area has:
Large open wounds Sensitive skin
Burns Bacterial infections
Skin Ulcers Skin disease
Gross Oedema (severe swelling) Malignancies like cancer
Extremely Hairy areas
Local massage techniques around the world
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
45

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 46 of 92
NPTE
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.
12.0 FUNCTIONAL TRAINING AND ORTHOTIC, PROSTHETIC AND SUPPORTIVE
DEVICES:
12.1 ADULT UPPER LIMB PROSTHETIC TRAINING:
 The impact of the sudden loss of a hand or arm upon a person cannot be overstated. The loss of fine,
coordinated movements of the hand, tactile sensation, proprioceptive feedback, and aesthetic
appearance can only be compensated for to a limited extent by three types of prostheses that are
currently available.
 As outlined in previous chapters, the three prosthetic options include (1) a passive cosmetic arm and
hand; (2) a cable-controlled, body-powered prosthesis; and (3) an electrically powered prosthesis
controlled by myoelectric sensors or specialized switches. In reality there are no perfect or ideal
replacements that take the place of the exquisite mechanisms and function of the human hand.
 An unusually high rejection rate of upper-limb prostheses can often be attributed to the following
reasons: development of one-handedness, which removes the functional need for the prosthesis; lack
of sufficient training or skill in using the prosthesis; poor comfort of the prosthesis; a poorly made
prosthesis; the unnatural look or profile of the prosthesis; and the reactions that the wearer gets from
other people.
 It is felt that successful outcomes in rehabilitation for the unilateral and bilateral amputee can be
attributed to the following reasons:
 Early post-traumatic intervention
 Experienced team approach
 Patient-directed prosthetic training
 Patient education
 Patient monitoring and follow-up
 The focus of this chapter is to stress the importance of postoperative, preprosthetic, and prosthetic
training principles. Listening to and acknowledging the patient's psychological and functional needs will
be critically important in determining the success or lack of success with prosthetic acceptance and
function.
12.1.1 POSTOPERATIVE THERAPY PROGRAM:
Awareness of postoperative and subsequent preprosthetic principles of care is crucial to
successful management of an individual who has just sustained traumatic limb loss. This phase of
care is one where the patient has little control over what is happening and must depend upon the
health care team to provide the best treatment possible.
Any member of the rehabilitation team, which may include the physician, nurse, and occupational
or physiotherapist, can address treatment goals of postoperative care. The goals are as follows:
1. Promote wound healing.
2. Control incisional and phantom pain.
3. Maintain joint range of motion.
4. Explore the patient's and family's feelings about a change in body image.
5. Obtain adequate financial sponsorship for the prosthesis and training.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
46

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 47 of 92
NPTE
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. PROMOTE WOUND HEALING:
Wound healing is generally monitored by the surgeon who performed the amputation and by
the nurse. The role of the nurse cannot be overemphasized since she is the member of the
team having continuous contact with the patient during this stage of healing. The nurse will
need to be active in the patient's rehabilitation program so that those activities taught to the
patient by the occupational and physiotherapists may be carried over successfully to the
nursing unit situation.
B. CONTROL INCISIONAL AND PHANTOM PAIN:
Narcotic agents given intravenously or intramuscularly generally manage acute incisional
pain. This is necessary for the first 3 to 4 postoperative days. Transcutaneous electrical nerve
stimulation (TENS) has also been used to decrease incisional and phantom pain in the
amputated limb. This modality can be used alone or in conjunction with oral analgesics.
The difference between a phantom limb and phantom pain should be clearly explained to
the amputee. A phantom limb is the feeling or sensation that the limb is still present, and
phantom pain is differentiated by the sensation of pain in the phantom limb. Significant
success in decreasing phantom pain has been achieved by using amitriptyline (Elavil) at
doses of 50 to 150 mg daily at bedtime. Elavil is involved in serotonin production and is
believed to modify pain perception.
Phantom limb pain may also be controlled by isometric exercise. These exercises can be
started within 5 to 7 days following surgery. Residual wrist extensors and flexors as well as
residual biceps and triceps are the muscles of choice to use in isometric exercise in transradial
and transhumeral amputees, respectively. These exercises should be performed every other
hour for 10 to 20 repetitions.
C. MAINTAIN JOINT RANGE OF MOTION:
Maintaining adequate range of motion in all joints of the upper limb is critical. This is
particularly true in the burn patient. Full range of motion is frequently lost at the glenohumeral
and elbow joints. Additionally, scapulohumeral mobility must be maintained and strengthened.
Full flexion and extension at the elbow combined with maintaining maximum pronation and
supination of the forearm cannot be overemphasized. These motions are crucial for terminal
device placement and subsequent function.
An active exercise program should be initiated by the physical or occupational therapist.
This can begin as early as the second postoperative day. The program should be closely
supervised and include active and active assistive joint range of motion. Gentle isometric
contractions can begin on the fifth postoperative day, and isotonic contractions can be
encouraged 7 to 10 days postoperatively. Active exercise practiced several times daily can
begin shortly thereafter and should be thoroughly reviewed with the patient.
D. EXPLORE THE FEELINGS OF THE PATIENT AND FAMILY:
The emotional impact of limb loss on the patient and his family is overwhelming. Often
there is a period of depersonalization that may occur during this time when other limbs and
body systems may be involved following severe traumatic injury. Reassurance and support
are vitally necessary not only at this time but throughout the rehabilitation process. All
members of the team should respect the individual's dignity, support the patient and family
throughout the grief process, as well as offer encouragement and realistic optimism with
respect to his future generally. It is premature to discuss prosthetic component options at this
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
47

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 48 of 92
NPTE
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.
time. Often the patient and his family are not ready to hear about or see prostheses until the
acute postoperative phase has passed.
E. FINANCIAL SPONSORSHIP:
It is important to identify and explore third-party sponsorship at this time. Specialized
prostheses are often costly. Sponsorship must be sought early, and these devices must be
adequately described to the payer so that a comprehensive rehabilitation program can be
realistically pursued.
12.1.2 PREPROSTHETIC THERAPY PROGRAM:
From the time the sutures are removed to the time the prosthetic prescription is being discussed
there are many goals that are important to address. The occupational therapist is the primary
person who will be managing and monitoring this program for the upper-limb amputee. Nursing is
an important adjunct, however, and all shifts of the nursing staff should be thoroughly familiar with
each of these areas.
The goals of the preprosthetic program are as follows:
 Residual limb shrinkage and shaping  Maximizing independence
 Myoelectric site testing (if myoelectric
 Residual limb desensitisation components are prescribed)
 Maintenance of normal joint range of
motion  Orientation to prosthetic options
 Exploration of patient goals regarding
 Increasing muscle strength the future
 Instruction in proper hygiene of the limb 
This phase generally occurs 2 to 3 weeks after surgery. Healing has essentially occurred by the
21st postoperative day and should allow a vigorous program for prosthetic preparation.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
48

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 49 of 92
NPTE
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. RESIDUAL LIMB SHRINKAGE AND SHAPING:
 Shrinking and shaping of the residual limb is usually accomplished by compression from
an elastic bandage, intermittent positive-pressure compression, or a tubular elastic
bandage. If an elastic bandage is used, it is important that the proper technique be taught
to the patient, family, and nursing staff. A figure-of-8 wrap is one that applies more
pressure distally than proximally; elastic bandaging should never be done in a
circumferential manner.
 The wrapping process begins with the end of the bandage placed diagonally at the distal
Fig 1 end of the residual limb. The wrap should encircle the limb from behind and wrap
diagonally upward to cross over the end of the bandage. This figure-of-8 process should
continue, with each pattern overlapping the previous one by approximately two thirds the
width of the bandage (.Fig 1). The bandage is then secured with tape or special clasps.
 No elastic bandage should be used for more than 48 hours without being washed with
mild soap and lukewarm water and thoroughly rinsed with clean water. Bandages should
not be twisted, but laid flat to dry. Washers and dryers decrease their longevity and ruin
their elasticity.
 The wrap should be reapplied every few hours or more frequently if it slips or bunches.
The elastic bandage should be worn all day and all night except when bathing. A
preparatory prosthesis might also be applied early in the shaping process; however, a
Fig 2 compression bandage is generally preferred because it affords better monitoring of skin
healing and points of pressure.
B. RESIDUAL LIMB DESENSITIZATION:
An equally important yet often overlooked factor is desensitization of the residual limb. It
can be accomplished with gentle massage and tapping techniques (Fig 2.). Desensitization
can also be accomplished by vibration, constant touch pressure, or the input of various
textures applied to the sensitive areas of the limb. The patient should be encouraged to do
these techniques himself. He is aware of his tolerance and can become more \"in touch\" with
his body by practicing this regularly. When healing has occurred, aggressive massage will
prevent adhesions from occurring and provide additional sensory input. It should be explained
that this would improve the patient's tolerance to the pressure that will be placed on the
residual limb by the prosthetic socket.
C. MAINTENANCE OF JOINT RANGE OF MOTION:
When establishing an effective treatment program, the maintenance of joint range of
motion is essential. As stated earlier, scapular, glenohumeral, elbow, and forearm range of
motions are crucial to maintain in order to aid in the prosthetic control motions and to
maximize the functional potential of the prosthesis.
D. INCREASING MUSCLE STRENGTH:
Increasing upper-limb muscle strength can be accomplished in conjunction with the range-of-
motion program. Active resistance applied by the therapist or cuff weights attached to the limb
can be utilized.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
49

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 50 of 92
NPTE
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.
E. INSTRUCTION IN PROPER HYGIENE OF THE LIMB:
Education in proper hygiene and care of the residual limb is equally important at this time.
The limb should be washed daily with mild soap and warm water. It should be rinsed
thoroughly and patted dry with a towel. This provides additional sensory input into the residual
limb as well as allows the patient to become more familiar with the changes in his body.
F. MAXIMIZING INDEPENDENCE:
Another important element in the preprosthetic phase of care is maximizing functional
independence. Instruction in change of dominance and teaching one-handed activities are
often indicated when working with the unilateral amputee. The bilateral acquired upper-limb
amputation presents a unique challenge to the amputee team. Before receiving his
prostheses, this amputee is essentially dependent in all activities of daily living, and this
results in very real anxiety and frustration. It is important to express reassurance, support, and
realistic optimism to these individuals during this time. A simple device such as a universal cuff
utilized with an adapted utensil, toothbrush, pen, or pencil can significantly enhance
Independence.
G. MYOELECTRIC SITE TESTING:
If a myoelectric prosthesis is being considered, this is an appropriate time to utilize a
myotester to gauge the electric potential generated by various muscles. The myotester results
should be discussed with a prosthetist, particularly for the proximal levels of amputation. The
occupational therapist, physician, and prosthetist should jointly determine the best positioning
for the electrodes and discuss the issues of prosthetic socket design.
H. ORIENTATION TO PROSTHETIC OPTIONS:
This is an important time to orient the amputee patient and his family to prosthetic options
available to him. The unique differences between body-powered and electric components
should be comprehensively described, and examples of each should be shown and
demonstrated if possible. Photographs or slides may be reasonable substitutions, but being
able to touch the device and understand how it operates is extremely helpful and informative
for the amputee. An overview of the advantages and disadvantages of body-powered and
electric components should be clearly explained.
A careful inventory of the patient's life-style, support system, educational background, and
future goals should be explored and discussed. The amputee patient is an integral part of the
decision-making process of this prosthetic prescription. Involving the patient in decisions that
affect his own health care will help to restore a sense of control over his life.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
50

