The pocketbook for physiotherapists [2 ed.] 9789350255605, 935025560X

Table of contents :
Prelims
Chapter-01_PHARMACOLOGY
Chapter-02_ELECTROTHERAPY
Chapter-03_CARDIORESPIRATORY
Chapter-04_NEUROLOGY
Chapter-05_MUSCULOSKELETAL
Chapter-06_MISCELLANEOUS
Index

Citation preview

The Pocketbook for PHYSIOTHERAPISTS

The Pocketbook for

PHYSIOTHERAPISTS SECOND EDITION

Gitesh Amrohit

MPT (Neuro) Chief Consultant and Director Amrohit Institute of Rehabilitation Sciences (AIRS) Raipur, Chhattisgarh, India President Physiotherapist Association® Managing Editor Right Sehat

®

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London

®

Jaypee Brothers Medical Publishers (P) Ltd. Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd., 83 Victoria Street London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: [email protected]

Jaypee-Highlights Medical Publishers Inc. City of Knowledge, Bld. 237, Clayton Panama City, Panama Phone: 507-317-0160 Fax: +50-73-010499 Email: [email protected]

Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2012, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: [email protected] This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. The Pocketbook for Physiotherapists First Edition: 2007 Second Edition: 2012 ISBN 978-93-5025-560-5 Printed at

Dedicated to My parents Dr Ramadhar Amrohit Smt Shruti Amrohit and My dearest twin brothers Jeetesh-Jeevesh

Preface to the Second Edition It gives me immense pleasure to present the second edition of the book The Pocketbook for Physiotherapists. In this edition, I have tried to expand it, without compromising its pocket size. Additional contents have been attached in every section and to make it easier to find the relevant information for the students. I hope that undergraduates, postgraduates and professionals find this book useful and informative. Wishing and praying for your bright future and all the success in your life. Gitesh Amrohit

Preface to the First Edition I was the undergraduate student of physiotherapy in the year 2002-2006. During this period, I and my classmates had to remember lots of normal values, special tests, drugs, pathology, anatomy and various others things and it was not possible to remember all the things at the same time, because the textbook did not used to be in our hand all the time and these problems were solved by preparing notes of all those stuffs. The main problem used to arise when we have to know and confirm certain things, while assessing and giving treatment to the patient and because of this; we were bound to carry all those heavy textbooks. Taking care of all these problems, The Pocketbook for Physiotherapists is written. In this there are all the important stuffs related to medical and physiotherapy and they are explained by the help of graphs, tables and text without modifying their original meaning. This book cannot be the textbook, but it can be used after a thorough study from the textbooks during the postings, clinics and the classroom. It has taken hard work to comprise all the medical and physiotherapy topics in this small handbook. So that you can take complete advantage of the book. Wishing and praying for your bright future and all the success in your life. Gitesh Amrohit

Acknowledgments

First of all, I thank God for the gift of life and all the blessings, He has poured on me. I would like to heartily thank my irreplaceable staff, who were there with me in every step from bottom of my heart. I would also like to acknowledge with thanks Mr Shravan Kumar and Mr Khomlal Chandeshwar; SK Medical Book House, who supported and kept motivating me. It was not possible for me to publish this book without their support. Last but not least, I would like to thank the entire team at M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, especially Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-Publishing) and Mr Prasun Bhattacharya (Manager-Nagpur Branch) for their unmatchable contribution in bringing this book to present shape.

Contents

CHAPTER 1: PHARMACOLOGY .................. 1 Drug Classes in Alphabetical Order 1; Acetazolamide 2; Acetylcysteine 2; Aciclovir 2; Adenosine 2; Adrenaline/Epinephrine 3; Albendazole 3; Alendronate 3; Alfentanil 3; Allopurinol 4; Amiodarone 4; Aminophyline 4; Amitriptyline 4; Amlodipine 5; Amoxicillin 5; Ampicillin 5; Alprazolam 5; Alendronate 6; Aspirin 6; Atenolol 6; Atracurium 6; Atropine 7; Azathioprine 7; Baclofen 7; Beclomethasone 7; Bendroflumethiazide/Bendrofluazide 8; Budesonide 8; Calcitonin 8; Captopril 8; Carbamazepine 9; Celecoxib 9; Chloramphenicol 9; Chlorpromazine 9; Chloroquine 10; Ciclosporin 10; Ciprofloxacin 10; Clofazimine 11; Clomipramine 11; Clonidine 11; Codeine Phosphate 11; Dapsone 11; Dexamethasone 12; Diazepam 12; Diclofenac 12; Didanosine 12; Digoxin 13; Dihydrocodeine/Df 118 13; Diltiazem 13; Dobutamine 13; Donepezil 13; Dopamine 14; Dornase Alfa 14; Dosulepin/ Dothiepin 14; Doxapram 14; Doxycycline 14; Enalapril 15; Efavirenz 15; Erythromycin 15; Etidronate 15; Fentanyl 16; Ferrous Sulphate 16; Flucloxacillin 16; Furosemide/Frusemide 16; Gabapentin 16; Gatifloxacin 17; Gentamicin 17;

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Gliclazide 17; Haloperidol 17; Heparin 18; Hydrocortisone 18; Ibuprofen 18; Insulin 18; Interferon 19; Ipratropium 19; Isoniazid 19; Isosorbide Mononitrate 19; Ketamine 20; Lactulose 20; Levodopa/L-dopa 20; Lignocaine/ Lidocaine 20; Liquid Paraffin 21; Lisinopril 21; Mannitol 21; Meloxiam 21; Metformin 21; Methotrexate 22; Methyldopa 22; Metronidazole 22; Midazolam 22; Morphine 23; Naproxen 23; Norfloxacin 23; Omeprazole 23; Ondansetron 24; Orphenadrine 24; Oxybutinin 24; Oxytetracycline 24; Pancuronium 25; Paracetamol 25; Penicillin-g 25; Pethidine 25; Phenytoin 25; Piroxicam 26; Prednisolone 26; Propranolol 26; Quinine 27; Ramipril 27; Ranitidine 27; Rifampicin 27; Salbutamol 28; Salcatonin 28; Senna 28; Streptokinase 28; Streptomycin 28; Sulfasalazine 29; Tetracycline 29; Theophylline 29; Timolol 29; Tinidazole 30; Tizanidine 30; Tolterodine 30; Tramadol 30; Trazodone 30; Trihexyphenidyl/Benzhexol 31; Vancomycin 31; Vecuronium 31; Verapamil 31; Warfarin 32; Zalcitabine 32; Zidovudine 32; List of Pharmacology Abbreviations 33 CHAPTER 2: ELECTROTHERAPY ............... 35 Principles of Electrotherapy Application 37; Interferential 42; Short Wave Diathermy 43; Ultraviolet Radiation 45; Laser Therapy 47; Ultrasound 48; Transcutaneous Electrical Nerve Stimulation (TENS) 50; Iontophoresis 51; Infrared Radiation 52; Paraffin Wax Bath 53; Neuromuscular Electrical Stimulation (NMES)

CONTENTS 55; Microwave Diathermy 56; Cryotherapy (Cold Therapy) 57; Hot Packs (Hydrocollator Packs)/ Electric Heating Pads 58; Whirlpool Bath 59; Contrast Bath 60; Sauna Bath 61; Electromyographic Biofeedback 62; Fluidotherapy 64; Intermittent Pneumatic Compression 65; Continuous Passive Motion 66; Traction 67; Strength Duration Curve 68; Motor Points 71

CHAPTER 3: CARDIORESPIRATORY ........ 77 Cardiorespiratory Anatomy Illustrations 79; Surface Marking of the Lungs 82; Respiratory Volumes and Capacities 84; Differences between Central and Peripheral Cyanosis 87; Sputum Analysis 87; Readings of Chest X-rays 88; Abnormal ECG Findings 93; Percussion Note 94; Auscultation 95; Palpation of Pulses 100; Apgar Scoring Method 101; Postural Drainage 101; Manual Chest Clearance Technique 107; Suctioning 108; Forced Expiratory Techniques 110; Tracheostomies 110; Aerosol Therapy 112; Humidity 113; Lung Function Test 114; Ambulatory Manual Breathing Unit (AMBU) Bag 115; Manual Hyperinflation 116; Cardiorespiratory Monitoring 117; Ventilations 120; Respiratory Pathologies 123; Normal Values 136; Blood Values and their Interfering Factors 138; Respiratory Assessment 139; Glossary of Cardiorespiratory Terms 143 CHAPTER 4: NEUROLOGY ........................ 147 Neuroanatomy Illustrations 149; Clinical Manifestations of Cerebrovascular Lesions 153;

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Localization of Lesion and their Signs of Impairment 155; Peripheral Nervous System 158; Splints Used for Various Nerve Injuries 162; Vertebrae and Corresponding Spinal Segment Relationship 163; Neurological Tests 164; Cranial Nerves 169; Reflexes 173; Differences of Upper Motor Neuron and Lower Motor Neuron Lesions 175; Glasgow Coma Scale 177; Modified Ashworth Scale for Grading Spasticity 178; Neurological Pathologies 178; Neurological Assessment 193; Glossary of Neurological Terms 197 CHAPTER 5: MUSCULOSKELETAL ......... 203 Muscles Listed by Function 204; Manual Muscle Testing Grading 209; Alphabetical Listing of the Muscles 210; Joint Range of Movement 278; Common Musculoskeletal Tests 288; Musculoskeletal Pathologies 315; Grades of Sprain and Treatment 328; Stages of Fracture Healing 329; Fractures with Eponyms 331; Musculoskeletal Assessment 336 CHAPTER 6: MISCELLANEOUS ................ 339 Diagnostic/Electrodiagnostic Testing 340; National Immunization Schedule 345; Proprioceptive Neuromuscular Facilitation (PNF) 345; Common Sports Injuries 346; Types of Aphasia 348; Gait 348; Levels of Amputations 351; Abbreviations 353; Normal Reference/Lab Values 376 Index ..................................................................... 381

PHARMACOLOGY

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CHAPTER Pharmacology •

Drug classes in alphabetical order

•

Prescription abbreviations

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DRUG CLASSES IN ALPHABETICAL ORDER ACETAZOLAMIDE Type: Diuretics. Uses: Glaucoma, epilepsy, acute mountain sickness, periodic paralysis, urinary tract infection. Side effects: Hypokalemia, drowsiness, acidosis, abdominal discomfort. ACETYLCYSTEINE Type: Mucolytic. Uses: Reduces the viscosity of secretions, antidote for paracetamol overdose. Side effects: Bronchoconstriction, nausea, vomiting. ACICLOVIR Type: Antiviral. Uses: Herpes simplex and varicella zoster infection. Side effects: Very rare. ADENOSINE Class: Antiarrhythmic. Uses: Tachycardias. Side effects: Nausea, bronchospasm, dyspnea, chest pain, facial flush.

PHARMACOLOGY

ADRENALINE/EPINEPHRINE Type: Sympathomimetic agent. Uses: During cardiopulmonary resuscitation to stimulate heart activity and raise low blood pressure, anaphylactic shock, glaucoma, in eye surgery. Side effects: Dry mouth, anxiety, restlessness, palpitations, tremor, blurred vision, headache, hypertension, tachycardias. ALBENDAZOLE Type: Anthelmintics. Uses: Filariasis, hydatid disease, trichinosis, tapeworms. Side effects: Diarrhea, nausea, abdominal pain. ALENDRONATE Type: Bisphosphonate. Uses: Postmenopausal osteoporosis, corticosteroids induced osteoporosis, Paget’s disease. Side effects: Gastrointestinal upset, esophageal irritation and ulceration. ALFENTANIL Type: Opioid analgesic. Uses: Respiratory depressant, during surgery.

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Side effects: Drowsiness, nausea, vomiting, constipation, dizziness, dry mouth. ALLOPURINOL Type: Antigout. Uses: Gout, kidney stones. Side effects: Nausea, itching, rash. AMIODARONE Type: Antiarrhythmic. Uses: Ventricular and supraventricular tachycardias. Side effects: Liver damage, reversible corneal depositions, thyroid disorders. AMINOPHYLINE Type: Bronchodilator. Uses: Acute severe asthma, reversible airway obstruction. Side effects: Nausea, headache, insomnia, arrhythmias, convulsions, palpitations, tachycardias. AMITRIPTYLINE Type: Tricyclic antidepressant. Uses: Depression, nocturnal enuresis in children.

PHARMACOLOGY

Side effects: Sweating, dry mouth, blurred vision, dizziness, drowsiness, fainting, palpitations, gastrointestinal upset. AMLODIPINE Type: Ca++ channel blocker. Uses: Congestive heart failure, angina. Side effects: Ankle edema, flushing, palpitation, headache, hypotension, gastrointestinal upset. AMOXICILLIN Please refer Ampicillin. AMPICILLIN Class: Antibiotic. Uses: Urinary tract infection, respiratory tract infection, meningitis, gonorrhea, typhoid fever, bacillary dysentery, bacterial endocarditis, septicemias, cholecystitis. Side effects: Diarrhea, rashes, lymphatic leukemia. ALPRAZOLAM Type: Benzodiazepines. Uses: Anxiety, depression. Side effects: Sedation, light headedness, vertigo, confusion, psychomotor and cognitive impairment.

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ALENDRONATE Type: Bisphosphonate. Uses: Postmenopausal osteoporosis, corticosteroids induced osteoporosis, Paget’s disease. Side effects: Esophageal irritations and ulceration, gastrointestinal upset, increased bony pain especially in Paget’s disease. ASPIRIN Type: NSAIDs and antipyretic. Uses: As analgesic, antipyretic, acute rheumatic fever, RA, OA, postmyocardial infarction and post-stroke. Side effects: Nausea, vomiting, epigastric distress, rhinorrhea. ATENOLOL Type: B-antiadrenergic. Uses: Arrhythmias, angina, hypertension, myocardial infarction, congestive heart failure. Side effects: Cold hand and feet, bradycardia, hypotension, fatigue. ATRACURIUM Type: Nondepolarizing muscle relaxant. Uses: As a muscle relaxant. Side effects: Hypotension, flushing, skin rashes.

PHARMACOLOGY

ATROPINE Type: Antimuscarinic. Uses: Corneal ulcers, peptic ulcers, pulmonary embolism, preanesthetic medication, bradycardia, motion sickness. Side effects: Dry mouth, difficulty in swallowing and talking, blurring of near vision, constipation, flushing, dry skin. AZATHIOPRINE Type: Immunosuppressant. Uses: Autoimmune and collagen disease including rheumatoid arthritis, polymyositis, systemic lupus erythematosus. Side effects: Nausea, vomiting, loss of hair, loss of appetite, bone marrow suppression. BACLOFEN Type: Skeletal muscle relaxant. Uses: For reducing spasticity. Side effects: Nausea, urinary disturbances, drowsiness. BECLOMETHASONE Type: Corticosteroid. Uses: Asthma, allergic rhinitis, in vasomotor symptoms.

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Side effects: Nasal discomfort, irritation, horse voice, cough, nosebleed, sore throat. BENDROFLUMETHIAZIDE/BENDROFLUAZIDE Type: Thiazide diuretic. Uses: Hypertension, cardiac failure, resistant edema, for reducing urinary calcium excretion. Side effects: Hypokalemia, dehydration, postural hypotension, gout, hyperglycemia. BUDESONIDE Type: Corticosteroid. Uses: Asthma, COPD. Side effects: Nasal discomfort, cough, sore throat. CALCITONIN Type: Hormone. Uses: Hypercalcemia, bone pain, osteoporosis. Side effects: Vomiting, nausea. CAPTOPRIL Type: ACE inhibitor. Uses: Hypertension, congestive heart failure, postmyocardial infarction, diabetic nephropathy. Side effects: Persistent dry cough, rashes, loss of taste sensation, reduces kidney function, postural hypotension.

PHARMACOLOGY

CARBAMAZEPINE Type: Antiepileptic. Uses: Partial and tonic–clonic seizures, trigeminal neuralgia. Side effects: Drowsiness, epigastric pain, nausea, confusion, blurred vision. CELECOXIB Type: NSAID. Uses: Osteoarthritis, rheumatoid arthritis. Side effects: Fluid retention, dizziness, hypertension, headache, itching, insomnia. CHLORAMPHENICOL Type: Broad spectrum antibiotics. Uses: Enteric fever, anerobic infections, intraocular infections, H. influenzae, meningitis. Side effects: Nausea, vomiting, diarrhea, gray baby syndrome, bone marrow depression. CHLORPROMAZINE Type: Antipsychotic. Uses: Schizophrenia, mania, organic brain syndrome, alcoholic hallucinosis. Side effects: Dry mouth, blurring vision, constipation, parkinsonian symptoms, dystonic,

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jaundice, akathisia, malignant neuroleptic syndrome symptoms. CHLOROQUINE Type: Antimalarial drug. Uses: Malaria. Side effects: Hypotension, vision loss, hearing deficit, nausea, vomiting, anorexia, itching. CICLOSPORIN Type: Immunosuppressant. Uses: Used to prevent rejection of organ and tissue transplantation. Rheumatoid arthritis, severe resistant psoriasis, severe dermatitis when other treatments have failed. Side effects: Nephrotoxicity, hypertension, increased body hair, nausea, tremors, swelling of gums. CIPROFLOXACIN Type: Prototype antibacterial. Uses: UTI, gonorrhea, bacterial gastroenteritis, typhoid, gynecological disease, tuberculosis, meningitis, respiratory infections. Side effects: Nausea, vomiting, anorexia, bad taste dizziness, headache, rashes, urticaria.

PHARMACOLOGY

CLOFAZIMINE Please refer Dapsone. CLOMIPRAMINE Type: Tricyclic antidepressant. Uses: Depression. Side effects: Sweating, drowsiness, dryness of mouth, blurring of vision, dizziness, fainting, palpitations, gastrointestinal upset. CLONIDINE Type: Alpha 2 adrenoceptor agonist. Uses: Migraine, menopausal flushing, hypertension. Side effects: Dryness of mouth, gastrointestinal upset, headache, dizziness, rashes, sedation, depression, bradycardia, retention of fluid, nocturnal unrest. CODEINE PHOSPHATE Please refer Morphine. DAPSONE Type: Antileprotic drug. Uses: Leprosy.

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Side effects: Hemolytic anemia, gastric intolerance, rashes, headache, lepra reactions, nausea, vomiting. DEXAMETHASONE Please refer Prednisolone. DIAZEPAM Type: Benzodiazepines. Uses: Anxiety, sleep disturbances, alcoholism and as muscle relaxants. Side effects: Unsteadiness, drowsiness, dizziness, confusion in elderly. Dependence develops with prolonged use. DICLOFENAC Type: NSAIDs and antipyretic. Uses: Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, post-traumatic and postoperative inflammatory conditions. Side effects: Epigastric pain, nausea, rashes, headache, dizziness. DIDANOSINE Please refer Zalcitabine.

PHARMACOLOGY

DIGOXIN Type: Cardiac glycoside. Uses: Heart failure, supraventricular arrhythmias. Side effects: Nausea, anorexia, vomiting, diarrhea, visual disturbances, headache, tiredness, palpitations. DIHYDROCODEINE/DF 118 Please refer Morphine. DILTIAZEM Please refer Amlodipine. DOBUTAMINE Type: Inotropic sympathomimetic. Uses: Heart failure. Side effects: Tachycardias. DONEPEZIL Type: Anticholinesterase. Uses: Dementia especially due to Alzheimer’s disease. Side effects: Insomnia, muscle cramps, fatigue, gastrointestinal upset.

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DOPAMINE Type: Inotropic sympathomimetic. Uses: Shock, heart failure. Side effects: Nausea, vomiting, peripheral vasoconstriction, hypotension, hypertension tachycardia. DORNASE ALFA Type: Mucolytic. Uses: Used by inhalation in cystic fibrosis to facilitate expectoration. Side effects: Laryngitis, pharyngitis, pain in chest. DOSULEPIN/DOTHIEPIN Please refer Clomipramine. DOXAPRAM Type: Respiratory stimulant. Uses: COPD with type-II respiratory failure. Side effects: Hypertension, cerebral edema, hyperthyroidism, dizziness, sweating, confusion, seizures, nausea, vomiting, tachycardia, perineal warmth. DOXYCYCLINE Please refer Tetracyclines.

PHARMACOLOGY

ENALAPRIL Type: ACE inhibitor. Uses: Hypertension, chronic heart failure. Side effects: Rashes, dry cough, loss of taste, postural hypotension, dizziness, headache, reduce kidney function. EFAVIRENZ Please refer Zalcitabine. ERYTHROMYCIN Type: Macrolide antibiotic. Uses: Inflammation, diphtheria, syphilis, gonorrhea. Side effects: Gastrointestinal discomfort, rashes, fever. ETIDRONATE Type: Bisphosphonate. Uses: Postmenopausal osteoporosis, corticosteroid induced osteoporosis, Paget’s disease, bone metastases in breast cancer. Side effects: Ulceration and esophageal irritation, gastrointestinal upset, increased bony pain in Paget’s disease.

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FENTANYL Type: Opioid analgesic. Uses: Mainly used to depress respiration in patients needing prolonged assisted ventilation. Side effects: Drowsiness, nausea, vomiting, constipation, dizziness, dry mouth. FERROUS SULPHATE Type: Iron salt. Uses: Iron deficiency anemia. Side effects: Constipation, epigastric discomfort, darkening of feces. FLUCLOXACILLIN Please refer Penicillin. FUROSEMIDE/FRUSEMIDE Type: Loop diuretic. Uses: For reducing acute pulmonary edema secondary to left ventricular failure. Side effects: Hypokalemia, postural hypotension, hyponatremia, hyperuricemia, gout, dizziness, nausea. GABAPENTIN Type: Anticonvulsant.

PHARMACOLOGY

Uses: Epileptic seizures, neuropathic pain, trigeminal neuralgia. Side effects: Dizziness, drowsiness, ataxia, nystagmus, tremor, diplopia, gastrointestinal upset, peripheral edema, amnesia, paresthesia. GATIFLOXACIN Please refer Ciprofloxacin. GENTAMICIN Type: Aminoglycoside antibiotics. Uses: Pseudomonas, Proteus, Klebsiella infections, respiratory infection’s meningitis. Side effects: Vestibular disturbances, auditory loss, nausea, vomiting. GLICLAZIDE Type: Sulphonylurea. Uses: Type-II diabetes mellitus. Side effects: Hypoglycemia, weight gain. HALOPERIDOL Type: Antipsychotic. Uses: Used for controlling violent and dangerously impulsive behavior associated with psychotic disorders like as schizophrenia, dementia and mania.

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Side effects: Acute dystonia, akathisia, drowsiness, postural hypotension, parkinsonism. HEPARIN Type: Anticoagulant. Uses: Pulmonary embolism, DVT. Side effects: Thrombocytopenia, hemorrhage. HYDROCORTISONE Please refer Prednisolone. IBUPROFEN Class: Nonsteroidal anti-inflammatory/NSAID. Uses: For reducing pain, stiffness, swelling. Osteoarthritis, rheumatoid arthritis, soft tissue injuries, headache, dental pain, operative pain. Side effects: Indigestion, heart burn. INSULIN Type: Peptide hormone. Uses: Insulin dependent and maturity onset diabetes mellitus. Side effects: Irritation over injection site, hypoglycemia, weakness, weight gain, sweating.

PHARMACOLOGY

INTERFERON Type: Antiviral and anticancer. Uses: Leukemia, multiple sclerosis, granulomatous disease. Side effects: Lethargy, chills, myalgia, fatigue, rashes, fever, headache, anorexia, irritation. IPRATROPIUM Type: Antimuscarinic. Uses: COPD. Side effects: Dry mouth and throat. ISONIAZID Type: Antitubercular drug. Uses: Tuberculosis. Side effects: Paresthesia, numbness, convulsions, mental disturbances, hepatitis. ISOSORBIDE MONONITRATE Type: Organic nitrate. Uses: Congestive heart failure, angina. Side effects: Throbbing headache, flushing, sweating, palpitation, dizziness, fainting.

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KETAMINE Type: Intravenous anesthetic. Uses: As anesthetics agent (not use in head and neck surgery). Side effects: Tachycardia, hallucinations, increased blood pressure, increased muscle tone, apnea, hypotension, other transient psychotic sequelae. LACTULOSE Type: Osmotic laxative. Uses: Constipation, hepatic encephalopathy. Side effects: Diarrhea, stomach cramps, flatulence, belching. LEVODOPA/L-DOPA Type: Dopamine precursor. Uses: Parkinson’s disease. Side effects: Nausea, vomiting, postural hypotension, cardiac arrhythmias, alteration in taste sensation, behavioral changes, abnormal movements, abdominal pain, dizziness, discoloration of urine and other body fluids. LIGNOCAINE/LIDOCAINE Type: Na+ channel blocker. Uses: As anesthetic and antiarrhythmic. Side effects: Dizziness, drowsiness, nausea, vomiting.