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 51 of 92
NPTE
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.
12.1.3 DETERMINING THE PROSTHETIC PRESCRIPTION:
The discussion of the prosthetic prescription is ideally accomplished in the presence of the
patient, physician, therapist, prosthetist, family, and third-party payer. Many amputees who have
sustained work-related injuries have the unique advantage of having a rehabilitation insurance
nurse or case manager assigned to their care. This individual is a valuable liaison between the
patient, insurance carrier, and medical providers. It is important to include these insurance
representatives in the discussion of the prosthetic prescription because they have a direct
influence on the financial approval of the prosthesis and the rehabilitation treatment plan.
The prosthetic prescription is based on a number of criteria that should be comprehensively
addressed and recorded.
These criteria frequently include the following:
Length of the residual limb Desire for function
Amount of soft-tissue coverage Desire for cosmesis
Presence of an adherent scar Patient attitude and motivation
Movement of proximal joints Vocational interests
Muscle strength in the residual limb Avocational interests
Muscle strength in the opposite limb Third-party payer considerations
Adequate ability to learn and retain new information Family preferences
Adequate sensation in the residual limb
A. FABRICATION AND TRAINING TIME:
 The steps involved in fabricating the prosthesis should also be explained at this time.
Several steps are required from the time the prosthesis is prescribed to the time it is
delivered to the patient. This process should be thoroughly explained to the patient and
third-party payer, particularly if the patient lives out of town so that transportation can be
arranged for prosthetic fitting and training.
 This is also an appropriate time to discuss the options of outpatient vs. inpatient
hospitalisations. Generally, all unilateral upper-limb amputee patients can be managed on
an outpatient basis. It is strongly recommended that all bilateral upper-limb amputees be
trained on an inpatient basis. The bilateral upper-limb amputee has not only issues of
functional independence to address but emotional issues as well. These can be more
closely monitored on an inpatient basis, with the family and patient becoming involved with
the social worker or psychologist on the amputee team. Recommended and approximate
training time schedules are as follows:
 Transradial, 5 hours
 Transhumeral/shoulder disarticulation, 10 hours
 Bilateral transradial, 12 hours
 Bilateral transhumeral, 20 hours
 Ideally this training should be managed on a daily basis for 1 to 2 hours a day.
 This is also an appropriate opportunity for the new amputee to meet others with similar
levels of limb loss that have worn prosthesis for a period of time. Common reactions,
frustrations, and anxieties can be shared. Positive achievements should be stressed,
however. It must be remembered that one amputee's experience does not directly parallel
another's. These encounters should be followed by an opportunity for the amputee to
discuss his feelings and reactions with an experienced psychosocial professional in
amputee rehabilitation.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
51

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 52 of 92
NPTE
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.
12.1.4 ADULT UPPER-LIMB PROSTHETIC TRAINING:
Before initiating a program of upper-limb prosthetic training, one must realistically orient the patient
to what the prosthesis can and cannot do. If the individual has an unrealistic expectation about the
usefulness of the prosthesis as a replacement arm, he will be dissatisfied with the ultimate
functioning of the prosthesis and may reject it altogether. On the other hand, if the expectations of
the amputee are more realistic at the beginning of training, then the ultimate acceptance will be
based upon the ability of the prosthesis to improve the individual's performance. It is imperative,
then, that the therapist be honest and positive about the function of the prosthesis. If he \"believes
in\" and understands the functional potential of the prosthesis, success can be more realistically
achieved.
A. INITIAL ASSESSMENT:
During the therapist's first encounter with the amputee patient in therapy, the following issues
need to be discussed and documented if they have not already been accomplished.
Etiology and onset Phantom pain or residual limb pain
Age Previous rehabilitation experience
Dominance Revisions
Viable muscle sites (for myoelectric
Other medical problems control)
Previous information regarding
Level of independence prostheses
Range of motion of all joints of the Background education and vocational
residual limb goals
Muscle strength of the remaining Goals and expectations regarding the
musculature prosthesis
Shape and skin integrity of the residual
limb
B. STATUS OF THE OPPOSITE UPPER LIMB: ·
Although this list may appear unreasonably long and too lengthy to document, the
assessment will make a significant difference in the therapist's awareness of the individual
with whom he is working. The nature of patient-therapist rapport and subsequent success of
therapy will be greatly enhanced if this information is gathered before therapy actually begins.
The period of time from casting until final fitting of the prosthesis is characterized by eager
anticipation and hope that the artificial arm will enable the individual to function as before the
amputation. Unfortunately, the finished prosthesis is often a disappointment for the patient. It
is perceived as \"artificial looking,\" heavy, uncomfortable, and awkward to operate. If the
patient is appropriately oriented to the realities of the prosthesis, how it looks and operates,
Fig 3 acceptance of the limitations of the prosthesis are more readily achieved following delivery.
C. INITIAL VISIT:
When the upper-limb amputee visits the occupational therapist for the first time, he will
probably be carrying the prosthesis in a bag or sack. It is important to understand this
awkwardness and reluctance in putting it on with others \"watching.\" A quiet, nondistracting
room with a mirror plus an atmosphere of acceptance and understanding is preferable.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
52

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 53 of 92
NPTE
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.
During the first couple of visits the following goals should be addressed: orientation to
prosthetic component terminology, independence in donning and doffing the prosthesis,
orientation to a wearing schedule, and care of the residual limb and prosthesis.
D. ORIENTATION TO PROSTHETIC COMPONENT TERMINOLOGY:
In view of the fact that the prosthesis has not become the patient's \"arm,\" it is important that
the patient learn to identify the major components of the prosthesis appropriately. Any
orientation to identifying such basic aspects as the figure-of-8 harness, cable, elbow unit or
elbow hinge, wrist unit, terminal device, and hook or hand will suffice at this time.
Independence in Donning and Doffing the Prosthesis
It is important that independence be established early in donning and doffing the prosthesis by
the \"pullover sweater\" method. As an alternative, the \"coat\" method may also be used (Fig 3.).
Bilateral amputees most often use the \"sweater\" method.
E. PROSTHETIC WEARING SCHEDULE:
Development of a wearing schedule is an extremely important aspect of this first visit. I nitial
wearing periods should be no longer than 15 to 30 minutes, with frequent examination of the
skin for excess pressure or poor socket fit. This is particularly important for the amputee with
insensate areas and adherent scar tissue. If redness persists for more than 20 minutes after
the prosthesis is removed, the patient should return to the prosthetist for socket modifications.
If no skin problems are present, wearing periods may be increased in 30-minute increments
three times a day. By the end of a week, the upper-limb amputee should be wearing his
prosthesis all day.
F. CARE OF THE RESIDUAL LIMB AND PROSTHESIS:
 Following amputation, the skin of the residual limb is subject to irritation and sometimes to
further injury and infection. Appropriate care of the skin is therefore a vital part of
rehabilitation. The residual limb should be bathed daily, preferably in the evening. It is
advisable to not wash the residual limb in the morning unless a stump sock is worn. Damp
skin may swell and stick to the prosthesis and may be irritated by rubbing. The limb should
be washed with mild soap and lukewarm water. It should be rinsed thoroughly with clean
water. If soap is left to dry on the skin, it may be irritating. After rinsing, the skin should be
dried thoroughly by using patting motions. Avoid brisk rubbing, which may irritate the skin.
Lotions, creams, and moisturizers should not be applied to the limb unless the physician
or therapist gives specific orders.
 The socket should be cleaned often, particularly if the individual perspires heavily. In warm
weather the socket may require cleaning at least once or twice daily. The socket should be
washed with warm water and mild soap. It should be thoroughly wiped out inside with a
cloth dampened in clean warm water. The socket can be left to dry through the night or
dried thoroughly with a towel inside if one plans to continue to wear the prosthesis
immediately.
 If stump socks are worn, several changes may be necessary during warm weather owing
to perspiration. If possible, the sock should be washed as soon as it is taken off, before
the perspiration dries on it. This will prolong the life of the stump socks. Mild soap and
warm water should be used, followed by the sock being thoroughly rinsed. Allow the sock
to dry slowly to avoid shrinkage.
 The amputee should be encouraged to inspect his skin daily. If skin disorders develop, the
physician should be called promptly. A minor disorder may become disabling if incorrect
treatment is used. It will probably be necessary to adjust the prosthesis, and therefore the
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
53

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 54 of 92
NPTE
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.
prosthetist is generally involved at this time as well. Strong disinfectants such as iodine
should never be used on the skin of the stump.
G. BODY CONTROL MOTIONS:
Prior to allowing the upper-limb amputee to practice prosthetic controls training, several
motions need to be reviewed. This is best done before the prosthesis is actually applied.
1. Scapular abduction. -Spreading the shoulder blades apart in combination with humeral
flexion, or alone, will provide tension on the figure-of-8 harness in order to open the
terminal device.
2. Chest expansion. -Deeply inhaling, expanding the chest as much as possible, and then
relaxing slowly should practice this motion. Chest expansion may be utilized in a variety
of ways for the transhumeral, shoulder disarticulation, or forequarter amputee.
Harnessing this motion with a cross-chest strap is determined by the prosthetic design; in
some instances of extensive axillary scarring, it may be preferred to the figure-of-8
harness.
3. Shoulder depression, extension, and abduction. - This is the combined movement
necessary to operate the body-powered, internal-locking elbow of the trans-humeral
prosthesis. It is advisable to have the amputee practice this motion by cupping one's hand
under the residual limb and instructing the patient to press down into the palm. This will
simulate the motion required to lock and unlock the elbow in the individual with
transhumeral amputation.
4. Humeral flexion. -The amputee is instructed to raise his residual limb forward to shoulder
level and to push his arm forward while sliding the shoulder blades apart as far as
possible. This motion applies pressure on the cable and allows the terminal device to
open. Scapular abduction and humeral flexion are the basic motions to review with the
transradial amputee.
5. Elbow flexion/extension. -It is critical to instruct the transradial amputee to maintain full
elbow range of motion. This range will enable him to reach many areas of his body without
undue strain or special modifications to the prosthesis.
6. Forearm pronation/supination. -In the long transradial amputee, it is equally important to
maintain as much forearm pronation and supination as possible. This will enable the
amputee to position the terminal device where he chooses without manually prepositioning
the wrist unit. If the amputee has retained more than 50% of his forearm, some degree of
forearm pronation and supination is maintained.
H. PROSTHETIC EVALUATION:
Before beginning functional training, it is important to ensure that the prosthesis fits
comfortably and that the components function in a satisfactory manner. Ideally this is
accomplished with the occupational therapist and prosthetist together. A formal prosthetic
checkout form for this purpose is available from Northwestern University.
The therapist is encouraged to communicate openly with the prosthetist on a frequent basis
not only initially but whenever concerns regarding fit or operation arise.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
54

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 55 of 92
NPTE
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.
I. PROSTHETIC CONTROLS TRAINING:
Manual controls are important to review after the prosthesis is applied. One control should be
taught at a time and then combined with others:
1. Positioning the terminal device in the wrist unit is accomplished by manual rotation with
the sound hand. In the bilateral upper-limb amputee, a force against an object in the
environment or between the individual's knees is necessary to accomplish this positioning.
2. Rotation at the elbow turntable is manually adjusted or controlled by leaning the prosthesis
against an object.
3. The friction shoulder joint is manually adjusted with the sound hand or by applying
pressure against an object or the arm of a chair.
4. If the prosthesis has a wrist flexion unit, this can be manually controlled by applying
pressure on the button or, for the bilateral amputee, by applying pressure against a
stationary object.
Active controls are equally important to review prior to functional training. The upper-limb
amputee incorporates the body-control motions he learned previously while wearing the
prosthesis. It is essential that the harness be adjusted properly before initiating these
exercises:
1. In all proximal levels of upper-limb loss, body-powered elbow flexion is facilitated by a
forearm lift assist that counterbalances the weight of the forearm. Elbow extension is
accomplished by gravity if the elbow unit is unlocked.
2. Elbow lock/unlock is perhaps one of the most difficult tasks to learn in the operation of
transhumeral prosthesis. The pattern of \"down, back, and out\" is often stated to the
amputee in an effort for him to repeat the shoulder depression, extension, and abduction
pattern. This pattern not only locks but also unlocks the elbow in an audible \"two-click
cycle.\" Practicing this task should occur in a quiet, nondistracting room where one can
hear the clicks without difficulty. This pattern may need to be exaggerated at first, but soon
it will be barely observable.
3. Before approaching terminal device operations, it is important for the amputee to practice
locking and unlocking the elbow in several positions.
4. In the shoulder disarticulation and forequarter amputee, the mechanism to lock and unlock
the elbow is often a nudge control \"button\" attached to the thoracic shell. By depressing
this button with the chin, one is able to position and lock the elbow where desired.
5. It is important to clearly explain that the elbow must be locked first, in the proper position,
before one is able to operate the terminal device. As described previously, biscapular
abduction and/or humeral flexion cause the conventional terminal device to open, while
relaxing allows it to close (Fig 4.).
J. CONTROLS PRACTICE:
A form board is frequently utilized to perfect prepositioning as well as tension control of the
terminal device (Fig 5.). Prepositioning involves both manual and active controls to place the
prosthesis in the most optimal position for a specific activity. Close attention must be paid to
the individual's awkward or compensatory body motions when he approaches an object. Often
the amputee will \"adjust\" his body rather than repositioning the elbow and wrist unit positions.
A mirror can be effective in assisting the amputee to see the way his body is positioned. It is
helpful to instruct the patient to \"think\" how his own arm would have been positioned to
approach the object. It is often necessary to remind him to maintain an upright posture and to
avoid extraneous body movements.
The five motion elements that are primarily used in hand manipulation are reach, grasp,
move, position, and release. A form board can be used in training to orient the individual to
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
55