PHARMACOLOGY

LIQUID PARAFFIN Type: Laxatives. Uses: Constipation, before surgery night. Side effects: Dehydration, lipid pneumonia. LISINOPRIL Type: ACE inhibitor. Uses: Hypertension, congestive heart failure, following myocardial infarction. Side effects: Nausea, vomiting, cough, taste alteration, hypotension. MANNITOL Type: Osmotic diuretic. Uses: Glaucoma, head injury, stroke. Side effects: Nausea, diarrhea, headache, fever. MELOXIAM Type: NSAID. Uses: Rheumatoid arthritis, ankylosing spondylitis, osteoarthritis. Side effects: Headache, gastrointestinal upset, dizziness, vertigo, rashes. METFORMIN Type: Biguanide.

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Uses: Type-II diabetes mellitus. Side effects: Anorexia, nausea, vomiting, diarrhea. METHOTREXATE Type: Cytotoxic and immunosuppressive. Uses: Leukemia, lymphoma, rheumatoid arthritis, psoriatic arthritis. Side effects: Diarrhea, bone marrow suppression, vomiting, inflammation. METHYLDOPA Type: Antihypertensive. Uses: High blood pressure. Side effects: Sedation, lethargy, disturbed mental capacity, impotence, postural hypotension. METRONIDAZOLE Type: Antiamebic. Uses: Giardiasis, amebiasis, trichomonas vaginitis, enterocolitis, gingivitis bacterial infections. Side effects: Nausea, vomiting, anorexia, headache, glossitis, rashes, dizziness. MIDAZOLAM Type: Benzodiazepine.

PHARMACOLOGY

Uses: Anxiety, mainly used during small procedures under local anesthetic and in ITU units for those on ventilator support. Side effects: Hypotension, apnea, drowsiness, headache, confusion, ataxia, amnesia, muscular weakness. MORPHINE Type: Opioid analgesic. Uses: Ventricular failure, pain. Side effects: Nausea, vomiting, constipation, dizziness, drowsiness, respiratory depression, dry mouth. NAPROXEN Type: NSAID. Uses: Rheumatoid arthritis, musculoskeletal disorders in acute stage, gout, menstrual cramps. Side effects: Gastrointestinal upset. NORFLOXACIN Please refer Ciprofloxacin. OMEPRAZOLE Type: Proton pumps inhibitor. Uses/Side effects: Please refer Ranitidine.

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ONDANSETRON Type: Serotonin antagonist. Uses: Used to treat nausea and vomiting associated with anticancer drug therapy, radiotherapy and following surgery. Side effects: Headache, constipation. ORPHENADRINE Type: Antimuscarinic. Uses: For reducing rigidity and tremor in younger patients with parkinsonism. Side effects: Dry mouth, dry skin, constipation, blurred vision, retention of urine. OXYBUTININ Type: Antimuscarinic. Uses: Urinary frequency, urgency and incontinence, nocturnal enuresis, neurogenic bladder instability. Side effects: Dry mouth, dry eye, gastrointestinal upset, difficulty in micturation, skin reaction, blurring of vision. OXYTETRACYCLINE Please refer Tetracycline.

PHARMACOLOGY

PANCURONIUM Please refer Vecuronium. PARACETAMOL Type: Nonopioid analgesic. Uses: Pain, fever. Side effects: Very rare. Overdose is dangerous causing liver failure. PENICILLIN-G Type: Benzyl penicillin. Uses: Streptococcal, pneumococcal, meningococcal infections, gonorrhea, syphilis, diphtheria. Side effects: Pain at inj. Site, nausea, rash, itching, urticaria, shock, exfoliative dermatitis. PETHIDINE Type: Opioid analgesic. Uses: Severe pain, pain during labor, anxiety, during anesthesia. Side effects: Nausea, vomiting, constipation, drowsiness, confusion. PHENYTOIN Type: Anticonvulsant. Uses: Epilepsy, trigeminal neuralgia.

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Side effects: Nausea, vomiting, confusion, headache, dizziness, ache, increased body hair. PIROXICAM Type: NSAID. Uses: Rheumatoid arthritis, acute gout, osteoarthritis, acute musculoskeletal disorders. Side effects: Gastrointestinal upset. PREDNISOLONE Type: Corticosteroid. Uses: Adrenal insufficiency, adrenogenital, syndrome, arthritides, collagen disease, asthma, lung and eye disease, malignancies, intestinal and skin disease. Side effects: Peptic ulcer, indigestion, acne, osteoporosis, glaucoma, growth retardation, fetal abnormalities, muscular weakness, Cushing’s habitus, fragile skin, psychiatric disturbances. PROPRANOLOL Type: Na+ channel blocker. Uses: Sinus tachycardia, atrial and nodal ESs. Side effects: Dizziness, nausea, vomiting, fatigue, cold peripheries, bronchoconstriction, bradycardia, heart failure, hypotension, gastrointestinal upset, sleep disturbances.

PHARMACOLOGY

QUININE Type: Antimalarial. Uses: Malaria. Also used to prevent nocturnal leg cramps. Side effects: Tinnitus, headache, blurred vision, confusion, gastrointestinal upset, rashes, blood disorders. RAMIPRIL Type: ACE inhibitor. Uses: Hypertension, congestive heart failure, myocardial infarction. Side effects: Nausea, vomiting, dizziness, headache, cough, dry mouth, taste disturbance. RANITIDINE Type: H2 blocker. Uses: Duodenal ulcer, gastric ulcer, gastritis, Zollinger-Ellison syndrome, GERD. Side effects: Nausea, loose stool, muscle and joint pain, dizziness, abdominal pain. RIFAMPICIN Type: Antitubercular. Uses: Tuberculosis, leprosy, meningitis, osteomyelitis.

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Side effects: Nausea, vomiting, malaise, bone pain, purpura, breathlessness. SALBUTAMOL Type: 2-agonist. Uses: Asthma, chronic bronchitis, emphysema. Side effects: Weakness, tremors, drowsiness, nervousness, tension. Anxiety, restlessness. SALCATONIN Please refer Calcitonin. SENNA Type: Stimulant laxative. Uses/Side effects: Please refer Lactulose. STREPTOKINASE Type: Fibrinolytic agent. Uses: Pulmonary embolism, thrombosed arteriovenous shunts. Side effects: Excessive bleeding, hypotension, nausea, vomiting, allergic reactions. STREPTOMYCIN Type: Aminoglycoside antibiotics. Uses: Tuberculosis, plague, bacterial endocarditis, tularemia.

PHARMACOLOGY

Side effects: Vestibular disturbances, auditory loss paresthesia. SULFASALAZINE Type: Aminosalicylate. Uses: Ulcerative colitis, Crohn’s disease, rheumatoid arthritis. Side effects: Nausea, vomiting, loss of appetite, headache, joint pain, abdominal discomfort, anorexia. TETRACYCLINE Type: Alpha-adrenoceptor agonist. Uses: For reducing spasticity associated with multiple sclerosis or spinal card injury. Side effects: Lethargy, fatigue, dry mouth, gastrointestinal upset, hypotension. THEOPHYLLINE Type: Methylxanthine. Uses: Asthma, bronchitis, emphysema. Side effects: Nausea, vomiting, palpitations. TIMOLOL Type: Beta blocker. Uses: Hypertension, angina, prophylaxis of myocardial infarction. Side effects: Please refer Propranolol.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

TINIDAZOLE Please refer Metronidazole. TIZANIDINE Type: Opioid analgesic. Uses: For treating moderate to severe pain. Side effects: Nausea, vomiting, dry mouth, tiredness, drowsiness, dependence. TOLTERODINE Type: Antimuscarinic. Uses: Mainly used to treat urinary frequency, urgency and incontinence. Also used for reducing unstable contraction of the bladder. Side effects: Headache, gastrointestinal upset, dry eye, dryness of mouth. TRAMADOL Type: Opioid analgesic. Uses: For treating moderate to severe pain. Side effects: Nausea, vomiting, dry mouth, tiredness, drowsiness, dependence. TRAZODONE Type: Antidepressant.

PHARMACOLOGY

Uses: Depression, anxiety. Side effects: Drowsiness. TRIHEXYPHENIDYL/BENZHEXOL Type: Antimuscarinic. Uses: For reducing rigidity and tremor in young patients with Parkinsonism. Side effects: Blurring of vision, urine retention, constipation, dry skin, dryness of mouth. VANCOMYCIN Type: Glycopeptide antibiotic. Uses: MRSA infections, endocarditis, gastrointestinal infection. Side effects: Disorder of the blood, nephrotoxicity, ototoxicity. VECURONIUM Type: Muscles relaxants. Uses: During general anesthesia, convulsions, trauma, tetanus, status epilepticus. Side effects: Respiratory failure, muscle soreness, hypotension. VERAPAMIL Type: Calcium channel blocker.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

Uses: Hypertension, supraventricular dysrhythmias. Side effects: Nausea, vomiting, constipation, headache, ankle swelling. WARFARIN Please refer Heparin. ZALCITABINE Type: Antiretroviral NRTI. Uses: For prevention of AIDS (commonly used in combination with other antiretroviral drugs). Side effects: Peripheral neuropathy, headache, insomnia, gastrointestinal upset, fatigue, liver damage, oral and esophageal ulcer, blood disorder, rashes, breathlessness, pancreatitis. ZIDOVUDINE Type: Antiretroviral NRTI. Uses: Mainly used to prevent maternal-fetal HIV transmission. Side effects: Peripheral neuropathy, headache, insomnia, gastrointestinal upset, fatigue, liver damage, oral and esophageal ulcer, blood disorder, rashes, breathlessness, pancreatitis, itching, chest pain, taste disturbance, anemia, increase frequency of urine, influenza like symptoms.

PHARMACOLOGY

LIST OF PHARMACOLOGY ABBREVIATIONS Abbreviation ac ad lib bd cap IM IV LA liq OC od om on opv ORS ORT pc prn qid qqh si sos stat susp syr tab tds

Meaning Before bed As desired Twice daily Capsule Intramuscular Intravenous Local anesthetic Liquid Oral contraceptive Once daily In the morning At night Oral poliomyelitis vaccine Oral rehydration salt Oral rehydration therapy After food When required Four times a day Every four hours Sublingual As required Immediately Suspension Syrup Tablet Three times a day.

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ELECTROTHERAPY

2

CHAPTER Electrotherapy •

Principles of electrotherapy application

•

Interferential

•

Short wave diathermy

•

Ultraviolet radiations

•

Laser therapy

•

Ultrasound

•

Transcutaneous electrical nerve stimulation (TENS)

•

Iontophoresis

•

Infrared radiation

•

Paraffin wax bath

•

Neuromuscular electrical stimulation (NMES)

•

Microwave diathermy

•

Cryotherapy (Cold therapy)

•

Hot packs/Electric heating pads

•

Whirlpool bath

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

36 CHAPTER

2

•

Contrast bath

•

Sauna bath

•

Electromyographic biofeedback

•

Fluidotherapy

•

Intermittent pneumatic compression

•

Continuous passive motion

•

Traction

•

Strength duration curve

•

Motor points

ELECTROTHERAPY

PRINCIPLES OF ELECTROTHERAPY APPLICATION RECEIVING THE PATIENT

• • • •

Good morning sir/madam. Please be seated (Please take your seat). I am your therapist who is going to treat you. Do not worry; I will do my best for you.

CASESHEET READING

• Laboratory investigation reports. • Assessment and diagnosis done by the physician. CHECKING GENERAL CONTRAINDICATIONS

• • • • • • • • • • • •

Hyperpyrexia Epilepsy Severe renal and cardiac problems Cardiac pacemakers Severe hypotension and hypertension Infections Pregnant women Metal implants Mentally retarded patients Mentally upset patients Malignancy Eyes.

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38 CHAPTER

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THE POCKETBOOK FOR PHYSIOTHERAPISTS ANTERIOR ASPECT OF NECK AND CAROTID SINUS Tray Preparation

Patient Tray or Skin Resistance Lowering Tray and Skin Sensation Testing Tray • Pillow • Cotton • Soap • Towel • Macintosh • Kidney tray • Petroleum jelly or vaseline • Test tubes (hot and cold) • U-pin (sharp and blunt) • Clips • Bowel of water • IR lamp • Hot and cold packs. Treatment Tray • Pillow • Towel • Bedsheet • Cotton • Adhesive tapes • Straps • Salt • Powder • Scissor • Inch tape

ELECTROTHERAPY

• • • • • • • • •

Paper Graph paper Pencil Eraser Scale Goggles Machine and accessories Sand bags Crepe bandages.