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 56 of 92
NPTE
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.
approach, grasp, and release objects differing in shape, weight, density, and size. Prehension
control can be practiced with a sponge or paper cup. The amputee is instructed to maintain
constant tension of the terminal device control cable so as not to crush the object being held.
Approach to an object should be such that the stationary hook finger makes contact with the
object and the movable finger actually \"grasps\" it. Flat objects can be moved to the edge of the
table and then grasped with the terminal device in a horizontal position. Prehension force is
generally controlled by rubber bands, which can be added as tolerated. Springs may be used
as an alternative.
Controls training for the bilateral upper-limb amputee are an aspect of therapy that may
require a period of time to perfect. To learn to separate the controls motion of two prostheses
is a complex and coordinated motor process that may need to be practiced frequently.
Passing an object back and forth, such as a rule, may help in reinforcing this pattern.
K. FUNCTIONAL USE TRAINING:
PREHENSION CONTROL  Functional use training is the most difficult and prolonged stage of the prosthetic training
process. The individual’s acceptance and usage of the prosthesis is dependent upon (1)
the motivation of the patient, (2) the comprehensiveness and quality of the tasks and
activities practiced, and (3), of critical importance, the experience and enthusiasm of the
occupational therapist. The training experience is most effective if the same therapist
remains with the patient throughout the entire process.
 It is extremely important to reinforce to the unilateral amputee that his prosthesis will play
Fig 5 a nondominant functional role. The prosthetic terminal device is most useful for gross
prehension activities and to hold and stabilize objects, while the sound limb performs fine
motor prehension activities. It is unreasonable to expect the prosthesis to assume any
more than 30% of the total function of the task in unilateral upper-limb activities. The
sound hand will always be dominant for all activities performed. The therapist must be
realistic and convince the patient to view the prosthesis as a \"helper.\"
 Unilateral patterns of independence occur quickly in the amputee who has lost an arm or
hand. It is therefore essential, if possible, to fit the unilateral amputee within 1 to 2 months
of the amputation. These individuals definitely show a greater propensity for wearing and
successfully using their prostheses. This applies to all amputees fitted with body-powered
or electric components.
 It is appropriate to practice activities of daily living that are useful and purposeful. Realistic
situations should be pursued so that the individual will automatically use the prosthesis
when he encounters the same activity in his daily routine. Examples include the following:
1. Cutting food 5. Washing dishes
PREHENSION
CONTROL 2. Using scissors 6. Hammering a nail and using tools
3. Dressing 7. Driving a car
4. Opening a jar or bottle
The importance of pre-positioning, prior to approaching these tasks, cannot be
overemphasized. The amputee should be instructed to orient the components of the
prosthesis in space to a position that resembles that of a normal limb engaged in the same
task. As a rule, most difficulties in use are a result of improper positioning.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
56

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 57 of 92
NPTE
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.
I. CUTTING FOOD:
It is easiest to cut food by holding the fork in the hook, with the hook fingers grasping the
flat surface of the fork handle and the upper handle of the fork resting on the dorsal
surface of the thumb of the hook. The sound hand holds the knife.
Fig 6 II. USING SCISSORS:
When using scissors, the material to be cut should be placed in the terminal device. The
sound hand holds the scissors. To avoid \"flopping,\" the area to be cut should be as close
to the area grasped as possible. The material should be repositioned as cutting angles are
changed (Fig 6.).
Fig 7
III. DRESSING:
Dressing activities such as fastening trousers are accomplished by the terminal device
holding the waistband or belt loop while the sound hand tucks in the shirt and fastens the
waist hook, snap, or button. The terminal device can \"pinch\" the fabric at the bottom of the
zipper to facilitate zipping with the sound hand. A buttonhook may be used to assist in
buttoning cuffs on the sound side (Fig 7.). With the proper prepositioning, the cuff can be
buttoned rapidly and reliably. Buttonhooks are particularly helpful for the transhumeral and
shoulder disarticulation amputee.
Fig 8
IV. OPENING A JAR OR BOTTLE:
When opening a jar or bottle, the terminal device grasps the middle of the container, and
the sound hand unscrews the lid. All tension should be removed from the cable to ensure
maximum grasp on the container.
V. WASHING DISHES:
To achieve the greatest security of grasp while washing dishes, the dish should be held in
the sound hand. Depending on the individual’s preference, a dishcloth or sponge is held
and manipulated by the terminal device. Submerging the hook in water should be avoided
because detergents dissolve the lubricating oils in the hook and wrist units. Periodic
cleaning and oiling of the stud threads and bearings may be necessary for the amputee
who engages in frequent dishwashing activities. When drying dishes, the sound hand
holds the dish while the terminal device grasps the towel.
VI. HAMMERING A NAIL AND USING TOOLS:
Hammering nails is accomplished by holding the nail in the hook fingers, rubber band
guard, or special attachment of the no. 3 or no. 7 Hosmer-Dorrance work hook. The hook
should be pronated to 90 degrees so that the nail is perpendicular to the wood. When
correctly positioned, the tip of the nail should just contact the wood.
As demonstrated (Fig 8.), the head of a large bolt may be secured in the hook terminal
device while the wrench is held in the sound hand to tighten or loosen the bolt. Again, the
amputee may need to be reminded that the prosthesis and terminal device are merely
\"functional assists\" to aid in stabilization. The sound limb always becomes the dominant
and active limb (Fig 9.).
(Fig 10.). This device is The voluntary-closing Grip II illustrates an alternative design in terminal devices
specifically designed by
Therapeutic Recreation
Systems, Inc. (TRS, 2860
Pennsylvania Ave, Boulder,
CO 80803), to hold and
manipulate objects by using
body power to close rather “MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
than to open the hook. 57

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 58 of 92
NPTE
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.
VII. DRIVING A CAR:
Driving a car is an important goal for the individual who has lost an arm. The sound limb
should do the actual turning of the steering wheel. If the prosthesis has sufficient function,
performance can be improved by using the prosthesis to assist the sound arm. A driving
ring is available from most prosthetic suppliers. The fingers of the hook are secure in the
ring for turning but can easily slip out in emergencies.
A list of activities and a rating guide designed by Northwestern University are helpful
adjuncts to the therapy plan in determining which activities are important for the unilateral
amputee to accomplish (Fig 11.).
Fig 11
VII. VOCATIONAL ACTIVITIES:
Discussing vocational needs and expectations with the amputee is very important.
Unfortunately, this is an area that is often overlooked or given only brief attention during
the rehabilitation process. This discussion should occur later in the training continuum
when the individual begins to acknowledge and accept his disability. Although not
everyone can return to the exact job held prior to the injury, a review of job responsibilities
and expectations can be explored with the therapist. It may be possible to break down the
tasks of a job into a step-by-step process that can be practiced and reinforced in therapy.
An example of how effective prosthetic hooks can be for drafting is illustrated in Fig 12. If
the therapist can do an on-the-job site evaluation, it would be a valuable addition to the
amputee's comprehensive rehabilitation.
Fig 12
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
58

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 59 of 92
NPTE
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.
IX. HOME INSTRUCTIONS:
At the conclusion of training, a home program of wearing, functional use, and care
instructions should be reviewed with the amputee and his family. Specific instructions
regarding which team member to contact when a problem arises should also be provided.
A follow-up appointment should be arranged, and an explanation of what to expect during
this visit is helpful in making the transition from the rehabilitation centre to the home
environment.
The following points are important to review with the amputee who has been fitted with
body-powered upper-limb prosthesis.
1. The harness should be washed when soiled because perspiration stains permanently
mark the straps. A household cleaner with ammonia works well.
2. Do not iron the Velcro closures on straps.
3. The elbow lock should be cleaned frequently and kept free from abrasive materials.
4. The cable should be examined frequently for cut or worn areas.
5. The neoprene lining of the hook may need to be periodically relined for a firmer grip.
The neoprene is resistant to gasoline, oil, and other petroleum products. It should,
however, be protected from hot objects.
6. When a rubber band wears out from use, grease, or injury, cut it off with scissors, and
replaces it with a new band. Rubber band applicators are obtained from the
prosthetist. Each rubber band is equivalent to approximately 1 lb of pinch force.
7. Take the prosthesis to the prosthetist as soon as damage occurs.
8. Never use the terminal device as a hammer, wedge, or lever.
9. The prosthesis should be hung up by the harness rather than by the cable or cable
strap.
10. Detergents should be avoided since they tend to dissolve the lubricating oils in the
hook and wrist unit mechanism. When an amputee washes dishes frequently, the stud
threads and bearings of the hook should be cleaned and oiled regularly.
11. Never reach for a moving object with the hook.
12. The cosmetic glove of a mechanical or myoelectric hand is easily stained. The
following substances cannot be removed unless immediately washed with water or
alcohol: ball point ink, shoe polish, egg yolk, carbon paper, colored lacquers, brightly
dyed fabric, fresh newsprint, tobacco tar, mustard/ketchup, and lipstick.
X. FOLLOW-UP ISSUES:
Following discharge from the therapy program, the amputee is regularly monitored and
reviewed in an outpatient clinic by the rehabilitation team. This is an appropriate time to
discuss the amputee's present status and successes as well as problems that may have
been encountered. The services of the prosthetist are available for consultation as well as
for any repairs and modifications to the prosthesis that may be required. This is a crucial
time for the upper-limb amputee, and patterns of prosthetic use and emotional well-being
must be carefully re-evaluated at each visit. In an attempt to define prosthetic function in a
quantitative manner, the author has designed the following use rating scale.
 100%-Wearing all day, using well in bilateral tasks, incorporating well in the body
scheme.
 75%-Wearing all day, using in gross and fine-motor tasks.
 50%-Wearing all day (primarily for cosmetic reasons), incorporating in gross activities
(used as a leaning surface, i.e., desk/paper tasks).
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
59

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 60 of 92
NPTE
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.
 0%-Not wearing or using the prosthesis. This individual is choosing to be essentially
unilaterally independent.
 Wearing patterns have been quantified as follows:
 Full-12 hours or more per day
 Moderate-6 to 12 hours per day
 Minimal-0 to 6 hours per day
 None-0 hours per day.
In addition to quantifying prosthetic function and wearing patterns, the following goals are
equally important to address during the follow-up visit.
1. Maximize prosthetic function.
2. Maintain prosthetic components.
3. Decrease assistive devices.
4. Resume previous vocation or explore new vocational options.
5. Resume avocational interests.
6. Re-enter the family and community environment.
7. Maintain a regular periodic follow-up with rehabilitation professionals.
The first follow-up visit is scheduled approximately 4 weeks after discharge from training.
Follow-up visits are then scheduled at wider intervals, e.g., 3 months, 6 months, and
eventually an annual visit. For the more complex amputee with specific skin, bone, or pain
problems, more frequent return visits may be necessary.
The complete rehabilitation process for an amputee is, indeed, a long one. Early fitting is
crucial to encourage successful functional outcomes for all upper-limb amputees.
Rehabilitation should not be considered complete until a stable, independent life-style has
been achieved and the individual's social and occupational niches have been re-established.
The amputee's potential is limitless. It is not solely dependent upon the quality of the
prosthesis, of medical care, or of therapy. All these areas ideally work in close harmony with
one another. Motivation and the desire of the patient to be independent are perhaps the most
important ingredients to cultivate and reinforce. It is the responsibility of all rehabilitation
professionals involved to create a conducive environment that will not only encourages this
process to occur but enhance it as well.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
60