Checking Local Contraindications • Open wounds • Scars • Local skin infections • Cuts • Abrasions • Eczema • Localized hemorrhagic spots • Skin sensitivity (testing). Apparatus Preparation • The apparatus and accessories needed should be assembled and suitably positioned. • Visually check the electrodes, leads, cables, plugs, power outlets, switches, controls, dials, and indicator lights for cracks and breaks. Apparatus Checking • Check the apparatus in front of the patient. • Demonstrate the treatment to the patient. • Give an explanation of the treatment to the patient.

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• Explained about the type of sensation, which will be experienced by the patient. POSITIONING THE PATIENT

• The position of the part to be treated should be completely relaxed. • Patient should be made comfortable by using maximum number of pillows and sand bags for the support. • Position of the patient should be such that all the joints of the body are completely relaxed. • If possible give the position in which patient can see the treatment. • Uncover the part to be treated. • Use pillows, macintosh, and towel for supporting and whipping off the water. • Make use of soap and possible hot water as it will make the skin surface warm. PLACEMENT OF ELECTRODES

• Place electrodes properly. • Use adhesive tapes or straps for placing the electrodes. • Apply electrode gel evenly on entire electrode. • Maintain good contact between the skin and the electrode. • Tie the electrodes with even pressure. • Wires or leads should not cross each other during the treatment. Again check all the connections.

ELECTROTHERAPY INSTRUCTIONS AND WARNINGS Instructions

• Do not move during the treatment. • Do not sleep while the treatment is going on. • Do not touch the cables, apparatus, therapist, and any other metal nearby you. Warnings

• As there are chances of getting a blister due to excessive current or overheating, so please inform me if the current is not comfortable or heating is more. • If there is any burning sensation, immediately inform me, as it might lead to burn. • Inform me, if the position is not comfortable. TREATMENT

• Explain the examiner about my operations. • Increase the intensity knob till it is comfortable for the patient. • Duration of the treatment is decided on the basis of the condition. • The patient must be observed throughout to ensure that treatment is progressing satisfactorily and without adverse effects. TERMINATION OF TREATMENT

• Switch off the machine and the main supply.

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42 CHAPTER

2

• Inspect the treated part for any adverse reactions. • If there is any mild erythema, apply powder. • If it is too severe, advise him/her to go to the physician. • An accurate record of all parameters of treatment including region treated, technique, dosage, and the resultant effect must be made. INTERFERENTIAL INDICATIONS

• • • • • • • • • • • • •

Arthritis Neuritis Neuralgia Muscle sprain Muscle weakness Sports injury Circulatory disorders Rheumatism Stress incontinence Contractures Gynecological conditions Migraine Asthma

CONTRAINDICATIONS

• Cardiac diseases • Hemorrhage

ELECTROTHERAPY

• • • • •

Pregnant uterus Artificial pacemakers During menstruation over the abdomen only Dermatological conditions Febrile conditions.

SKIN SENSATION TEST

Pin-prick test. PRESCRIPTION WRITING

• Electrode type—Small/medium/large • Site of application • Type of current—Dipole/isoplaner vector filed • Frequency • Base frequency • Spectrum • Spectrum mode—Rectangular/triangular/ trapezoidal • Treatment time • Intensity • Sessions • Specific precautions • Remarks. SHORT WAVE DIATHERMY INDICATIONS

• Gynecology—Pelvic endometriosis

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44 CHAPTER

2

• Traumatology—Sprains, muscular pain • Rheumatology—Neuralgia, inflammatory pain, arthritis • Respiratory—Asthma, emphysema • Neurology—Anti spasmodic action • Others—Reynaud’s diseases, visceral pain, automatic dystonia • Abscesses • Carbuncles. CONTRAINDICATIONS

• • • • • • • • • • •

Metal implants Pacemaker Deep X-ray therapy recently Circulatory deficiency Pregnancy and menstruation Local or general infection’s Diminished thermal sensation Deep vein thrombosis Severe swellings Acute traumatic or inflammatory lesions Malignancy.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Patient position • Site of application

ELECTROTHERAPY

• Electrode type—Pad/disc/wire coil • Electrode placement—Coplanar/controplanar/crossfire • Spacing—Medium/narrow • Dosage: Acute Subthermal Subacute Mild thermal Chronic Thermal • Duration: Acute 10-15 min Subacute 15-20 min Chronic 20-30 min • Session • Specific precautions • Supplementary therapy • Remarks. ULTRAVIOLET RADIATIONS INDICATIONS

• • • • • • • • •

Wounds Acne vulgaris Alopecia Pressure sores Rickets Counter irritation Psoriasis Vitiligo Psychological benefits.

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2

CONTRAINDICATIONS

• • • • • • • •

Deep X-ray or cobalt therapy Recent skin grafting Hypersensitivity to sun rays Arteriosclerosis Cardiac, hepatic or renal failure Diabetes Hyperthyroidism Febrile disorders.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• • • •

• • • • •

Patients position Spectrum Distance Dosage Base Wall For infected ulcers Floor Focusing point Duration Session Specific precautions Remarks.

}

ELECTROTHERAPY

LASER THERAPY INDICATIONS

• Wounds • Tensile strength of scar tissues pain • Musculoskeletal conditions (tendonitis/ bursitis) • Fractures (for healing). CONTRAINDICATIONS

• • • • • •

Cardiac conditions Pregnancy Over the eye Hemorrhage Cancers Photosensitized patients.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• • • • • • • •

Patients position Therapist position Site of application Dosage Duration Session Specific precautions Remarks.

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2

ULTRASOUND INDICATIONS

• • • • • • • • • • • • • • •

Bursitis Capsulitis Tendinitis Epicondylitis Ankylosing spondylitis Scar tissue Hematoma Keloid tissue Joint stiffness Dupuytren’s contracture Plantar fasciitis Chronic indurate edema Myalgia Herpes-zoster Brachial neuritis, lumbago, sciatica intercostals neuritis (for reduction of pain), varicose ulcers and pressure sores • Plantar warts. CONTRAINDICATIONS

• • • • • •

Thrombophlebitis Hemorrhage Ischemic tissue Pregnant uterus Malignancy Anesthetic area

ELECTROTHERAPY

• All intratissue prosthetic and metallic substances • Recent grafts • Defective skin sensation • Deep X-ray therapy • Acute infection • Over cardiac area (in advanced cardiac diseases). SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Patients position • Mode • Method—Direct/water bag/under water bath • Site of application • Duration • Intensity • Pulsed ratio • Attenuation • Field • Coupling media: Water/oil/liquid paraffin/ aqua sonic gel • Size of head • frequency • Phonophoretic agent (if used) • Session

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50 CHAPTER

2

• Specific precautions • Remarks. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) INDICATIONS

• • • • • • • • •

Postsurgical pain Obstetric pain Phantom limb pain Sciatic pain Periarthritic pain Reflex sympathetic dystrophy Low backache Pain due to scoot tissue Cervical spondylosis (with neurological involvement).

CONTRAINDICATIONS

• • • • • •

Cardiac pacemakers First trimester of pregnancy Hemorrhagic conditions Open wounds Over carotid sinus, mouth and near eyes Epilepsy.

SKIN SENSATION TEST

Pin-prick test.

ELECTROTHERAPY PRESCRIPTION WRITING

• • • • • • • • •

Type—High/low Frequency Pulse width Intensity Site of application Duration Session Specific precautions Remarks.

IONTOPHORESIS INDICATIONS

• • • • • • • • • •

Inflammation Calcific tendonitis Myositis ossification Soft tissue adhesions Soft tissue pain and inflammation Muscle and joint pain Edema Skeletal muscle spasm Skin ulcers Hyperhidrosis.

CONTRAINDICATIONS

• Cardiac pacemakers • Uncontrolled hypertension • Pregnancy

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52 CHAPTER

2

• • • •

Osteoporosis Epilepsy Cancer Over the pharyngeal area.

SKIN SENSATION TEST

Pin-prick test. PRESCRIPTION WRITING

• • • • • • • • • •

Patients position Drug/solutions Type of electrode—Small/medium/large Electrode placement Site of application Intensity Duration Session Specific precautions Remarks.

INFRARED RADIATION INDICATIONS

• • • • •

Pain relief Muscle relaxation Edema Elimination of waste products Superficial wounds.

ELECTROTHERAPY CONTRAINDICATIONS

• • • • • • • •

Vascular insufficiency Arterial diseases Hemorrhage Anesthetic area Pregnancy and during menstruation Skin diseases, e.g. psoriasis, eczema Thermal hypothesia Deep X-rays therapy.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• • • • • • • • • • •

Patients position Apparatus type—Luminous/Nonluminous Generator type—Lamp/tunnel bath Distance Focus point Wave-length Frequency Duration Session Specific precautions Remarks.

PARAFFIN WAX BATH INDICATIONS

• Joint stiffness

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

54 CHAPTER

2

• • • •

Osteoarthritis Adhesions Scars Rheumatoid arthritis.

CONTRAINDICATIONS

• • • • • • • •

Skin rashes Allergic conditions Open wounds Diminished skin sensation Defective arterial supply Open suture After taking analgesic drugs After application of liniments.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Patients position • Temperature • Method—Pouring/brushing/dipping/ bandaging • Site of application • Duration • Session • Specific precautions • Remarks.

ELECTROTHERAPY

NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) INDICATIONS

• • • • • • • • •

Foot drop Bell’s palsy Paraplegia Hemiplegia Quadriplegia Radial nerve injury (wrist drop) Median nerve injury (claw hand) Erb’s paralysis Deltoid and quadriceps inhibition.

CONTRAINDICATIONS

• • • • • • • • • • • •

Sensory deficit Hypertension Open wounds Pacemakers Malignant tissue Epilepsy Hyperpyrexia Active tissue infections Deep X-rays therapy Peripheral vascular disease Over the excessive adipose tissue Mentally retarded.

SKIN SENSATION TEST

Pin-prick test

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56 CHAPTER

2

PRESCRIPTION WRITING

• • • • • • • • • •

Patients position Instruction for patients Site of application Current type—Faradic/galvanic/others Pulse Frequency Duration Session Specific precautions Remarks.

MICROWAVE DIATHERMY INDICATIONS

• • • • •

Pain relief Trapezius spasm Arthritic conditions Abscesses Carbuncles.

CONTRAINDICATIONS

• • • • • • •

Malignancy Tuberculosis Deep X-ray therapy Non-palpable edema Hypersensitive areas Anesthetic areas Psychic patients

ELECTROTHERAPY

• Paralytic patients • Recent injury. SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Patients position • Type of applicator—Small/large circular/ rectangular • Site of application • Distance • Frequency • Intensity • Duration • Session • Specific precautions • Remarks. CRYOTHERAPY (COLD THERAPY) INDICATIONS

• • • • •

Spasticity Swelling Pain Ligament sprain Muscle strain.

CONTRAINDICATIONS

• Cryoglobinemia

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58 CHAPTER

2

• • • • • •

Peripheral nerve injury Cardiac diseases Vascular diseases Cold sensitivity Cold urticaria Psychic patients.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Patients position • Type of application—Ice massage/towels/ immersion/cold packs/evaporative cooling/ excitatory cold/cold gel/cold compression • Site of application • Duration • Session • Special precautions • Remarks. HOT PACKS (HYDROCOLLATOR PACKS)/ ELECTRIC HEATING PADS INDICATIONS

• Muscle spasm • Pain • Joint stiffness.

ELECTROTHERAPY CONTRAINDICATIONS

• • • • •

Impaired skin sensation Open wounds Allergic conditions Hemorrhage Impaired circulation.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• • • • • • • •

Patients position Layers of towel Types of packs—Small/large/contoured Site of application Duration Session Specific precautions Remarks.

WHIRLPOOL BATH INDICATIONS

• • • •

Rheumatic conditions Stiffness Joint pain Fatigue.

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60 CHAPTER

2

CONTRAINDICATIONS

• • • •

Skin allergy Skin infections Open wounds Hemorrhage.

SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• • • • • •

Patients position Temperature Duration Session Specific precautions Remarks.

CONTRAST BATH INDICATIONS

• • • • •

Edema Circulatory disorders Tight amputation stump Post-traumatic swelling Joint sprains.

CONTRAINDICATIONS

• Skin infections • Open wounds

ELECTROTHERAPY

• Hemorrhage • Skin allergy • Diabetes. SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Temperature: – Warm – Cold • Timing in: – Warm – Cold • Repetition • Session • Specific precautions • Remarks. SAUNA BATH INDICATIONS

• • • •

Weight reduction Pain Relaxation Psoriasis.