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 61 of 92
NPTE
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.
12.2 PHYSIOTHERAPYMANAGEMENT OF ADULT LOWER-LIMB AMPUTEES:
Most limb amputations are now done because of vascular insufficiency. In 1987, 4985 new limb amputees
were referred to the disablement service centers (previously known as artificial limb and appliance centers)
in England. Two thirds of these amputations were done for peripheral vascular disease and more than a
fifth for the complications of diabetes mellitus. About 80% of the patients were over 60 years old at the time
of amputation. The problems to be faced after amputation, therefore, are not only those of achieving
independent mobility, but also of managing illnesses associated with advancing years and returning to the
community.
There are three important aims:
 To produce a soundly healed stump and a patient who can walk/perform. The level of amputation is
therefore crucial: above the knee amputations heal readily but many patients who have them never
master walking on prosthesis. The converse is true of below knee amputations
 Early rehabilitation with a prosthesis
 Cost effectiveness.
These may be achieved with a hospital based rehabilitation team that liaises closely with the disablement
service center, the general practitioner, and the community services.
 The prosthetist and the physiotherapist, as members of the rehabilitation team, often develop a very
close relationship when working together with lower-limb amputees.
 The prosthetist is responsible for fabricating and modifying the specific socket design and providing
prosthetic components that will best suit the life-style of a particular individual.
The physiotherapist's role is threefold.
 First, the amputee must be physically prepared for prosthetic gait training and educated about
residual-limb care prior to being fitted with the prosthesis.
 Second, the amputee must learn how to use and care for the prosthesis. Prosthetic gait training can be
the most frustrating, yet rewarding phase of rehabilitation for all involved. The amputee must be
patiently educated in the biomechanics of prosthetic gait. Once success is achieved, the amputee may
look forward to resuming a productive life.
 Third, the therapist should introduce the amputee to higher levels of activities beyond just learning to
walk. Although the amputee may not be ready to participate in recreational activities immediately,
providing the names of support groups and disabled recreational organizations can furnish the
necessary information for the individual to seek involvement when ready.
From the ancient
pyramids to World War
I, the prosthetic field
has morphed into a
sophisticated example
of man's determination
to do better.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
61

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 62 of 92
NPTE
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.
12.2.1. PRESURGICAL MANAGEMENT:
A. INITIAL PATIENT CONTACT:
This time provides an opportunity for the therapist to introduce himself to the patient and,
in conjunction with other qualified members of the rehabilitation team, to prepare the
patient for the events to come. Specifically, the therapist will attempt to develop a
professional rapport with the patient and earn his trust and confidence. This period also
offers the therapist an excellent opportunity to explain the time frame of the rehabilitation
process. Fear of the unknown can be extremely frightening to many patients; therefore,
having the comfort of knowing what the future holds as well as what will be expected of
them can ease the process. A visit from another amputee who has been successfully
rehabilitated can assist in this process. The visiting amputee should be carefully screened
by appropriate personnel and should have a suitable personality for this task. Additional
considerations should be given to similarities between level of amputation, age, gender,
and outside interests. If available, any information on various prostheses or videos
showing recreational activities may benefit the patient. The therapist must also keep in
mind how much information the patient is psychologically prepared to hear. Many
hospitals have affiliations with local support groups, where amputees visit other amputees
to help them throughout the healing process.
The pragmatic aspect of the therapist's responsibilities presurgically will include discussing
the possibilities of phantom limb sensation and discomfort, joint contracture prevention, as
well as overall functional assessment. If the patient so desires, prosthesis may be
introduced at this point to satisfy curiosity.
12.2.2. POSTSURGICAL MANAGEMENT & EVALUATION:
A. PAST MEDICAL HISTORY:
A complete medical history should be taken from the patient or obtained from the medical
records to provide the therapist with information that may be pertinent to the rehabilitation
program.
B. MENTAL STATUS:
An accurate assessment of the patient's mental status can lend insight into the likely
comprehension level for future prosthetic care. The therapist should be concerned with
assessing the patient's potential to cognitively perform activities such as donning and
doffing the prosthesis, residual-limb sock regulation, bed positioning, skin care, safe
ambulation, and other functional activities of the amputee. If the patient does not
possess the necessary level of cognition, family members and/or friends should
become involved in the rehabilitation process to help ensure a successful outcome.
C. RANGE OF MOTION:
A functional assessment of gross upper-limb and sound lower-limb motions should be made.
A measurement of the residual limb's range of motion (ROM) should be recorded for future
reference. Joint contractures are complications that can greatly hinder the amputee's ability to
ambulate efficiently with prosthesis; thus extra care should be taken to avoid them. The most
common contracture for the transfemoral amputee is hip flexion, external rotation, and
abduction, while knee flexion is the most frequently seen contracture for the transtibial
amputee. During the ROM assessment the therapist should determine whether the patient has
a fixed contracture or just soft-tissue tightness from immobility that can be corrected within a
short period of time. This may affect the manner in which the prosthesis is fabricated.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
62

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 63 of 92
NPTE
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 STRENGTH:
Functional strength of the major muscle groups should be assessed by manual muscle testing
of all limbs including the residual limb and the trunk. This will help determine the patient's
potential skill level to perform activities such as transfers, wheelchair management, and
ambulation with and without the prosthesis.
E. SENSATION:
Evaluation of the amputee's sensation is useful to both the patient and therapist alike. The
therapist can gain insight into the possible insensitivity of the residual limb and/or sound limb.
This may affect proprioceptive feedback for balance and single-limb stance, which in turn can
lead to gait difficulties. The patient must be made aware that decreased pain, temperature,
and light touch sensation can increase the potential for injury and tissue breakdown.
F. BED MOBILITY:
The importance of good bed mobility extends beyond simple positional adjustments for
comfort or to get in and out of bed. The patient must acquire bed mobility skills to maintain
correct bed positioning in order to prevent contractures or excessive friction of the sheets
against the suture line or frail skin. If the patient is unable to perform the skills necessary to
maintain proper positioning, assistance must be provided. As with most patients, adequate
bed mobility is a basic requirement for higher-level skills such as bed-to-wheelchair transfers.
G. BALANCE/COORDINATION:
Sitting and standing balance are of major concern when assessing the amputee's ability to
maintain the center of gravity over the base of support. Coordination assists with ease of
movement and the refinement of motor skills. Both balance and coordination are required for
weight shifting from one limb to another, thus improving the potential for an optimal gait. After
evaluating mental status, ROM, strength, sensation, balance, and coordination, the therapist
will have a good indication of what would be the most appropriate choice of assistive device to
use initially with the individual amputee.
H. TRANSFERS:
Transfer skills are essential for early mobility. Additional functional transfers such as toilet,
shower, and car transfers must also be assessed before discharge to more completely
determine the patient's level of independence. For transtibial amputees who are not
ambulatory candidates, a very basic prosthesis may be indicated for transfers only.
I. WHEELCHAIR PROPULSION:
The primary means of mobility for a large majority of amputees, either temporarily or
permanently, will be the wheelchair. The energy conservation of the wheelchair over prosthetic
ambulation is considerable with some levels of amputation. Therefore, wheelchair skills should
be taught to all amputees during their rehabilitation program.
J. AMBULATION WITH ASSISTIVE DEVICES WITHOUT PROSTHESIS:
A traditional evaluation of the amputee's potential for ambulation is performed, including
strength of the sound lower limb and both upper limbs, single-limb balance, coordination, and
mental status. The selection of an assistive device should meet with the amputee's level of
skill, while keeping in mind that with time the assistive device may change. For example,
initially an individual may require a walker, but with proper training, forearm crutches may
prove more beneficial as a long-term assistive device.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
63

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 64 of 92
NPTE
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.
Some patients who have difficulty in ambulating on one limb secondary to obesity,
blindness, or generalized weakness can still be successful prosthetic ambulators when the
additional support of a prosthesis is provided (Fig 1.0 and Fig 1.1.).
K. CARDIAC PRECAUTIONS FOR AMPUTEES:
 During the initial chart review, the therapist should make note of any history of coronary
artery disease, congestive heart failure, peripheral vascular disease, arteriosclerosis,
hypertension, angina, arrhythmias, dyspnea, angioplasty, myocardial infarction, arterial
bypass surgery, as well as prescribed cardiovascular medications that may affect the
blood pressure and heart rate.
 The heart rate and blood pressure of every patient should be closely monitored during
initial training and thereafter as the intensity of training increases. If the amputee
experiences persistent symptoms such as shortness of breath, pallor, diaphoresis, chest
pain, headache, or peripheral edema, further medical evaluation is strongly
recommended.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
64

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 65 of 92
NPTE
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.
12.2.3 PATIENT EDUCATION: LIMB MANAGEMENT:
A. LIMB CARE:
It is important that the patient understand the care of the residual limb and sound limb. For
example, the dysvascular patient's prosthetic gait training could be delayed 3 to 4 weeks if an
abrasion should occur. The patient must be taught the difference between weight-bearing
areas and pressure-sensitive areas and also be oriented to the design of the socket and the
functions of the prosthetic componentry.
I. PROBLEM DETECTION/SKIN CARE:
Every patient should be instructed to visually inspect the residual limb on a daily basis or
after any strenuous activity. More frequent inspection of the residual limb should be
routine in the initial months of prosthetic training. A hand mirror may be used to view the
posterior aspect of the residual limb. Reddened areas should be monitored very closely
as potential sites for abrasions. If a skin abrasion occurs, the patient must understand that
in most cases the prosthesis should not be worn until healing occurs.
II. PROSTHETIC MANAGEMENT:
The socket should be cleaned daily to promote good hygiene and prevent deterioration of
prosthetic materials. As a rule, solid plastic materials are cleaned with a damp cloth and
foam materials with rubbing alcohol. The patient should also be reminded that routine
maintenance of the prosthesis should be performed by the prosthetist to ensure maximum
life and safety of the prosthesis.
III. SOCK REGULATION:
Sock regulation is of extreme importance to prevent pistoning from occurring. The patient
should carry extra socks at all times in case of pistoning or extreme perspiration. A thin
nylon sock (sheath) should cover the residual limb to assist in reducing friction at the
residual-limb/socket interface. Stump socks are available in assorted plies or thickness
that permit the patient to obtain the desired fit within the socket. Socks should be applied
wrinkle free, with the seams horizontal and on the outside to prevent additional pressure
on the skin.
IV. DONNING AND DOFFING OF THE PROSTHESIS;
Today, there is a wide variety of suspension systems for all levels of amputation. To list
just a few possibilities, the transtibial amputee has the option of a hard socket with or
without a soft insert, which could include auxiliary suspension, a medial wedge, and
suction or suction silicone sockets, while the transfemoral amputee has the choice of a
nonsuction external suspension or a suction suspension socket that can be donned with
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
65

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 66 of 92
NPTE
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.
an elastic bandage, pull sock, wet fit, or a silicone sleeve. The methods of donning each of
these combinations are too numerous for the scope of this chapter; however, what is
important is that the amputee become proficient in the method of donning and doffing his
particular prosthesis.
V. RESIDUAL-LIMB WRAPPING:
 Early wrapping of the residual limb can have a number of positive effects:
 Decrease edema and prevent venous stasis by ensuring a proper distal-to-proximal
pressure gradient,
 Assist in shaping,
 Help counteract contractures in the transfemoral amputee,
 Provide skin protection,
 Reduce redundant-tissue problems,
 Reduce phantom limb discomfort/sensation, and desensitize the residual limb with
local pain. Controversy does exist concerning the use of traditional elastic bandaging
vs. the use of residual-limb shrinkers. Currently, many institutions prefer commercial
shrinkers for their ease and reproducibility of donning. Advocates of elastic bandaging
state that more control over pressure gradients and tissue shaping is provided.
Regardless of individual preference, application must be performed correctly to
prevent circulation constriction,
 Poor residual-limb shaping, and Edema (Fig 1.2. and Fig 1.3.).
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
66

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 67 of 92
NPTE
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.
Fig: 1.2
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
67

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 68 of 92
NPTE
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.
Fig:1.3
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
68

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 69 of 92
NPTE
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.
12.2.4 PREPROSTHETIC EXERCISE:
A. STRENGTHENING:
Eisert and Tester first described dynamic residual-limb exercises in 1954. Since then, their
antigravity exercises have been the most favored method of strengthening the residual limb.
These dynamic exercises require little in the way of equipment. A towel roll and step stool are
all that is required. They also offer benefits aside from strengthening, such as desensiti-zation,
bed mobility, and joint ROM. The exercises are relatively easy to learn and can be performed
independently, thus permitting the therapist to spend patient contact time on other more
advanced skills.
Incorporating isometric contractions at the peak of the isotonic movement will help to
maximize strength increases. A period of a 10-second contraction followed by 10 seconds of
relaxation for 10 repetitions gives the patient an easy mnemonic to remember, the \"rule of
ten.\" The rationale behind a 10-second contraction is that a maximal isometric contraction can
be maintained for 6 seconds; however, there is a 2-second rise time and a 2-second fall time
for a total of 10 seconds.
All amputees should consider performing abdominal and back extensor strengthening
exercises to maintain trunk strength, decrease the possible risk of back pain, and assist in the
reduction of gait deviations associated with the trunk.
The following illustrations demonstrate the basic dynamic strength training program for
transfemoral and transtibial amputees (Fig 1.4.).
Amputees who have access to isotonic and isokinetic strengthening equipment can take
advantage of the benefits derived from these forms of strengthening with few modifications in
their positioning on the machines.
Fig: 1.4
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
69

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 70 of 92
NPTE
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.
I. RANGE OF MOTION:
Prevention of decreased ROM and contractures is a major concern to all involved. Limited
ROM can often result in difficulties with prosthetic fit, gait deviations, or the inability to
ambulate with a prosthesis altogether. The best way to prevent loss of ROM is to remain
active and ensure full ROM of affected joints. Unfortunately, not all amputees have this
option, and therefore, proper limb positioning becomes important. The transfemoral
amputee should place a pillow laterally along the residual limb to maintain neutral rotation
with no abduction when in a supine position. If the prone position is tolerable during the
day or evening, a pillow is placed anteriorly under the residual limb for 20 to 30 minutes,
two to three times daily, to maintain hip extension. Transtibial amputees should avoid knee
flexion for prolonged periods of time. A stump board will help maintain knee extension
when using a wheelchair. All amputees must be made aware that continual sitting in a
wheelchair without any effort to promote hip extension may lead to limited motion during
prosthetic ambulation (Fig 1.5.).
Amputees who have already developed a loss of ROM may benefit from many of the
traditional therapy procedures such as passive ROM, contract-relax stretching, soft-tissue
mobilization, myofascial techniques, joint mobilization, and other methods that promote
increased ROM.
Fig: 1.5
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
70

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 71 of 92
NPTE
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.
II. FUNCTIONAL ACTIVITIES:
Encouraging activity as soon as possible after amputation surgery helps speed recovery in
several ways. First, it will offset the negative affects of immobility by promoting movement
through the joints, muscle activity, and increased circulation. Second, the patient will begin
to re-establish personal independence, which may be perceived as threatened due to limb
loss. Finally, the psychological advantage derived from activity and independence will
continue to motivate the patient throughout the rehabilitation process.
III. GENERAL CONDITIONING:
A decrease in general conditioning and endurance are contributory factors leading to
difficulties in learning functional activities and prosthetic gait training. Regardless of age or
present physical condition, a progressive general exercise program should be prescribed
for every patient beginning immediately after surgery, continued throughout the
preprosthetic period, and finally incorporated as part of the daily routine.
The list of possible general strengthening/endurance exercise activities is long: cuff
weights in bed, wheelchair propulsion for a predetermined distance, dynamic residual-limb
exercises, ambulation with an assistive device prior to prosthetic fitting, lower or upper-
limb ergo meter work, wheelchair aerobics, swimming, aquatic therapy, lower and upper-
body strengthening at the local fitness center, and any sport or recreational activity of
interest. The amputee should select one or more of these, begin participation to tolerance,
and progress to 1 hour or more a day.
The advantages of participation extend well beyond improving the chances of ambulating
well with a prosthesis. The individual has the opportunity to experience and enjoy activities
thought impossible for an amputee. If difficulties are experienced, the amputee is still
within an environment where assistance may be readily obtained either from the therapist
or from a fellow amputee who has mastered a particular activity.
IV. BED MOBILITY:
The severely involved patient may be taught to utilize a trapeze, side rail, or human
assistance when learning bed mobility. This practice, however, should not be employed for
the general amputee population because, while easier initially, continued use of these
methods will only hamper the future rehabilitation process. Regardless of age, each
patient should be taught a safe and efficient manner in which to roll, come to sitting, or
adjust their position. Log rolling, followed by side lying to sitting or supine lying on elbows
to long sitting, are two acceptable methods that incorporate all the necessary skills for
efficient bed mobility.
V. TRANSFERS:
Once bed mobility is mastered, the patient must learn to transfer from the bed to a chair or
wheelchair and then progress to more advanced transfer skills such as to the toilet, tub,
and car. Unilateral amputees initially are taught single-limb transfers where the wheelchair
is positioned on the sound-limb side and the patient pivots over the limb while maintaining
contact with either the bed or chair. In most cases, it is advised that transfers to both the
sound and involved side be taught since the patient will frequently be in situations where
transferring to the sound side will not be possible. As the patient's single-limb standing
balance improves, more advanced transfers may be taught to improve the patient's
independence. In cases where an immediate postoperative or preparatory prosthesis is
utilized, weight bearing through the prosthesis can assist the patient in the transfer and
provide additional safety.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
71

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 72 of 92
NPTE
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.
Bilateral amputees who are not fitted with an initial prosthesis transfer in a \"head-on\"
manner. The wheelchair approaches the mat or chair, with the front of the chair abutting
the transferring surface. The patient then slides forward onto the desired surface by lifting
the body and pushing forward with both hands. Until adequate strength of the Latissimus
dorsi and triceps is attained for this transfer, a lateral sliding-board transfer will be
necessary to minimize friction and to cross the gap between the chair and desired
surface (Fig 1.6.).
Fig 1.6. Head-on wheelchair-to-
mat transfer.
VI. NOTE FOR THE PT (TRANSFERRING A PATIENT)
 Transfers safety is crucial for the health care provider and the patient. The general
principle of “Do No Harm” also applies with transfers. If a patient with total hip
replacement is only able to be partial weight bearing on the right lower extremity then
the weight bearing status must be maintained during the transfer for prevention of
injury.
 Excessive weight bearing on the right lower extremity could lead to injury.
 Transferring a patient who has a CVA (cerebrovascular accident) or an acute THR
(total hip replacement) may be your most difficult transfers. Cerebrovascular
accidents can affect one side of the body or both. This can lead to spasticity of
muscles, limited coordination, cognitive deficits and decreased coordination.
Consequently, transfers and gait can be extremely difficult. A patient with a THR often
has total hip precautions following surgery. Most commonly these precautions include
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
72

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 73 of 92
NPTE
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.
limited hip flexion, limited hip adduction, and limited hip internal rotation. Sometimes
it’s difficult to maintain these precautions during difficult transfers.
 Always get more help if you think you will need it. Don’t try and be “superman” lifting
patients. Your back will not tolerate poor biomechanical lifts and transfers over a long
period of time. You may be able to get away with bad transfer technique; however,
eventually you will injure yourself.
 If you get injured in the job, report it to your supervisor immediately. Early intervention
is critical for successful outcomes. You may be asked to report to the ER (emergency
room) or a doctor’s office for an evaluation.
Latur Handicapped Children’s School Polio Corrective surgery Handicap Tricycle
patient with new calipers
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
73

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 74 of 92
NPTE
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.
PHYSICAL THERAPY CLASS
AT THE CENTER FOR
INDEPENDENT LIVING
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
74

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 75 of 92
NPTE
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.
VII. WHEELCHAIR PROPULSION:
Wheelchair mobility is the first skill that will give the amputee independence in the world
outside of the hospital room. The degree of skill and mastery of the wheelchair varies
depending on age, strength, and agility. Basic skills such as forward propulsion, turns, and
preparation for transfers, i.e., parking and braking, should be taught immediately. Later,
advanced wheelchair skills should be taught: ascending and descending inclines,
wheelies, floor-to-wheelchair transfers, and curb jumping. The time dedicated to
wheelchair skills is dependent on the degree to which the amputee may potentially require
the wheelchair. Bilateral and older amputees may require greater use of the wheelchair,
while unilateral and younger amputees will be more likely to utilize other assistive devices
when not ambulating with their prosthesis. Because of the loss of body weight anteriorly
the amputee will be prone to tipping backward while in the standard wheelchair. Amputee
adapters set the wheels back approximately 5 cm, thus moving the amputee's center of
gravity forward to prevent tipping, especially when ascending ramps or curbs.
VIII.UNSUPPORTED STANDING BALANCE:
In preparation for ambulation without a prosthesis, all amputees must learn to
Fig 1.7. Balancing activities. compensate for the loss of weight of the amputated limb by balancing the center of gravity
over the sound limb. Although this habit must be broken when learning prosthetic
ambulation, single-limb balance must be learned initially to provide confidence during
stand pivot transfers, ambulation with assistive devices, and eventually hopping,
depending on the amputee's level of skill. A patient should be able to balance for at least
0.5 seconds to allow for smooth and safe progression of an assistive device during
ambulation.
3-WHEEL One method of progressive ambulation starts with the amputee standing in the parallel
MOTORCYCLE bars while using both hands for support. Once confidence in standing with double arm
support is attained, the hand on the same side as the amputated limb should be removed
from the bars; subsequently both hands are removed as independent balance is achieved.
In order to improve balance and righting skills, the patient should be challenged by gently
tapping the shoulders in multiple directions or tossing a ball back and forth (Fig 1.7.).
Allow enough time between taps or throws for the patient to regain a comfortable standing
posture. Once confidence is gained within the parallel bars, the patient should practice
these skills outside the parallel bars, eventually progressing to hopping activities.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
75

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 76 of 92
NPTE
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.
IX. AMBULATION WITH ASSISTIVE DEVICES:
 All amputees will need an assistive device for times when they choose not to wear
their prosthesis or for occasions when they are unable to wear their prosthesis
secondary to edema, skin irritation, or poor prosthetic fit. Other amputees will require
an assistive device while ambulating with the prosthesis. There are a variety of
assistive devices to choose from. While safety is a primary factor in selecting an
appropriate assistive device, mobility is a secondary consideration that cannot be
overlooked. The criteria for selection should include
 Unsupported standing balance,
 Upper-limb strength,
 Coordination and skill with the assistive device, and
 Cognition.
 A walker is chosen when an amputee has fair to poor balance, strength, and
coordination. If balance and strength are good to normal, forearm crutches may be
used for ambulation with or without prosthesis. A quad or straight cane may be
selected to ensure safety when balance is questionable while ambulating with a
prosthesis.
12.2.5 PREGAIT TRAINING:
A. BALANCE AND COORDINATION:
After the loss of a limb, the decrease in body weight will alter the body's center of gravity. In
order to maintain the single-limb balance necessary during stance without a prosthesis,
ambulating with an assistive device, or single-limb hopping, the amputee must shift the center
of gravity over the base of support, which in this case is the foot of the sound limb. As
amputees become more secure in their single-limb support, there is greater difficulty in
reorienting them to maintaining the center of gravity over both the sound and prosthetic limbs.
Ultimately, amputees must learn to maintain the center of gravity and their entire body weight
over the prosthesis. Once comfortable with weight bearing equally on both limbs, the amputee
can begin to develop confidence with independent standing and eventually with ambulation.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
76

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 77 of 92
NPTE
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.
12.2.6 ORIENTATION TO THE CENTER OF GRAVITY AND BASE OF SUPPORT:
Orientation of the centre of gravity over the base of support in order to maintain balance requires
that the amputee become familiar with these terms and aware of their relationship. The body's
centre of gravity is located just anterior to the second sacral vertebra. Average persons stand with
their feet 5 to 10 cm (2 to 4 in.) apart, varying according to body height. Various methods of
proprioceptive and visual feedback may be employed to promote the amputee's ability to maximize
the displacement of the centre of gravity over the base of support. The amputee must learn to
displace the centre of gravity forward and backward, as well as from side to side (Fig 1.8. and Fig
1.9.). These exercises vary little from traditional weight-shifting exercises; with the one exception
that concentration is placed on the movement of the centre of gravity over the base of support
rather than weight bearing into the prosthesis. Increased weight bearing will be a direct result of
improved centre of gravity displacement and will establish a firm foundation for actual weight
shifting during ambulation.
Fig 1.8. Lateral weight-shifting and Fig 1.9. Forward and backward weight-
balance orientation. shifting and balance orientation.
A. SINGLE-LIMB STANDING:
 Weight acceptance in the prosthesis is one of the most difficult challenges facing both
therapist and amputee. Without the ability to maintain full single-limb weight bearing and
balance for an adequate amount of time (0.5 seconds minimum) the amputee will exhibit a
number of gait deviations, including decreased stance time on the prosthetic side,
 A shortened stride length on the sound side, or lateral trunk bending over the prosthetic
limb. Strength, balance, and coordination are the primary physical factors influencing
single-limb stance on prosthesis.
 Additionally, fear, pain, and lack of confidence in the prosthesis must be considered when
an amputee is demonstrating extreme difficulty in overcoming weight bearing on the
prosthesis. It is important to recognize the need to promote adequate weight bearing and
balance on the prosthesis prior to and during ambulation.
 Single-limb balance over the prosthetic limb while advancing the sound limb should be
practiced in a controlled manner so that when required to do so in a dynamic situation
such as walking, this skill can be employed with relatively little difficulty. The stool-stepping
exercise is an excellent method by which this skill may be learned. Have the amputee
stand in the parallel bars with the sound limb in front of a 10- to 20-cm (4- to 8-in.) stool (or
block), its height depending on the patient’s level of ability. Then ask the amputee to step
slowly onto the stool with the sound limb while using bilateral upper-limb support on the
parallel bars. To further increase this weight-bearing skill asks the patient to remove the
sound-side hand from the parallel bars and eventually the other hand. Initially, the speed
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
77