CONTRAINDICATIONS

• Psychic conditions

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2

• Loss of skin sensations • Dehydration. SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• Temperature of hot chamber • Expanded time in: – Sweating phase – Cooling phase • Pause between two phases • Duration (total) • Session • Specific precautions • Remarks. ELECTROMYOGRAPHIC BIOFEEDBACK INDICATIONS

• • • • • • • • •

Spinal card injury Hemiplegia Spasticity Dystonic conditions Recovering peripheral nerve injury Specific muscle activity training Balance control Weight-bearing control Incontinence control

ELECTROTHERAPY

• • • • • • • • • •

Joint angle control Practice of movement Control of posture Functional breathing disorder Hypertension Epilepsy Migraine Cardiac arrhythmias Raynaud’s disease Tension headache.

CONTRAINDICATION

Psychic conditions SKIN SENSATION TEST

• Hot and cold • Pin-prick test. PRESCRIPTION WRITING

• Patient position • Type of biofeedback devices—Myoelectrical/ postural/goniometric/force/pressure/orofacial control/toilet training/cardiovascular/ stress/temperature • Treatment duration • Type of electrode—Surface/needle • Session • Specific precautions • Remarks.

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2

FLUIDOTHERAPY INDICATIONS

• • • • •

Swelling Pain Relaxation Stiffness Muscle spasm.

CONTRAINDICATIONS

• Psychic conditions • Loss of skin sensations • Dehydration. SKIN SENSATION TEST

Hot and cold. PRESCRIPTION WRITING

• • • • • • • •

Patient position Area of treatment Temperature Exercise guidelines inside the unit Specific precautions Duration Session Remarks.

ELECTROTHERAPY

INTERMITTENT PNEUMATIC COMPRESSION INDICATIONS

• • • • • • •

Edema Lymphedema Arterial insufficiency Wound healing DVT Stump reduction in amputee limbs Venous stasis ulcer.

CONTRAINDICATIONS

• • • • •

Acute pulmonary edema Congestive heart failure Recent DVT Acute fracture Acute skin allergy.

SKIN SENSATION TEST

Pin-prick test. PRESCRIPTION WRITING

• • • • • • •

Patient position Area of treatment Pressure Inflation time Deflation time Duration Session

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

• Specific precautions • Remarks. CONTINUOUS PASSIVE MOTION INDICATIONS

• Decreased joint ROM after any surgical procedure • Joint stiffness • Decreased joint ROM after fracture management. CONTRAINDICATIONS

• Large wound • Excess pain PRESCRIPTION WRITING

• Patient position • Area of treatment—Knee/shoulder/elbow/ ankle • Movement and range Shoulder: Abduction/adduction with synchronized rotation Abduction/adduction with fixed rotation Rotation with fixed abduction/adduction Flexion/extension Elbow: Extension/flexion

ELECTROTHERAPY

• • • •

Extension/flexion with synchronized pronation-supination Knee: Flexion/extension Ankle: Dorsiflexion/planter flexion Duration Session Specific precautions Remarks.

TRACTION INDICATIONS

• Radiculopathy • Tight soft tissues not muscle spasm. CONTRAINDICATIONS

• Fracture, dislocation or subluxation of the spine • Cancer, RA, OA, osteoporosis or infection of the spine • Hiatal or abdominal hernia • Spinal cord compression • Hypertension • Aortic aneurysm • Pregnancy • Temporomandibular joint pain or dysfunction • Chronic obstructive pulmonary disease (COPD).

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68 CHAPTER

2

THE POCKETBOOK FOR PHYSIOTHERAPISTS PRESCRIPTION WRITING

• Position of the patient • Position of the spine—Neutral/flexion/ extension • Method—Mechanical/manual/positional/ gravity/inversion • Type—Static/intermittent • Magnitude of force • Total treatment duration • Duration of Hold – Rest (if Intermittent) • Specific precautions • Remarks. STRENGTH DURATION CURVE (FIGS 2.1 TO 2.5)

Fig. 2.1: Normally innervated muscle: In constant current

ELECTROTHERAPY

69 CHAPTER

2

Fig. 2.2: Normally innervated muscle: In constant voltage

Fig. 2.3: Complete denervated muscle: In constant voltage

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

CHAPTER

2

Fig. 2.4: Complete denervated muscle: In constant current

Fig. 2.5: Partially denervated muscle

ELECTROTHERAPY

MOTOR POINTS (FIGS 2.6 TO 2.11)

Fig. 2.6: Motor points of the muscles supplied by the facial nerve

Fig. 2.7: Motor points of the back

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

CHAPTER

2

Fig. 2.8: Motor points of the posterior aspect of the right arm

ELECTROTHERAPY

73 CHAPTER

2

Fig. 2.9: Motor points of the anterior aspect of the right arm

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CHAPTER

2

Fig. 2.10: Motor points of the anterior aspect of the right leg

ELECTROTHERAPY

75 CHAPTER

2

Fig. 2.11: Motor points of the posterior aspect of right leg

CARDIORESPIRATORY

3

77 CHAPTER

3 CHAPTER Cardiorespiratory •

Cardiorespiratory anatomy illustrations

•

Surface marking of the lungs

•

Respiratory volumes and capacities

•

Differences between central and peripheral cyanosis

•

Sputum analysis

•

Readings of chest X-ray

•

Abnormal ECG findings

•

Percussion note

•

Auscultation

•

Palpation of pulses

•

Apgar scoring method

•

Postural drainage

•

Manual chest clearance technique

THE POCKETBOOK FOR PHYSIOTHERAPISTS

78 CHAPTER

3

•

Suctioning

•

Forced expiratory techniques

•

Tracheostomies

•

Aerosol therapy

•

Humidity

•

Lung function test

•

Ambulatory manual breathing unit (AMBU) bag

•

Manual hyperinflation

•

Cardiorespiratory monitoring

•

Ventilations

•

Respiratory pathologies

•

Normal values

•

Blood values and their interfering factors

•

Respiratory assessment

•

Glossary of cardiorespiratory terms

CARDIORESPIRATORY

CARDIORESPIRATORY ANATOMY ILLUSTRATIONS

Fig. 3.1: Surface marking of the fissures and lobes of the right lung

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CHAPTER

3

Fig. 3.2: Lung markings—anterior view

Fig. 3.3: Lung markings—posterior view

CARDIORESPIRATORY

81 CHAPTER

3

Fig. 3.4: Bronchial tree

Fig. 3.5: Bronchopulmonary segments (lateral aspect)

THE POCKETBOOK FOR PHYSIOTHERAPISTS

82 CHAPTER

3

SURFACE MARKING OF THE LUNGS APEX

• Anteriorly 2.5 cm above the medial 1/3rd of clavicle. • Posteriorly 2 cm lateral to C7 spinous process. ANTERIOR BORDER OF RIGHT LUNG

• Sternoclavicular joint • Midline in the sternal angle • Above the xyphoid process in the midline. INFERIOR BORDER OF RIGHT LUNG

• • • •

6th rib in the midclavicular line 8th rib in the midaxillary line 10th rib laterally to errecter spinae muscle 2 cm lateral to spinous process of T10.

POSTERIOR BORDER OF RIGHT LUNG

• 2 cm lateral to T10 spinous process • 2 cm lateral to C7 spinous process ANTERIOR BORDER OF LEFT LUNGS

• • • •

Sternoclavicular joint Mid point in the sternal angle 3 cm from sternal margin in the 4th rib 4 cm lateral to midline in the 6th rib.

CARDIORESPIRATORY INFERIOR AND POSTERIOR BORDER OF LEFT LUNG

Same as the right lung FISSURES Oblique

• 7.5 cm lateral to midline in 6th rib • Midaxillary line in 5th rib • T3 spinous process. Horizontal

• Costal cartilage 4th rib • 5th rib, midaxillary line • T3 spinous process posteriorly. TRACHEAL BIFURCATION

• Anterior—Manubriosternal junction • Posterior—T4 vertebra. DIAPHRAGM Left

• 6th rib anteriorly • T10 posteriorly • 8th rib midaxillary.

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84 CHAPTER

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Right

• 5th rib anteriorly • T9 posteriorly • 8th rib midaxillary. RESPIRATORY VOLUMES AND CAPACITIES (FIG. 3.6) LUNG VOLUMES Tidal Volume (TV)

Volume of the air moved into or out of the lungs during quiet breathing at rest. Value—500 ml (0.5 liter). Inspiratory Reserve Volume (IRV)

Maximum amount of air that can be inspired on top of a normal tidal inspiration. Value—3300 ml (3.3 liter). Expiratory Reserve Volume (ERV)

Maximum amount of air that can be exhaled following a normal tidal expiration. Value—1000 ml (1 liter)

CARDIORESPIRATORY Residual Volume (RV)

Volume of air remaining in the lungs after a maximum expiration. Value—1200 ml (1.2 liter) Minimal Volume (MV)

The amount of air that would remain when the lungs collapsed. Value—30-120 ml.

Fig. 3.6: Lung volumes and capacities LUNG CAPACITIES

It is the combination of two or more lung volumes.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Total Lung Capacity (TLC)

Total volume of air in the lungs after a maximal inspiration. TLC = VT + IRV + ERV + RV Value—6000 ml Vital Capacity (VC)

Maximum volume of air that can be expired after a maximum inspiration. VC = VT + IRV + ERV Value—4500 ml Inspiratory Capacity (IC)

Maximum volume of air that can be inspired from the end point of quiet expiration at rest. IC = VT + IRV Value—3500 ml Functional Residual Capacity (FRC)

Volume of the air remaining in the lungs at the end of quiet expiration at rest. FRC = ERV + RV Value—2500 ml Note: The values for the average female adult are 25% less.

CARDIORESPIRATORY

DIFFERENCES BETWEEN CENTRAL AND PERIPHERAL CYANOSIS Mechanism Sites

Central Diminished arterial oxygen saturation

Peripheral Diminished flow of blood to the local part

On skin and On skin only mucous membranes, e.g. tongue, lips, cheeks, etc.

Clubbing and Usually associated polycythemia

Not associated

Temperature of the limb

Warm

Cold

Local heat

Cyanosis remains

Cyanosis abolished

Breathing pure oxygen

Cyanosis decreased

Cyanosis persists

SPUTUM ANALYSIS Characteristic

Associated features

Interpretation

Saliva

Clear, watery fluid

Normal

Mucoid

Clear and sticky

Bronchial asthma, Chronic bronchitis

Purulent

Thick viscous – Yellow – Dark green/brown – Rusty – Redcurrant jelly

Mucopurulent

Initially the sputum is mucoid and later slightly discolored

Haemophilus, Pseudomonas, Pneumococcus, Mycoplasma, Klebsiella Bronchiectasis, Cystic fibrosis, Lung abscess

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Associated features

Interpretation

Foul smelling and copious

Long standing lung diseases

Bronchiectasis

Hemoptysis

Old blood

Infection or chest trauma Cardiac disease

Black

Black specks in mucoid secretions

Smoke inhalation

Frothy

Pink or white

Pulmonary edema, Heart failure

Sputum examination is noted in the terms of: • Quantity • Viscosity • Color • Odor • Frequency • Time of day • Ease of expectoration. READINGS OF CHEST X-RAYS (FIGS 3.7A AND B) DEFINITION

The X-rays are a form of invisible electromagnetic radiation that can penetrate the body and produce an image on an X-ray film. INDICATIONS

• Any type of sign and symptoms, which are related to respiratory or cardiovascular diseases.

CARDIORESPIRATORY

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A

B

Figs 3.7A and B: (A) Normal PA chest X-ray, (B) Structures normally visible on X-rays

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• To identify the tumors. • Preoperative evaluation of patient’s for intrathoracic surgery. • Follow-up and monitoring of patient’s with life support devices. • To detect the trauma to the rib cage or lungs, see foreign bodies that may have been swallowed or inhaled. VIEW APPEARANCES

Air (In the lungs) - Black Fat, skin, muscles (Soft tissues) - Gray Bone - White DATABASE

Patient’s name, Patient’s identification number, given by radiologist, date, time, side markings L or R (L = Left, R = Right). CHECKLIST

• Skeletal frame, mainly rib’s, clavicle, scapulae, costochondral junctions, vertebral column • Lung field, fissures • Lungs hilli • Heart shadow • Mediastinum • Trachea and bronchial air shadow • Costophrenic and cardiophrenic angles • Domes of both the diaphragms and the space beneath them • Soft tissue shadows (especially breast shadows in women).