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 78 of 92
NPTE
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.
of the sound leg will increase when upper-limb support is removed, but with practice the
speed will become slower and more controlled, thus promoting increased weight bearing
on the prosthesis (Fig 1.10.).
 The amputee's ability to control sound-limb advancement is directly related to the ability to
control prosthetic limb stance. The following are three contributing factors that may help
the amputee achieve adequate balance over the prosthetic limb.
 First, control of the musculature of the residual limb is necessary to maintain balance over
the prosthesis.
 Second, the patient must learn to utilize the available proprioceptive sensation at the
residual-limb/socket interface to control the prosthesis.
 Third, the amputee must visualize the prosthetic foot and its relationship to the ground.
New amputees will find it difficult to understand this concept at first but will gain a greater
appreciation as time goes on.
FIG 1.10. STOOL-STEPPING EXERCISE.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
78

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 79 of 92
NPTE
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.
12.3 GAIT-TRAINING SKILLS:
12.3.1 SOUND LIMB AND PROSTHETIC LIMB TRAINING:
Another component in adjusting to the amputation of a limb is restoration of the gait biomechanics
that were unique to a particular person prior to the amputation. That is to say, not everyone has
the same gait pattern. Prosthetic developments in the last decade have provided limbs that more
closely replicate the mechanics of the human leg. Therefore, the goal of gait training should be the
restoration of function to the remaining joints of the amputated limb. Prosthetic gait training should
not alter the amputee's gait mechanics for the prosthesis, but instead, the mechanics of the
prosthesis should be designed around the amputee's individual gait.
A. PELVIC MOTIONS:
The pelvis, with the body's center of gravity, moves as a unit in four directions: it displaces
vertically, shifts laterally, tilts horizontally, and rotates transversely. Each of these motions can
directly affect the amputee's gait and result in gait deviations or increased energy consumption
during ambulation. If restoration of function to the remaining joints of the amputated limb is a
goal of gait training, then the pelvic motions play a decisive role in determining the final
outcome of an individual's gait pattern.
1. Vertical displacement is simply the rhythmic upward and downward motion of the body's
center of gravity. The knee must flex 10 to 15 degrees during foot flat, and full extension
must be obtained during midstance. The transtibial amputee has the ability to flex and
extend the knee during the stance phase of gait. The transfemoral amputee is at a
disadvantage because the knee must remain in extension throughout the entire stance
phase to avoid buckling of the knee (Fig 1.11.).
2. Lateral shift occurs when the pelvis shifts from side to side approximately 5 cm (2 in.). The
amount of lateral shift is determined by the width of the base of support, which is 5 to 10
cm (2 to 4 in.), depending on the height of the individual. Amputees have to spend an
inordinate amount of time in single-limb standing on the sound limb when they are on
crutches and hopping without the prosthesis or during relaxed standing. Because of this,
they become adept at maintaining their center of gravity over the sound limb and therefore
have a habit of crossing midline with the sound foot, which leaves inadequate space for
the prosthetic limb to follow a natural line of progression. The result is an abducted or
circumducted gait with greater-than-normal lateral displacement of the pelvis toward the
prosthetic side. While more frequently observed in transfemoral amputees, this altered
base of support may also be seen with transtibial amputees (Fig 1.12.).
3. Horizontal dip of the pelvis is normal up to 5 degrees; anything greater is considered a
gluteus me-dius gait. Usually, this is directly related to weak hip abductor musculature,
more specifically, the gluteus medius. Maintenance of the residual femur in adduction via
the socket theoretically places the gluteus medius at the optimal length-tension ratio.
However, if the limb is abducted, the muscle is placed in a compromised position and is
unable to function properly. The result is a gluteus medius gait where the trunk leans
Fig 1.11. A, nonamputee vertical laterally over the side of the weak limb in an attempt to maintain the pelvis in a horizontal
displacement of the center of gravity. position (Fig 1.12.).
B, transfemoral amputee vertical
displacement of the center of gravity.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
79

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 80 of 92
NPTE
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. Transverse rotation of the pelvis occurs around the longitudinal axis approximately 5 to 10
degrees to either side. This transverse rotation assists in shifting the body's center of
gravity from one side to the other. In addition, it also helps to initiate the 30 degrees of
knee flexion during toe-off that is necessary to achieve 60 degrees of knee flexion during
the acceleration phase of swing. Knee flexion during toe-off is created by other influences
Fig 1-13. Transverse rotation of the as well, including plantar flexion of the foot, horizontal dip of the pelvis, and gravity. No
pelvis is approximately 5 degrees prosthetic foot permits active plantar flexion, and horizontal dip greater than 5 degrees is
abnormal; therefore restoration of transverse rotation of the pelvis becomes of great
importance in order to obtain sufficient knee flexion (Fig 1.13.).
Normalization of trunk, pelvic, and limb biomechanics can be taught to the amputee in
a systematic way. First, independent movements of the various joint and muscle groups
are developed. Second, the independent movements are incorporated into functional
movement patterns of the gait cycle. Finally, all component movement patterns are
integrated to produce a smooth normalized gait.
One suggested method of training is as follows:
1. Strengthening of all available musculature by dynamic residual-limb exercises (see
Fig 1.15. Rhythmic initiation \"Preprosthetic Exercise\").
designed to promote transverse
2. Proprioceptive neuromuscular facilitation (PNF), Feldenkrais, or any other movement
awareness techniques may be performed for trunk, pelvic, and limb re-education patterns.
These exercises encourage rotational motions and promote independent movements of
the trunk, pelvic girdle, and limbs.
3. Pregait training exercises (see \"Pregait Training\").
4. Sound-limb stepping within the parallel bars is performed with the amputee stepping
forward and backward, heel rise to heel strike, with both hands on the bars. The purpose
of this activity is for the amputee and therapist to become familiar with the gait mechanics
of the sound limb without having to be concerned about weight bearing and balance on
the prosthetic limb. This also affords the therapist an opportunity to palpate the anterior
superior iliac spines (ASIS) in order to gain a feeling for the patient's pelvic motion, which
Fig 1.16. Resistive gait techniques are
in most cases is close to normal for that individual (Fig 1.14.).
proprioceptive neuromuscular facilitation
techniques to assist and establish a normalized 5. Prosthetic-limb stepping in the parallel bars is similar to the activity described above
except that the amputee uses the prosthetic limb. As the therapist palpates the ASIS, in
many cases a posterior rotation of the pelvis will be observed. This is often the result of
the amputee's attempt to kick the prosthesis forward with the residual limb. The pelvis
rotates posteriorly, just as it would if someone were kicking a football. It is important that
the amputee feel the difference between the pelvic motion on the prosthetic side and the
sound side.
6. To restore the correct pelvic motion, the amputee places the prosthetic limb behind the
sound limb while holding on to the parallel bars with both hands. The therapist blocks the
prosthetic foot to prevent forward movement of the prosthesis. Rhythmic initiation is
employed to give the amputee the feeling of rotating the pelvis forward as passive flexion
of the prosthetic knee occurs. As the amputee becomes comfortable with the motion, he
can begin to move the pelvis actively, eventually progressing to resistive movements when
the therapist deems them appropriate (Fig 1.15.).
7. Once the amputee and therapist are satisfied with the pelvic motions, the swing phase of
gait can be taught. The amputee is now ready to step forward and backward with the
prosthetic limb. Attention must be given to the pelvic motions, that the line of progression
Fig 1.14. Sound-leg stepping is design
to orient the amputee to gait biomecha of the prosthesis remains constant without circumducting, and that heel contact occurs
within boundaries of the base of support (Fig 1.16.). As the amputee improves, release the
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
80

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 81 of 92
NPTE
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.
sound-side hand from the parallel bars and eventually both hands. There should be little if
any loss of efficiency with the motion, but if there is, reverts to the previous splinter skill.
8. Return to sound-limb stepping with both hands on the parallel bars. Observe that the
mechanics are correct and that the sound foot is not crossing midline as heel strike
occurs. When ready, have the amputee remove the sound-side hand from the bars. At this
time, there may be an increase in the speed of the step, a decrease in step length, and/or
lateral leaning of the trunk. This is a direct result of the inability to bear weight or balance
over the prosthesis. Cue the amputee in remembering the skills learned while performing
the stool-stepping exercise (see \"Pregait Training\"). After adequate skill is perfected,
sound-limb stepping without any hand support may be practiced until sufficient mastery of
single-limb balance over the prosthetic leg is acquired (Fig 1.17.).
When each of the skills described above is developed to an acceptable level, the amputee
is ready to combine the individual skills and actually begin walking with the prosthesis.
Initially, begin in the parallel bars with the therapist and amputee facing each other, the
therapist's hands on the amputee's ASISs, and the amputee holding onto the bars. As the
amputee ambulates within the bars, the therapist applies slight resistance through the hips
to provide proprioceptive feedback for the pelvis and musculature of the involved lower
limb.
10. When both the therapist and the amputee are comfortable with the gait demonstrated in
Fig 1.17. Sound-side stepping to
promote equal stride length of the the parallel bars, the same procedure as described above is practiced out of the bars, with
sound limb and stance time of the the amputee initially using the therapist's shoulders as support and progressing to both
prosthetic limb. hands free when appropriate. The therapist may or may not continue to provide
proprioceptive input to the pelvis (Fig 1.18.). As the amputee begins to ambulate
independently, verbal cueing may be necessary as a reminder to keep the sound foot
away from midline in order that the proper base of support can be maintained.
Maintenance of equal stride length may not be immediately forthcoming because many
amputees have a tendency to take a longer step with the prosthetic limb than the sound
limb. When adequate weight bearing through the prosthetic limb has been achieved, have
the amputee begin to take longer steps with the sound limb and slightly shorter steps with
the prosthetic limb. This principle also applies when increasing the cadence. When an
amputee increases his speed of ambulation, the prosthetic limb often compensates by
taking a longer step, thus increasing the asymmetry. By simply having the amputee take a
longer step with the sound limb and a moderate step with the prosthetic limb, increased
speed of gait is accomplished without increased asymmetry.
11. Trunk rotation and arm swing are the final missing components in restoring the
biomechanics of gait. During human locomotion, the trunk and upper limbs rotate opposite
the pelvic girdle and lower limbs. Trunk rotation is necessary for balance, momentum, and
symmetry of gait. Many amputees have a decreased trunk rotation and arm swing,
especially on the prosthetic side. This may be the result of fear of displacing their center of
gravity too far forward or backward over the prosthesis (Fig 1.19.). Normal cadence is
considered to be 90 to 120 steps per minute, or 2.5 mph. Arm swing provides balance,
Fig 1.18. Once correct momentum, and symmetry of gait and is directly influenced by the speed of ambulation.
biomechanics are established
within the parallel bars, resistive
With acceleration of gait, arm swing excursion becomes greater, thus permitting a more
gait training may be performed in efficient gait due to increased forward momentum. Similarly, amputees who walk at slower
an open area to build confidence speeds will demonstrate a diminished swing excursion and hence less gait efficiency.
and independent gait skills. Restoring trunk rotation and arm swing is easily accomplished by utilizing rhythmic
initiation or passively cueing the trunk as the amputee walks. The therapist stands behind
the amputee with one hand on either shoulder. As the amputee walks, the therapist gently
rotates the trunk. When the left leg steps forward, the right shoulder is rotated forward and
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
81