CARDIORESPIRATORY VIEWS Posteroanterior (PA)

It means that the X-rays have entered the chest from the posterior chest wall. The X-rays should be ideally viewed from a distance of three to four feet. Anteroposterior (AP)

Anteroposterior view is generally taken, when the clavicles are projected above the ribs and heart appear enlarged. AP views are taken with the patient erect but in ICU and casualty generally taken with supine position. Lateral

Lateral view helps to easily indentify smaller lesions. The main problem in this view is positioning the arms out of the X-rays field. Lateral Decubitus

Lateral decubitus view may help to identify the free fluid or air in the pleural cavity. Apicogram or Lardotic

It is useful to demonstrate the calcifications, nodules azygos lobe and middle lobe collapse. Expiratory Film

The view is taken during expiration. By the help of this view pulmonary hydatid cyst. Azygos vein and vascular lesions are easily demonstrated.

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The view is taken with Trendelenburg position. It is mainly help to demonstrate the movement of the fungal ball in cavity. Oblique

It is most often used to demonstrate the ribs, assess the heart and aorta. NORMAL CHARACTERISTICS OF A CHEST X-RAY—PA VIEW

• No skeletal abnormalities. • Posterior portions of the ribs should be horizontally and the anterior portions should be oblique. • Trachea lies centrally and vertically. • The left hilum should be at a higher level than the right. • The right dome of diaphragm is about 2 cm higher than the left, because the right lobe of liver is situated directly underneath. • The diameter of heart is usually less than half the total diameter of the thorax. • Both lung fields should be equally translucent and should not have any other shadows. Costophrenic angle: It is a angle where the diaphragms meets the ribs. Cardiophrenic angle: It is a angle where the diaphragm meets the heart.

CARDIORESPIRATORY

Silhouette sign: Border of the adjacent organ will be blurred, if there is any lesion contiguous with the organ. COMMON ABNORMALITIES IN X-RAYS

Lobar collapse—Homogeneous opacity Consolidation—Patchy opacity Pleural effusion—Dense opacity Pneumothorax—No lung marking is present Lung abscess—Rounded opacity Pulmonary tuberculosis—Soft confluent shadow calcification Bronchiectasis—Multiple ring shadows. ABNORMAL ECG FINDINGS Left atrial — Wide, notched P wave enlargement (lead II) Right atrial — Tall P wave (lead II) enlargement Ventricular — Wide QRS, ST hypertrophy depression Atrial tachycardia — Abnormally shaped P waves Atrial flutter — P wave replaced by saw-tooth baseline Atrial fibrillation — No P waves visible Sinoatrial block — P wave fails Atrioventricular — Prolongation of PR block interval

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Bundle branch block — QRS interval abnormal, ST segment depressed, T wave inverted Myocardial infarction — ST segment elevated, (MI) T wave inverted Mitral valve disease — Bifid, broad P waves Myocardial ischemia — ST segment depressed (Posterior MI) Hyperkalemia, — Tall T waves acute MI Hypokalemia, — Small T waves hypothyroidism, pericardial effusion Pericardial effusion — Small QRS complex Wolf-ParkinsonWhite (WPW) — Short PR intervals, less syndrome than 0.12 sec. PERCUSSION NOTE Evaluation technique designed to assess the lung density, specifically the air to solid ratio in the lungs. TECHNIQUE

The middle finger of the left hand (pleximeter finger) is placed in close contact with the chest wall in the intercostals space, a firm sharp tap is then made by the middle finger of the right hand (plexor finger), kept at right angle to the

CARDIORESPIRATORY

pleximeter finger. All areas of the chest are percussed (front, back, and both axillae). The pitch of the note is determined by whether the lungs contain air, solid or fluid and will either sound normal or abnormal. Abnormalities

Conditions

Impaired note

Decreasing amount of air in alveoli (consolidation, collapse, fibrosis)

Dull note

Consolidated lung area or area of collapse

Strong dull note

Pleural effusion

Tympanic note

Pneumothorax, emphysema

Skodaic resonance Empty cavity and pleural effusion (boxy note) Hyper-resonance

Pneumothorax, large cavity bullae formation, chronic bronchitis, congenital lung cyst

BELL TYMPANY

Metallic type of sound heard in case of massive pneumothorax. Coin is placed on one side of chest and percussed with another coin. Bell-like sound is heard on opposite side of chest through a stethoscope or ear. AUSCULTATION Stethoscope is used to determine the quality, character and intensity of breath sounds, vocal resonance and adventitious sound (Fig. 3.8).

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Fig. 3.8: Stethoscope position BREATH SOUNDS

More prominent at the top of the lungs and centrally, with the volume decreasing towards the bases and periphery. The stethoscope diaphragm is placed near the root of the neck. Two lungs sounds are heard: 1. On inspiration: A window through stress sound heard. 2. On expiration: Low pitched sound. There is no pause between the two and they are rustling in quality. It is also called as vesicular breath sound.

CARDIORESPIRATORY

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Fig. 3.9: Location of normal breath sounds ABNORMAL BREATH SOUNDS (FIG. 3.9) Causes

1. Abnormal generation—Abnormality in larger airways. 2. Abnormal transmission—Abnormality at the level of alveoli. There are two types of abnormal breath sounds: 1. Tracheal breath sound heard over lung tissue areas (also called as bronchial breathing). Sound is heard in patients with cavity, consolidation, pleural effusion, partial collapse of lungs and open pneumothorax.

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2. Absence of lung tissue sounds, occurs when transmission of sounds is impeded (e.g. in pneumothorax, lung tissue collapse, pleural effusion, asthma). VOCAL RESONANCE

These are the sound heard through the stethoscope, when the patients is asked to say “99” or “aah.” Normal

The sound can be clearly heard, over the trachea and are muffled and softer over lung tissue. Abnormal

Bronchophony—”99" can be clearly heard over lung tissue. Whispering pectoriloquy: The whispered “99” can be heard over lung tissue. Both of these are due to consolidation. ADVENTITIOUS SOUNDS Rhonchi or Wheezes

These sound are either high or low pitched and monophonic (single notes) or polyphonic (where several airways may be obstructed). These sound indicate obstruction or narrowing airways. These sounds is usually indicative of

CARDIORESPIRATORY

bronchial asthma, chronic bronchitis, lung tumors, COPDs, cardiac failure, etc. Crepitation or Crackles

Heard when airways that have been narrowed or closed, are suddenly forced open on inspiration. This sound can help to determine the site of abnormally as follows: 1. Start of inspiration—Large airways 2. Mid inspiration—Medium smaller airways 3. End of inspiration—Small airways and lung tissue. Crackles are indicative of bronchitis. Left heart failure, pneumonia, lung abscess, bronchiectasis, pulmonary edema, pulmonary fibrosis and other obstructive respiratory diseases. Pleural Rub

It is due to roughening of the pleural surfaces as in pleurisy. Pleural surfaces rub together and creating a cracking or grating sound. Stridor

Loud sound, heard during inspiration due to obstruction of the respiratory track. It indicates a serious condition. Laryngeal stridor is a high pitched sound heard over the larynx due to laryngeal obstruction, with foreign body, diphtheria, etc. whereas tracheal stridor is a low pitched sound heard over the trachea due to trached obstruction.

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PALPATION OF PULSES Pulse is palpated under following headings: Rate Rhythm Volume Force Tension (pulsus mollis/pulsus durus) Contour (rise/summit/fall) Equality Condition of arterial wall (hard/muscular/ tube like) Any abnormal character. COMMON LOCATIONS

Radial: Slightly medical to the styloid process. Brachial: Cubital fossa. Carotid: Upper end of the thyroid cartilage along the medial border of the sternomastoid muscles. Femoral: Groin region. Popliteal: Popliteal fossa. Posterior tibial: Groove between the medial malleolus and tendo Achilles. Dorsalis pedis: Lateral to the extensor hallucis tendon. Axillary: Groove behind coracobrachialis.

CARDIORESPIRATORY

101

Anterior tibial: Between tibialis anterior and extensor hallucis longus tendon, above the level of ankle joint. Temporal: Temple directly in front of ear. Ulnar: Little finger side of wrist. APGAR SCORING METHOD Sign

0

1

2

Heart rate

Absent

Below100

Over 100

Respiratory effort

Absent

Weak cry

Strong cry

Muscle tone

Limp

Flexion of extremities

Active movements

Reflex irritability

No response

Grimace

Cry

Color

Blue

Pink

Completely pink

SCORE

Under seven—Resuscitation require. Seven or over—Normal Between five and seven—Clearing airway and O2 therapy require. POSTURAL DRAINAGE Positioning the patient to allow gravity to assist the drainage of the secretions from specific areas of lungs (Figs 3.10 to 3.20).

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Fig. 3.10: Apical segments of both upper lobes—sitting upright

Fig. 3.11: Posterior segment of right upper lobe— left side lying, towards 45° turned prone

Fig. 3.12: Posterior segment of the left upper lobe— right side lying turned 45° towards prone, shoulder raised 30 cm

CARDIORESPIRATORY

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Fig. 3.13: Anterior segments of both upper lobes— supine position

Fig. 3.14: Lateral and medial segments of middle lobe—supine, quarter turned to left. Foot end of bed raised 35 cm

Fig. 3.15: Superior and inferior segments of the lingual lobe—supine, quarter turned to right. Foot end of bed raised 35 cm

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Fig. 3.16: Apical segments of both lower lobes— prone, head turned to side

Fig. 3.17: Anterior basal segments of both lower lobes—supine, foot end of bed raised 46 cm

Fig. 3.18: Posterior segments of both lower lobes— prone, head turned to side, foot end of bed raised 46 cm

CARDIORESPIRATORY

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Fig. 3.19: Lateral basal segment of the left lower lobe and the medial basal segment of the right lower lobe— right side lying, foot end of bed raised 46 cm

Fig. 3.20: Lateral basal segment of the right lower lobe—left side lying, foot end of bed raised 46 cm ALTERNATIVE METHOD OF POSTURAL DRAINAGE (FIGS 3.21 TO 3.23)

Fig. 3.21: Postural drainage over towels

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Fig. 3.22: Postural drainage over chair

Fig. 3.23: Postural drainage over foam wedge CONTRAINDICATIONS

• Head injuries including cerebral vascular accidents • Hypertension • Hemoptysis • Aortic aneurysms

CARDIORESPIRATORY

• • • • • • • • •

Pulmonary edema Surgical emphysemas Tension pneumothorax Eye operations Facial burns Filling cycle of peritoneal dialysis Hiatus hernia Cardiac arrhythmias Pregnancy.

Note: In recent neurosurgery, head down positioning may cause increased intracranial pressure; if PD is required modified positions can be used. MANUAL CHEST CLEARANCE TECHNIQUE Percussion, vibration and shaking along with postural drainage are called manual chest clearance technique. AIM

• To mechanically loosen the secretions • To improve the distribution of ventilations • To assist the movement of secretions in larger airways. PERCUSSION RATE

• 100-460 times/min manually • Force: 58-65 N

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MODIFICATIONS OF TECHNIQUES FOR PEDIATRICS PATIENTS

In • • • •

spite of hand percussion, we may use: Bell of stethoscope Facemask for babies Small medicine cup (30 ml) Tenting finger.

PRECAUTIONS

• • • • • • • • • • • •

Rib fracture Burns Pain Surgical emphysema Flail chest Hemoptysis Pulmonary embolism Acute infections Metastatic conditions Unstable cardiovascular conditions Recent skin graft or flap Severe clotting disorder.

SUCTIONING The removal of bronchial secretions through a suction catheter is called suctioning. INDICATIONS

• Very sick spontaneously breathing patient • Patient unwilling to cough voluntarily

CARDIORESPIRATORY

• Patient who have no cough reflex • All intubated patients. CONTRAINDICATIONS

• • • •

Pulmonary edema Stridor CSF leakage Bronchospasm.

MODES OF ENTRY

• • • •

Nose (nasopharyngeal) Mouth (oropharyngeal) Via tracheostomy Via endotracheal tube.

PRECAUTIONS

• • • •

Lung transplant Pneumonectomy Recent esophagectomy Clotting disorders.