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 82 of 92
NPTE
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.
vice versa. Once the amputee feels comfortable with the motion, he can actively take over
the motion. Amputees who will be independent ambulators as well as those who will
require an assistive device can benefit to varying degrees from the above systematic
rehabilitation program. Most patients can be progressed to the point of ambulating out of
the parallel bars. At that time, the amputee must practice ambulating with the chosen
assistive device and maintaining pelvic rotation, an adequate base of support, equal
Fig 1-19. Passive trunk
rotation will assist in restoring stance time, and equal stride length, all of which can have a direct influence on the energy
arm swing for improved
balance, symmetry of gait,
cost of walking. Trunk rotation will be absent in amputees utilizing a walker, but those
and momentum ambulating with crutches or a cane should be able to incorporate trunk rotation into their
gait.
12.3.2 VARIATIONS:
Naturally, the time and degree of prosthetic training required is individual to each amputee,
depending on many factors such as age and motivation, as well as the cause and level of
amputation.
Syme ankle disarticulates have a major advantage over transtibial amputees due to the ability
to bear weight distally. This allows them to have better kinesthetic feedback for placement of the
prosthetic foot. Because of this kinesthetic capability and the increased length of the lever arm,
minimal prosthetic gait training is required. Although Syme ankle disarticulates are able to
progress rapidly with weight shifting and other basic gait skills, they may require practice to attain
equal stride length and stance time.
Knee disarticulates have several advantages over transfemoral amputees, including a longer
lever arm, enhanced muscular control, improved kinesthetic feedback, and greater distal-end
weight bearing. Although these advantages do provide an opportunity for decreased rehabilitation
time, the knee disarticulate must learn all the same skills as a transfemoral amputee.
Hip disarticulates and transpelvic (hemipelvectomy) amputees have the additional
responsibility of learning to master the skills of a mechanical hip joint as well as the knee joint and
foot/ankle assembly. The gait-training procedures are essentially the same as for transfemoral
amputees. In some cases the mechanical hip joint may dictate that a slight vaulting action is
necessary in order to clear the ground.
Amputees of all levels should be educated in residual-limb sock regulation, knowledge of
pressure and relief areas, care of the prosthesis, and residual-limb donning and doffing
techniques.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
82

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 83 of 92
NPTE
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.
12.3.3 ADVANCED GAIT-TRAINING ACTIVITIES:
A. STAIRS:
Ascending and descending stairs is most safely and comfortably performed one step at a time
(step by step). A few exceptional transfemoral amputees can descend stairs step over step,
with or without a railing, or by the \"jackknifing\" method. Even fewer, very strong transfemoral
amputees can ascend stairs step over step. Most transtibial amputees have the option of
either method, while hip disarticulates and transpelvic amputees are limited to the step-by-step
method.
B. STEP BY STEP:
This method is essentially the same for all levels of amputees. When ascending stairs, the
body weight is shifted to the prosthetic limb as the sound limb firmly places the foot on the
stair. The trunk is slightly flexed over the sound limb as the knee extends and raises the
prosthetic limb to the same step. The same process is repeated for each step. When
descending stairs, the body weight is shifted to the sound limb, which lowers the prosthetic
limb to the step below primarily by eccentric contraction of the quadriceps muscle. Once the
prosthetic limb is securely in place, body weight is transferred to the prosthetic limb, and the
sound limb is lowered to the same step.
Transfemoral Amputees:
C. STEP OVER STEP:
Timing and coordination become critical factors in executing stair climbing step over step. As
the transfemoral amputee approaches the stairs, the prosthetic limb is the first to ascend the
stairs by rapid acceleration of hip flexion with slight abduction in order to achieve sufficient
knee flexion to clear the step. Some transfemoral amputees will actually hit the approaching
step with the toe of the prosthetic foot to achieve adequate knee flexion. With the prosthetic
foot firmly on the step, usually with the toe against the step riser, the residual limb must exert a
great enough force to fully extend the hip so that the sound foot may advance to the step
above. As the sound-side hip extends, the prosthetic-side hip must flex at an accelerated
speed to achieve sufficient knee flexion to place the prosthetic foot on the next step above.
Placing only the heel of the prosthetic foot on the stair below and then shifting the body weight
over the prosthetic limb, thus passively flexing the knee, achieve descending stairs. The sound
limb must quickly reach the step below in time to catch the body's weight. The process is
repeated at a rapid rate until a rhythm is achieved. Most transfemoral amputees who have
mastered this skill descend stairs at an extremely fast pace, much faster than would be
considered safe for the average amputee. In fact, both ascending and descending stairs step
over step for transfemoral amputees is so difficult and energy demanding that the majority who
master these skills still prefer the step-by-step method.
D. TRANSTIBIAL AMPUTEES: STEP OVER STEP:
When ascending stairs, the transtibial amputee who does not have the ability to dorsiflex his
foot/ankle assembly must generate a stronger concentric contraction of the knee and hip
extensors in order to successfully transfer body weight over the prosthetic limb.
Descending stairs is very similar to normal descent with one exception: only the prosthetic
heel is placed on the stair. This compensates for the lack of dorsiflex-ion within the foot/ankle
assembly.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
83

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 84 of 92
NPTE
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.
E. CRUTCHES:
When using crutches with stairs, hold both crutches in the hand opposite the handrail, or use
both crutches in the traditional manner.
F. CURBS:
The methods described for stairs are identical for curbs. Depending on the level of skill, the
amputee can step up or down curbs with either leg.
G. UNEVEN SURFACES:
A good practice with gait training is to have the amputee ambulate over a variety of surfaces,
including concrete, grass, gravel, uneven terrain, and varied carpet heights. Initially, the new
amputee will have difficulty in recognizing the different surfaces secondary to the loss of
proprioception. To promote an increased awareness, spending time on different surfaces and
becoming visually aware of the changes help to initiate this learning process. Additionally, the
amputee must realize that it is important to observe the terrain ahead to avoid any slippery
surfaces or potholes that might result in a fall.
H. RAMPS AND HILLS:
 Ascending inclines presents a problem for all amputees because of the lack of dorsiflexion
present within most prosthetic foot/ankle assemblies. For most amputees, descending
inclines is even more difficult than ascending, primarily because of the lack of plantar
flexion in the foot/ankle assembly. Prosthesis wearers with knee joints have the added
dilemma of the weight line falling posterior to the knee joint, resulting in a flexion moment.
 When ascending an incline, the body weight should be slightly more forward than normal
to obtain maximal dosiflexion with articulating foot/ankle assemblies or to keep the knee in
extension. Depending on the grade of the incline, pelvic rotation with additional
acceleration may be required in order to achieve maximal knee flexion during swing.
 Descent of an incline usually occurs at a more rapid pace than normal because of the lack
of plantar flexion resulting in decreased stance time on the prosthetic limb. Amputees with
prosthetic knees must exert a greater-than-normal force on the posterior wall of the socket
to maintain knee extension.
 Most amputees find it easier to ascend and descend inclines with short but equal strides.
They prefer this method since it simulates a more normal appearance as opposed to the
sidestepping or zigzag method.
 When ascending and descending hills, the amputee will find sidestepping to be the most
efficient means. The sound limb should lead and provide the power to lift the body to the
next level, while the prosthetic limb remains slightly posterior to keep the weight line
anterior to the knee and act as a firm base.
 During descent the prosthetic limb leads but remains slightly posterior to the sound limb.
The prosthetic knee remains in extension, again acting as a form of support so that the
sound limb may lower the body.
 For hip disarticulates or transpelvic amputees, sidestepping is the most common
alternative regardless of the grade of the incline.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
84

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 85 of 92
NPTE
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.
I. SIDESTEPPING:
Sidestepping, or walking sideways, can be introduced to the amputee at various times
throughout the rehabilitation program. He can begin with simple weight shifting in the parallel
bars and later perform higher-level activities such as unassisted sidestepping around tables or
a small obstacle course that requires many small turns. During early rehabilitation this skill
provides the amputee with a functional exercise for strengthening the hip abductors and, later
in the rehabilitation process, with an opportunity to progress into multidirectional movements.
J. BACKWARD WALKING:
Walking backward is not difficult for transtibial amputees but poses a problem for amputees
requiring a prosthetic knee since there is no means of actively flexing the knee for adequate
ground clearance. In addition, the weight line falls posterior to the knee, and this causes a
flexion moment with possible buckling of the knee.
The most comfortable method of backward walking is by the amputee vaulting upward
(plantar-flexing) on the sound foot to obtain sufficient height so that the prosthetic limb that is
moving posteriorly can clear the ground. The prosthetic foot is placed well behind the sound
limb, with the majority of the body's weight being born on the prosthetic toe, thus keeping the
weight line anterior to the knee. The sound limb is then brought back, usually at a slightly
faster speed and a somewhat shorter distance. The trunk is also maintained in some flexion in
order to maintain the weight forward on the prosthetic toe. With a little practice most amputees
become quite proficient in backward walking.
K. MULTIDIRECTIONAL TURNS:
 Changing direction during walking or manoeuvring within confined areas often magnifies
an amputee's difficulty in controlling the prosthesis. “hip-hiking” the prosthesis and pivoting
around the sound limb often overcome situations such as crowded restaurants, elevators,
or just simply turning around. This method is effective but hardly the most aesthetic means
of manoeuvring.
 When turning to the sound side, two key factors for a smooth transition should be
remembered: first, maintain pelvic rotation in the transverse plane, and second, perform
the turn in two steps. Simply move the prosthetic limb over the sound limb 45 degrees,
rotate the sound limb 180 degrees, and complete the turn by stepping in the desired
direction with the prosthetic limb and leading with the pelvis to ensure adequate knee
flexion (Fig 1.20.).
 Fig 1.20. Turning to the sound side: 1-3, maintain normal gait biomechanics; 4, move the
prosthetic limb over the sound limb 45 degrees; 5, rotate the sound limb 180 degrees; 6,
complete the turn by stepping in the desired direction.
 Turning to the prosthetic side is performed almost exactly the same way as turning to the
sound side with one exception: slightly more weight is maintained on the prosthetic toe in
order to keep the weight line anterior to the knee, thus preventing knee flexion. For
example, by crossing the sound limb 45 degrees over the prosthetic limb, the weight line is
automatically thrown forward. The prosthetic limb is rotated as close to 180 degrees as
possible without losing balance (135 degrees is usually comfortable), and stepping in the
desired direction with the sound limb completes the turn. If necessary, remind the
amputee to maintain knee extension by applying a force with the residual limb against the
posterior wall of the socket (Fig 1.21.).
Fig 1.21. Turning to the prosthetic side: 1-3, maintain normal gait biomechanics; 4, move
the sound limb over the prosthetic limb 45 degrees; 5, rotate the prosthetic limb
approximately 135 degrees; 6,7, complete the turn by stepping in the desired direction.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
85

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 86 of 92
NPTE
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.
 One exercise that will reinforce turning skills is follow the leader, where the amputee
follows the therapist who is making a series of turns in all directions and with various
speeds and degrees of difficulty.
 The level of skill in turning will vary among amputees. All functional ambulators should be
taught to turn in both directions regardless of the prosthetic side. Those with poor balance
may be limited to unidirectional turns and require a series of small steps to complete the
turn.
L. TANDEM WALKING:
Walking with a normal base of support is of prime importance. However, tandem walking can
assist with balance and coordination and improve prosthetic awareness for the amputee.
Place a 5- to 10-cm (2- to 4-in.)-wide strip on the floor. The amputee is asked to walk in three
different ways: first, with one foot to either
side of the line; second, heel to toe with one foot in front of the other; and third, with one foot
crossing over in front of the other so that neither foot touches the line and yet the left foot is
always on the right side and vice versa.
M. BRAIDING:
Braiding (cariocas) may be taught either in the parallel bars or in an open area depending
upon the person's ability. Simple braiding is one leg crossing in front of the other. As the
amputee's skill improves, the prosthetic limb can alternate, first in front of and then behind the
sound limb, and vice versa. As ability improves, the speed of movement should increase. With
increased speed the arms will be required to assist with balance, and likewise, trunk rotation
will increase, further emphasizing the need for independent movement between the trunk and
Fig 1.22. Braiding is an exercise designed
to improve prosthetic control, balance, and
pelvis (Fig 1.22.).
coordination by crossing one leg in front of
or behind the other in a continuous manner.N. SINGLE-LIMB SQUATTING:
Single-limb balance is taught during the early stages of rehabilitation for crutch walking,
hopping, and other skills. Single-limb squatting is considerably more difficult but can help
improve balance and strength. When first attempting this skill, half squats with a chair
underneath the individual are recommended in case balance is lost.
O. FALLING:
Falling or lowering oneself to the floor is an important skill to learn not only for safety reasons
but also as a means to perform floor-level activities.
During falling, amputees must first discard any assistive device to avoid injury. They should
land on their hands with the elbows slightly flexed to dampen the force and decrease the
possibility of injury. As the elbows flex, they should roll to one side, further decreasing the
impact of the fall.
Lowering the body to the floor in a controlled manner is initiated by squatting with the sound
limb followed by gently leaning forward onto the slightly flexed upper limbs. From this position
the amputee has the choice of remaining quadruped or assuming a sitting posture.
XV. FLOOR TO STANDING:
Many techniques exist for teaching the amputee how to rise from the floor to a standing
position. The fundamental principle is to have the amputee use the assistive device for
balance and the sound limb for power as the body begins to rise. Depending on the type
of amputation and the level of skill, the amputee and therapist must work closely together
to determine the most efficient and safe manner to successfully master this task.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
86