HAZARDS

• • • • • •

Infections Mucosal trauma Hypoxia Atelectasis Pneumothorax Bronchospasm

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• Raised ICP • Cardiac arrhythmias. FORCED EXPIRATORY TECHNIQUES It consists of one or two huffs from midlung volume to low lung volume followed by a period of relaxed diaphragmatic breathing. INDICATIONS

• Cystic fibrosis • Chronic lung diseases • After surgery (sometimes). TRACHEOSTOMIES It is an operation performed on the anterior wall of trachea to facilitate ventilation. Surgery is performed at the level of 2nd and 3rd or 3rd and 4th tracheal rings done under general anesthesia in which a horizontal incision is made in neck. FUNCTIONS

• Increase alveolar ventilation • Provide alternate pathway for breathing • Protection of the airway from oral and gastric secretions. INDICATIONS

• Respiratory obstruction • Respiratory insufficiency • Retained secretion.

CARDIORESPIRATORY CONTRAINDICATION

Anaplastic carcinoma thyroid. TYPES OF TRACHEOSTOMY

• Emergency—To save the life of patient • Permanent—When lesion of upper airway or esophagus. Types of Tube

1. Metal or plastic 2. Cuffed or uncuffed 3. Single or double lumen. Complications

• • • • • • • •

Tracheal irritation, necrosis, ulceration Hemorrhage Pneumothorax Secretions occluding tube Surgical emphysema Tracheoesophageal fistula Infection of tracheostomy site Stenosis of trachea.

Advice at Discharge

Tracheostomy done after laryngectomy is permanent. Patient should learn to use metal tracheostomy, cleaning the tubes, etc.

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AEROSOL THERAPY Actual particulate matter suspended in a gas is called as aerosol. It act as a liquifire and mobilizer of pulmonary secretions in the respiratory tract. Only 0.15 to 0.25 μ particle shows the greater deposition in the alveoli. The device that produces an aerosol is known as nebulizer. TYPES OF NEBULIZER Pneumatic Jet

Consist of a water reservoir and a capillary tube submerged into water. A high velocity gas flow is introduced into the system, which cause the water from the reservoir to advance upward through the tube. This creates fine mist of particles which are inturn move into the baffle. Aerosol particles hit the baffle and are broken down into smaller particle. It produces 3-5 μ size of particles. Ultrasonic

Electrical energy is converted by a piezo-electric transducer to mechanical or vibrational energy with an ultra-high frequency of 1.35 mega cycle per second. The nebulizer chamber receive vibrational energy and aerosol effect is created. The nebulus is then transmitted via the buffle to the patients 0.5 to 3 μ sizes of particles is generated.

CARDIORESPIRATORY PATIENT’S POSITION

Sitting or half lying. USES

It is mainly used in delivery of drugs specially bronchodilator. HAZARDS

Bronchospasm, shortness of breath because of swelling of secretions, cross contamination. HUMIDITY Adequate humidity is necessary for proper respiratory function. The device which deliver a maximum amount of water vapour to respiratory that is called humidifier. INDICATIONS

• • • • • • •

Ventilated Intubated Receiving supplemental oxygen Newborn babies Patient’s with severe chest injury COPD, asthma, pneumonia, atelectasis Thermal respiratory burns.

METHODS

• Systemic hydration—By oral or intravenous • Water bath

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• Nebulizers • Instillation/infusion • Heat and moisture exchangers/condensors. HAZARDS

• Bronchoconstriction • Infections. LUNG FUNCTION TEST USES

Understand clearly the type of functional disorder: • To measure progression or regression • To decide on feasibility of thoracic operation • To access the degree of respiratory failure. TESTS

a. Airways function test: All volumes and capacities are assessed by spirometry. b. Blood gas analysis: PaO2 and PaCO2 is assessed by blood gas analyzer. c. Blood acid/alkaline reaction Normal pH—7.4 pH— a low pH (< 7.4 )—acidosis a high pH (> 7.4 )—alkalosis. d. Exercise tolerance test: During these test minute ventilation and oxygen consumption are measured.

CARDIORESPIRATORY In Field

Test • 12 minutes, 6 minutes, 2 minutes, walk test • Endurance walking test • Step test • Shuttle test. In Laboratory

• Treadmill • Cycle ergometer. TEST PROTOCOLS

• • • • • • • • •

Bruce Modified bruce or Sheffield Cornell Balkeware ACIP and MACIP Naughton Ware Modified Sheffield Northwick park.

AMBULATORY MANUAL BREATHING UNIT (AMBU) BAG This is the apparatus used for mouth to mouth respiration, by the help of face mask, endotracheal tube or tracheostomy, the air is driven into the patient’s lung by squeezing the bag. When the pressure is released a self-restoring

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foam rubber insert causes the bag to inflate automatically. The chest recoil causes air to leave the lung by an expiratory valve protected by wire gauze. Bages without this filters are very dangerous since they allow bits of deteriorated rubber spong to enter the lungs. MANUAL HYPERINFLATION The technique of giving deep breaths manually to fully expand the lungs of loosen the secretions increasing the lung compliance of an anesthetic rebreathing bag is used for it. The maximum peak airway pressure is 40 cm H2O. CONTRAINDICATIONS

• • • • • • • • • •

Undrained pneumothorax Bullae Surgical emphysema Severe bronchospasm (if PAP > 40 cm H2O). Acute head injury Cardiovascular instability Recent pneumonectomy Recent lobectomy Hemoptysis Patient at risk of barotrauma.

ADVERSE EFFECTS

• Barotrauma • Cardiac arrhythmia

CARDIORESPIRATORY

• • • • •

Reduced oxygen saturation Reduced respiratory drive Raised intracranial pressure Bronchospasm Hemodynamic variations—Reduced or increased flow pressure.

CARDIORESPIRATORY MONITORING ARTERIAL BLOOD PRESSURE (ABP)

It is the lateral pressure exerted by the contained column of blood on the wall of arteries. ABP is expressed in different terms. Systolic pressure: Maximum pressure during systole of heart, i.e. 20 mm Hg. Range—110 to 140 mm Hg. Diastolic pressure: minimum pressure during diastole of heart, i.e. 80 mm Hg. Range—60 to 90 mm Hg Pulse pressure: Difference between systolic and diastolic pressure, i.e. 40 mm Hg. Mean arterial pressure: Diastolic blood pressure plus one-third pulse pressure: DBP + 1/3 PP, i.e. 93 mm Hg. CARDIAC OUTPUT

Amount of blood pumped from each ventricles. CO = Stroke volume × heart rate

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Normal value = 50 to 6 L/min Average = 5.5 L/min/ventricles. STROKE VOLUME

The amount of blood pumped out by each ventricle during each beat. Normal value = 70 ml (60 to 80 ml). MINUTE VOLUME

Amount of blood pumped by each ventricle in one minute. Normal value = 5-6 L/min. CARDIAC INDEX

This is the minute volume expressed in relation to square meter of body surface is called CI. CI = CO + body surface area. Normal value = 2.5-4 L/min/m2. HEART RATE

The number of time the heart contracts in a minute. Normal = 50-100 bpm Tachycardia > 100 bpm at rest Bradycardia < 50 bpm at rest. CENTRAL VENOUS PRESSURE

This is the pressure found in the veins emerging in heart. Normal value—3-6 mm Hg or 3-15 cm H2O

CARDIORESPIRATORY CEREBRAL PERFUSION PRESSURE (CPP)

Pressure required to ensure adequate blood supply to the brain. CPP = MAP-ICP Normal value > 70 mm Hg. INTRACRANIAL PRESSURE

Pressure exerted by the brain tissue, CSF of blood volume with in the skull of meninges. Normal value = 0-10 mm Hg PULMONARY ARTERY PRESSURE (PAP)

It is measure of pressures of the vena cava, right atrium and right ventricle. Normal value = 15-25/8-15 mm Hg. Mean value = 10-20 mm Hg. RESPIRATORY RATE

Number of breathes taken in a minute. Normal value = 12-16 breaths/min Tachypnea > 20 breaths/min Bradypnea < 10 breaths/min. EJECTION FRACTION

It is the ratio of stroke volume (i.e. blood ejected from left ventricle during systole) to the end diastolic volume (EDV). EF = SV/EDV Normal value = 65-75%.

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VENTILATIONS SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)

Mandatory breaths are delivered in synchrony with the patient’s breathing. The patient may breath on his own but the mandatory breaths will be delivered at a time in the ventilatory cycle, that is convenient for the patient. INTERMITTENT MANDATORY VENTILATION (IMV)

Breaths are delivered at a respiratory rate and tidal volume that are determined by adjusting the ventilator controls, but patient may breath spontaneously between the mandatory breaths. CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

Oxygen is delivered in a positive pressure throughout inspiration and expiration during spontaneous breathing. It decreases the work of breathing, O 2 consumption but increases the forced respiratory capacity and PaO2. POSITIVE END EXPIRATORY PRESSURE (PEEP)

PEEP is used when PaO2 is < 200 mm Hg. Generally PEEP is used in minimum 5 cm water in all mechanically ventilated patient’s. It prevents the alveolar collapse and increases the forced respiratory cycle.

CARDIORESPIRATORY INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB)

It is a mechanical device that augment gas flow. IPPB maintains positive airway pressure throughout inspiration with airway pressure returning to atmospheric pressure during expiration. Model—Bird mak7, Bennett Contraindications: Facial fracture, undrained pneumothorax, lung abscess, head injury, vomiting. CONTROLLED MECHANICAL VENTILATION (CMV)

At a preset tidal volume, pressure and flow rate, CMV delivers a preset number of breaths to the patient. BIPHASIC POSITIVE AIRWAY PRESSURE (BiPAP)

BiPAP is a single ventilation mode which permits spontaneous breathing not only during expiration but also during mandatory breaths. It reduces atelectasis, less sedation, higher inspiratory drive and maintained spontaneous breathing. BiPAP is most commonly used as a partial ventilatory support device, to reduce the workload of breathing in acute exacerbations of COPD. It can also be used as a step down measure leading up to weaning of mechanical ventilatory support.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS HIGH FREQUENCY VENTILATION (HFV)

It delivers low tidal volume or equal to anatomical dead space volume at high respiratory frequencies varing, between 60 and 300 breaths/minute. Types

a. High frequency positive pressure ventilation b. High frequency jet ventilation (HFJV) c. High frequency oscillation (HFO)

60-110 breaths/min. 110-600 breaths/ min. 600-3000 breaths/ min.

ASSIST—CONTROL MODE VENTILATION (A/C MODE)

In this, breathing is initiated by a patient during ventilatory cycle and ventilator delivers gas at a preset tidal volume or preset pressure. PRESSURE CONTROLLED VENTILATION (PCV)

During PCV, all breaths are pressure limited and time cycled. There is no possibility for patient triggering. PRESSURE SUPPORT (PS)

During PS tidal volume, respiratory rate and flow rate is controlled by patient himself through his inspiratory efforts.

CARDIORESPIRATORY NONINVASIVE VENTILATION (NIV)

NIV is the ventilatory support used without intubation through a mask. It is rarely used. Positive pressure devices are pressure, volume or time controlled. The modes which are used are pressure support ventilation, control/assist ventilation, controlled mechanical ventilation, BiPAP, CPAP and proportional assist ventilation. RESPIRATORY PATHOLOGIES ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

Progressive breathlessness and respiratory failure caused by a variety of acute diffuse lung injuries. Causes

Shock, burns, severe nonthoracic trauma, septicemia, aspiration, pneumonia, fat embolism, overdoses of drugs likely to damage pulmonary circulation. Clinical Features

Dyspnea, tachypnea, crackles and wheezes sound, shock, septicemia, renal failure, liver failure, CNS depression. ARDS tends to reach its maximum initial severity over next 24 to 48 hours and may be rapidly fatal if severe.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS ATELECTASIS OF LUNG

Loss of volume in one or more segments or lobes of the lungs. Causes

Bronchial obstruction, carcinoma of bronchus, aneurysm, enlarged glands. Clinical Features

Fever, tachycardia, tachypnea, ineffectual cough, weakness of respiratory muscle. BRONCHIAL ASTHMA

Increased responsiveness of trachea and bronchi to various stimuli and manifested by acute, recurrent or chronic attacks of widespread bronchial-bronchiolar narrowing. Types

Extrinsic and intrinsic asthma. Clinical Features

Cough, wheeze, chest tightness, dyspnea. These symptoms can range from mild-tosevere; and may even result in death. BRONCHIECTASIS

Chronic permanent dilatation of one or more bronchi, which impairs the drainage of bronchial

CARDIORESPIRATORY

secretions and leads to persistent infection in the affected segment or lobe. Causes

Congenital: Kartagener’s syndrome, cystic fibrosis, hypogammaglobulinemia with respiratory infection. Acquired • Infections: Measles, whooping cough and influenza, pneumonia, lung disease, tuberculosis, bronchopulmonary aspergillosis • Obstruction: Foreign body, bronchial stenosis, bronchial carcinoma. Types

Saccular: Affects proximal bronchi. Cylindrical: Affect distal bronchi. Varicose: Intermediate between saccular and cylindrical. Clinical Features

Productive cough, fever with chills, weakness, lassitude, anorexia, loss of weight, pleuritic pain and night sweats. BRONCHITIS Types

Acute bronchitis: Acute infection of mucous membrane of trachea and bronchi produced by viruses, bacteria or external irritants.