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 87 of 92
NPTE
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.
P. RUNNING SKILLS:
For most amputees, the inability to run is the single most common factor limiting participation
in recreational activities, and yet it is the most desired skill. Many amputees who do not have a
strong desire to run for sport or leisure do have an interest in learning how to run for the
simple peace of mind of knowing that they
could move quickly to avoid a threatening situation. Rarely, if ever, is running taught in the
rehabilitation setting. Running, as with all gait-training and advanced skills, takes time and
practice to master. If the amputee is exposed to the basic skills of running during rehabilitation,
then the individual may make the decision to pursue running at a later date.
Syme ankle disarticulates and transtibial amputees do have the ability to achieve the same
running biomechanics as able-bodied runners if emphasis is placed on the following principles.
At ground contact, the hip on the amputated side should be flexed and moving toward
extension with the knee flexed and the prosthetic foot passively dorsiflexing. The knee flexion
not only permits greater shock absorption but in addition creates a backward force between
the ground and the foot to provide additional forward momentum. As the center of gravity
passes over the prosthesis during the stance phase, the ipsilateral arm should be fully forward
(shoulder flexed to 60 to 90 degrees), while the contralateral arm is simultaneously extended.
Extreme arm movement can initially be difficult for the amputee concerned with maintaining
balance. During late mid-stance to toe-off, the hip should be forcefully driven downward and
backward through the prosthesis as the knee extends. If the prosthetic foot is of the dynamic-
response type, the force produced by hip extension should deflect the keel so that the
prosthetic foot will provide additional push-off. Forward swing and the float phase are periods
when the hip should be rapidly flexing and elevating the thigh. The arms should again be
opposing the advancing lower limb, with the ipsilateral arm backward and the contralateral arm
forward. During foot descent, the hip should be flexed and then begin to extend as the knee is
rapidly extending and reaching forward for a full stride (Fig 1.23.).
Fig 1.23. Normal running gait cycle.
Transfemoral amputees and knee disarticulates traditionally run with a period of double
support on the sound limb during the running cycle, commonly referred to as the \"hop-skip\"
running gait pattern. The typical running gait cycle begins with a long stride by the prosthetic
leg, followed by a shorter stride with the sound leg. In order to give the prosthetic leg sufficient
time to advance, the sound leg takes a small hop as the prosthetic limb clears the ground and
moves forward to complete the stride. The speed that a transfemoral amputee runner may
achieve will be hampered because every time either foot makes contact with the ground, the
foot's forces are travelling forward and the reaction force of the ground must therefore be in a
backward or opposite direction (Newton's third law). The result is that each time the foot
contacts the ground, forward momentum is decelerated. In other words, with every stride the
amputee is slowing down when running with the \"hop-skip\" gait.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
87

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 88 of 92
NPTE
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.
The ability to run \"leg over leg\" has been achieved by a number of transfemoral amputees who
have developed this technique through training and working with knowledgeable coaches. The
transfemoral amputee takes a full stride with the prosthetic leg, followed by a typically shorter
stride with the sound leg. With training, equal stride length and stance time may be achieved.
This running pattern is a more natural gait where the double-support phase of the sound limb
is eliminated and forward momentum maintained by both legs. Initially, problems that may
occur include excessive vaulting off the sound limb to ensure ground clearance of the
prosthetic limb, decreased pelvic and trunk rotation, decreased and asymmetrical arm swing,
and excessive trunk extension. Again with training, many of these deviations will decrease and
possibly be eliminated (Fig 1.-24.).
Fig 1.24. Transfemoral amputee running gait cycle.
The transfemoral amputee has an additional consideration when learning to run. To date, no
knee system permits flexion during the prosthetic support phase, and this results in the
residual limb having to absorb the ground reaction force during initial ground contact. Another
problem with present knee units that transfemoral amputees must contend with is maintaining
A woodcut of the reduction of a the appropriate cadence during swing. Hydraulic knee units offer the ability to adjust the
dislocated shoulder with a hydraulic resistance during knee flexion and extension. During running, less resistance in
Hippocratic device. extension permits faster knee extension, while increased resistance in flexion decreases the
amount of heel rise with beginning runners. Seasoned runners often reduce knee flexion
resistance to permit the prosthetic shank to bounce off the socket and thus return to the
extended position at an accelerated rate. Collectively, these adjustments decrease the amount
of time required for the prosthetic swing phase.
The \"leg-over-leg\" running style does permit the transfemoral amputee to run faster for short
distances but at a greater metabolic cost. While the \"leg-over leg\" style is preferred, the hop-
skip method is often more easily taught and less demanding physically on the amputee. If the
sole purpose of instructing running is to permit the individual to move quickly in a safe and
sure manner, the hop-skip method is most frequently suggested.
Q. RECREATIONAL ACTIVITIES:
By definition, recreation is any play or amusement used for the refreshment of the body or
mind. That is to say, the term recreational activities need not exclusively mean athletics such
as running or team sports. In fact, many people enjoy recreational activities such as
gardening, shuffleboard, or playing cards as a means of socializing or relaxing. A
comprehensive rehabilitation program should include educating the amputee on how to return
to those activities that are found pleasurable. For example, the therapist can teach physical
splinter skills such as weight shifting, necessary to help the amputee participate in
shuffleboard, or various methods of kneeling for gardening. In addition, there are many
national and local recreational organizations and support groups that provide clinics, coaching,
or another amputee who can teach from experience how to perform various higher-level
recreational skills. Providing the amputee with information on how to contact these groups is
the first step to mainstreaming the patient back into a life-style complete with recreational skills
as well as activities of daily living.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
88

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 89 of 92
NPTE
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.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
89

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 90 of 92
NPTE
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.
13.0 PROFESSIONAL ROLES AND MANAGEMENT:
13.1 PATIENT CARE ACTIVITIES:
13.1.1 DIRECT PATIENT CARE:
Those activities which are diagnostic / evaluative / therapeutic, and which require the
presence of the patient or significant others.
13.1.2 INDIRECT PATIENT CARE ACTIVITIES:
 Those activities which support or supplement the diagnosis / evaluation / treatment of a
specific patient, for which the presence of the patient, or significant other is not required.
Examples of indirect patient care activities include:
 Preparation for assessment / treatment e.g., reading literature related to the specific
client condition
 Patient-related discussions / consultation e.g., meetings / conferences with other
 Health care professionals regarding a specific client's status; telephone contacts with
clients to assess their situation
 Clinical documentation e.g., all forms of written communication in which the client or
significant other are not present
 Off-site visits to client's home
 Therapeutic adaptation e.g., making a splint for a client who is not present
13.2 NON-PATIENT CARE ACTIVITIES:
 Activities which are part of departmental activities, but which do not involve the care of a specific
patient. Non-patient care activity time is part of worked hours. Non-patient care activities do not
include professional development time, which is considered a benefit hour.
Library
 Non-Patient Care Activities include:
 Functional center management: Clerical, organizing, orienting personnel, recording workload,
participating in quality improvement activities, employee meetings, travel including portering, etc.
 Hospital / community / professional: Attendance at meetings, public relations, consultation to
community regarding care of non-registered clients, etc.
 In-Service teaching: The dissemination of knowledge pertaining to physiotherapy / occupational
therapy and health care by means of lectures / demonstrations / presentations, etc; preparation
for orientation and instruction of departmental staff, other students and hospital personnel
regarding therapy principles and theories and inter-professional working relationships; in-service
education; etc.
 Research: formally designed and approved clinical investigations for the purpose of improving the
quality of patient care, by means of scientific methodologies and procedures.
CONSULTATION TO
COMMUNITY
“MEDICINE” IS A NOBLE REGARDING CARE
PROFESSION, IT SERVES HUMANITY
90

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 91 of 92
NPTE
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.
13.3 THE ROLE OF THE PHYSIOTHERAPIST:
 Physiotherapy is a very vital component of both patient care and treatment; therefore it has
certain components as well as specific protocols to follow.
 Good physiotherapy includes the following:
 Examination of subjects with physical impairment, functional limitation, disability or some disease
process in order to establish diagnosis, prognosis and intervention.
 Researching and designing appropriate therapy in order to alleviate impaired function and
physical limitation.
 Prevention of future impairments and disabilities by maintaining fitness and well being through
continuous physical therapy on long term basis.
 A continuous and concentrated approach towards research, providing education to the patients
regarding their fitness and well being along with emphasis on consultation.
13.3.1 EXPECTED PROVISIONS FROM THE PHYSIOTHERAPIST BY THE PATIENT:
 Patients must expect the physiotherapist to provide them the following:
 A proper and complete physical examination supported with proper and relevant
laboratory tests, in order to correctly diagnose the inciting problem.
 A proper evaluation system involving not just the physiotherapist, but sometimes also
referral to doctors for further examination and tests.
 Determination of a prognosis according to the physical examination necessary tests.
 Alleviating impairment and providing any necessary rehabilitation.
 Assessment of the patient after different types of physical therapy provided.
 Proper cessation of treatment procedures after complete or satisfactory recovery.
 Prevention of future injuries and after effects of previous injuries due to stress and over
exertion.
 Education about individual’s condition and continuous consultation plans and screening
visits.
A. RESPONSIBILITIES TO THE CLIENT:
1. Physiotherapists shall respect the client's rights, dignity, needs, wishes and values.
2. Physiotherapists may not refuse care to any client on grounds of race, religion, ethnic
or national origin, age, sex, sexual orientation, social or health status.
3. Physiotherapists must respect the client's or surrogate's right to be informed about
the effects of treatment and inherent risks.
4. Physiotherapists must give clients or surrogates the opportunity to consent to or
decline treatment or alterations in the treatment regime.
5. Physiotherapists shall confine themselves to clinical diagnosis and management in
those aspects of physiotherapy in which they have been educated and which the
Responsibilities to the Client profession recognizes. (Physiotherapists are responsible for recognizing and
practicing within their levels of competence. Taking a history and conducting a
physical and functional examination establish the clinical diagnosis. The identification
of the client's problems and the physiotherapeutic management is based on this
diagnosis in conjunction with an understanding of pertinent biopsychosocial factors.
This rule does not restrict the expansion of the scope of physiotherapy practice.)
6. Physiotherapists shall assume full responsibility for all care they provide.
7. Physiotherapists shall not treat clients when the medical diagnosis or clinical
condition indicates that the commencement or continuation of physiotherapy is not
warranted or is contraindicated.
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
91

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 92 of 92
NPTE
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.
8. Physiotherapists shall request consultation with, or refer clients to, colleagues or
members of other health professions when, in the opinion of the physiotherapist,
such action is in the best interest of the client.
9. Physiotherapists shall document the client's history and relevant subjective
information, the physiotherapist's objective findings, clinical diagnosis, treatment plan
and procedures, explanation to the client, progress notes and discharge summary.
10. Physiotherapists shall respect all client information as confidential. Such information
shall not be communicated to any person without the consent of the client or
surrogate except when required by law.
11. Physiotherapists, with the client or surrogate's consent, may delegate specific
aspects of the care of that client to a person deemed by the physiotherapist to be
competent to carry out the care safely and effectively.
12. Physiotherapists are responsible for all duties they delegate to personnel under their
supervision.
13.3.2 DIFFERENT TYPES OF PHYSIOTHERAPY:
Types of physiotherapy can be based on the type of specialty department in which the Physio
is performed, or based on type of physical therapy applied:
 According to department specialty:
 Pediatric physiotherapy.
 Geriatric physiotherapy.
 Orthopedic physiotherapy.
 Neurological physiotherapy.
 Cardio-pulmonary physiotherapy.
According to therapy applied:
 Heat application.
 Cold application (ice packing).
 Hydrotherapy (using water to reduce joint weight).
 Ultrasound therapy.
 Electrical stimulation.
 Acupuncture.
 Manual therapy (Message, Manipulation, Mobilization).
 Exercises (strengthening work outs).
“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
92