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Chronic bronchitis: Condition associated with mucous production amounting to cough and expectoration for more than three months in a year and for two to three years consecutively with other causes rules out. Clinical Features

Malaise, fever, palpitation, sweating, productive cough, wheezing, dyspnea. Because of irreversible narrowing of the airway, patient leads to develop dyspnea, cyanosis, hypoxia, hypercapnia and some times heart failure. This condition is called blue bloaters. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD is mainly associated with emphysema and chronic bronchitis. Risk factors: Smoking, recurrent infections, pollution, genetics. Clinical Features

Chest tightness, cough, dyspnea, excessive mucus production. CYSTIC FIBROSIS

A progressive genetic disorder of the mucus— secreting glands of the lungs. Pancreas, mouth, gastrointestinal tract and sweat glands.

CARDIORESPIRATORY Clinical Features

Recurrent respiratory infection, poor growth malnutrition, abnormal heart. Rhythms, dyspnea, malabsorption. Complications: Vasculitis, liver disease, diabetes mellitus, infertility. This is a fatal disease. EMPHYSEMA

Enlargement of the airspaces distal to the terminal bronchioles, either from dilatation or destruction of their walls. Clinical Features

Dyspnea, productive cough, wheeze, recurrent respiratory infection, weight loss, hyperinflated chest. These patients are often called as pink puffers who may hyperventilate typically by over-using their accessory respiratory muscles, and breath with pursed lips in order to maintain airway pressure to decrease the amount of airway collapse. EMPYEMA

An accumulation of pus in the pleural cavity following nearby lung infection.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Clinical Features

Chest pain (increasing or inspiration, coughing, sneezing, laughing, etc.) dyspnea, fever, anorexia, malaise, weight loss. HEMOTHORAX

An accumulation of blood in pleural cavity. It results from injury to internal mammary artery, intercostals artery and also found in patient’s with lung and pleural cancer or in those who have undergone thoracic or heart surgery. Clinical Features

Absent breath sounds on affected side, reduced chest expansion, dullness to percussion. If bleeding continue, features of shock develops. LUNG ABSCESS

Circumscribed suppurative inflammation of lung by pyogenic organisms leading to cavitation and necrosis. Clinical Features

Fever, pleuritic chest pain, cough, fetid breath, hemoptysis, clubbing of fingers, loss of weight, anorexia.

CARDIORESPIRATORY PLEURAL EFFUSION

Pleural effusion is a collection of serous fluid in the pleural space. Types

I. Acute pleural effusion: Trauma, pancreatitis, pulmonary infraction. II. Purulent effusion: Pyogenic infections, septicemia, penetrating wound of chest III. Hemorrhagic effusion: Tumor, tuberculosis, pulmonary infarction, bleeding. IV. Tuberculous pleural effusion. V. Milky effusion (chylous, opalescent). VI. Iatrogenic. VII. Recurrent. VIII. Bilateral. IX. Phantom. Clinical Features

Pleuritic pain, dyspnea, toxemia. PLEURISY: INFLAMMATION OF PLEURA Causes

Infection, infarction of lung, lung cancer injury to chest wall, rheumatoid arthritis. Clinical Features

Pain on respiration, unproductive cough, rapid shallow breathing, chilly sensations, fever.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS PNEUMONIA

Inflammation of lung parenchyma, involving respiratory bronchioles and alveolar unit distal to the conduction zone. Types

I. Anatomical a. Lobar b. Segmental c. Lobular. II. Clinical a. Primary b. Secondary (associated with any disease). III. Etiological a. Bacterial (E. coli, Klebsiella, Pseudomonas) b. Atypical (viral, mycoplasmal) c. Protozoal (E. histolytica) d. Fungal (actinomycosis, aspergillosis) e. Allergic f. Radiation g. Collagenosis h. Chemical. Clinical Features

Dry and painful cough, pleuritic pain, fever, fatigue, after few days purulent with blood in sputum.

CARDIORESPIRATORY PNEUMOTHORAX

Pneumothorax is air in the pleural cavity. Air may enter the pleural cavity through the chest wall, mediastinum or diaphragm or from a puncture of the visceral pleura covering the lung. Causes

I. Primary spontaneous: Idiopathic. II. Secondary spontaneous: Caused by ruptured emphysematous bullae or due to ulceration of active tuberculous lesion through the pleura or rupture of local emphysematous area from old tuberculous scarring. Frequently affected are tall, thin young men, especially smokers. III. Traumatic and iatrogenic: Stab wounds, fractured ribs, crush injury, lung biopsy, faulty tracheostomy, cardiothoracic surgery. IV. Artificial: Because of an antitubercular drugs. Types

Closed: The opening in the lungs is very small and rapidly heals. Thus allowing the lung to reexpand. Open: The opening remains patent and pressure in the pleural cavity is equal to that of the atmosphere.

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Tension: The opening is valvular –air enters the pleural space during inspiration but cannot escape during expiration so that a positive pressure occurs in the pleural cavity. Clinical Features

Increased respiration distress, hypotension, cyanosis, tachycardia, decreased movement of chest wall. PULMONARY EMBOLISM

Blockage of the pulmonary vasculature by blood clots, venous thrombi, fat, air, foreign bodies or fragment of malignant tumors. Clinical Features

Dyspnea, chest pain, hemoptysis Risk factors: Prolonged sitting, femur fracture, surgery. PULMONARY EDEMA

An increase in the fluid content of the extravascular tissues of the lung. Cause

Myocardial infarction, LV failure, mitral stenosis, shock, infections, fluid overload, etc.

CARDIORESPIRATORY Clinical Features

Wheezing, shortness of breath sweating tachycardia, short and copious frothy cough. PULMONARY TUBERCULOSIS

A chronic infectious disease caused by mycobacterium tuberculosis that is spread via the circulatory system or the lymph nodes. Sites: Lungs, lymph nodes, bones, gastrointestinal tract, kidney, skin, and meninges. Types

a. Miliary tuberculosis: The lungs are studded with firm white tubercles about 1 mm in diameter. b. Chronic fibrocaseous: Firstly cavities are formed at the apex. c. Acute tuberculous caseous pneumonia: Lesion ulcerate through bronchial walls. Clinical Features

Cough, hemoptysis, weight loss, fatigue, fever, night sweats. RESPIRATORY FAILURE

Condition when normal blood gas pressures cannot be maintained at rest.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Types

Hypoxemic respiratory failure: A decreased PaO2 with a normal or low PaCO2 Causes: Chronic bronchitis, emphysema, ARDS PaO2 < 8 kPa (60 mm Hg) Ventilatory failure: A decreased PaO2 with an increased PaCO2. Causes: Muscular dystrophy, lung disease, Guillain-Barré syndrome. PaO2 < 8 ka (60 mm Hg) PaCO2 > 6.7 kPa (50 mm Hg) Clinical Features

Central cynosis, loss of judgment, fatigue, dizziness, dimness of vision, headache. Arterial Blood Gas Classification of Respiratory Failure pH Acute

PaCO2

HCO3-

Decreased Increased

Normal

Chronic

Normal

Increased

Increased

Acute on chronic

Decreased Increased

Increased

CARDIORESPIRATORY SARCOIDOSIS

Granulomatous disease involving several organs. Common site: Mediastinal, lymph nodes, lungs, liver, spleen, skin, eyes. Clinical Features

Lymph node enlargement, fever, weight loss, dry cough, uveitis arrhythmias. SLEEP APNEA

There is recurrent collapse of upper airway due to which there is difficulty or obstruction in breathing for more than 10 sec leading to disturbed sleep. Clinical Features

Restlessness, reduced sleep, reduced muscle tone, enlarged tonsils or adenoids, abnormal use of accessory respiratory muscle. Complication

Pulmonary hypertension, respiratory or heart failure. It occurs due to loss of muscle tone of pharynx or abnormal central nervous system.

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NORMAL VALUES Age group Heart rate mean (range) (beats/min)

Respiratory rate range (breaths/ min)

Blood pressure systolic/ diastolic (mm Hg)

Preterm

150 (100-200)

40-60

39-59/16-36

Newborn

140 (80-200)

30-50

50-70/25-45

< 2 years

130 (100-190)

20-40

87-105/53-66

> 2 years

80 (60-140)

20-40

95-105/53-66

> 6 years

75 (60-90)

15-30

97-112/57-71

Adults

70 (50-100)

12-16

95-140/60-90

ARTERIAL BLOOD

pH PaO2 PaCO2 HCO3– Base excess

7.35-7.45 [H+] 45-35 nmol/L 10.7-13.3 kPa (80-100 mm Hg) 4.7-6.0 kPa (35-45 mm Hg) 22-26 mmol/L –2 to +2

VENOUS BLOOD

pH pO2 pCO2

7.31-7.41 [H+] 46-38 nmol/L 5.0-5.6 kPa (37-42 mm Hg) 5.6-6.7 kPa (42-50 mm Hg)

CARDIORESPIRATORY

137

VENTILATION/PERFUSION

Alveolar Breathing air Breathing oxygen

CHAPTER

: Arterial oxygen gradient A— PaO2 : 0.7-2.7 kPa (5-20 mm Hg) : 100% 3.3-8.6 kPa (25-65 mm Hg)

PRESSURES mm Hg

kPa

Right atrial (RA) pressure

Mean

–1 to +7

0.13 to 0.93

Right ventricular (RV) pressure

Systolic Diastolic

15-25 0-8

2.0-3.3 0-1.0

Pulmonary artery (PA) pressure

Systolic Diastolic mean

15-25 8-15 10-20

2.0-3.3 1.0-2.0 1.3-2.7

Pulmonary capillary wedge pressure (PCWP)

Mean

6-15

0.8-2.0

Central venous pressure

3-15 cm H2O

Intracranial pressure (ICP) Peak inspiratory mouth pressure (pi max)

Peak expiratory mouth pressure (pe max.)

upper limb)

Superior frontal gyrus

Urinary incontinence

Corpus callosum

Apraxia

Uncertain localization

Abulia, slowness, lack of spontaneity

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BASAL GANGLIA Nuclei

• Putamen • Caudate • Globus pallidus. Clinical Manifestations

• • • • • • • • •

Bradykinesia Rigidity Tremors Akinesia Chorea Athetosis Choreoathetosis Hemiballismus Dystonia.

MYOTOMES Root Action to be tested C1 Flexion of upper cervical C2 Extension of upper cervical C3 Side flexion of cervical C4 Elevation of shoulder girdle C5 Shoulder abduction C6 Elbow flexion C7 Elbow extension C8 Ulnar deviation T1 Digits—abduction, adduction

NEUROLOGY

L2 L3 L4 L5 S1 S2

Hip flexion Knee extension Dorsiflexion Great toe extension Planter flexion External rotation

DERMATOMES (FIG. 4.9)

Fig. 4.9: Dermatomes of the whole body

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THE POCKETBOOK FOR PHYSIOTHERAPISTS UPPER QUARTER SCREEN

C2 C3 C4 C5 C6 C7 C8 T1 T2

Occipital protuberance Supraclavicular fossa Acromioclavicular joint Lateral antecubital fossa Thumb Middle finger Little finger Medial antecubital fossa Apex of axilla

LOWER QUARTER SCREEN

L1 L2 L3 L4 L5 S1 S2 S3 S4

Upper anterior thigh Mid anterior thigh Medial femoral condyle Medial malleolus Dorsum 3rd MTP joint Lateral heel Popliteal fossa Ischial tuberosity Perianal area

PERIPHERAL NERVOUS SYSTEM AXILLARY NERVE (C5, C6)

Innervation of muscles: Deltoid, teres minor. Sensory distribution: Lateral arm over lower portion of deltoid.

NEUROLOGY

Clinical features: Loss of shoulder abduction, also affect the lateral rotation of shoulder. MUSCULOCUTANEOUS NERVE (C5, C6)

Innervation of muscles: Coracobrachialis biceps brachialis. Sensory distribution: Anterolateral surface of forearm. Clinical features: Loss of elbow flexion, also affect supination. RADIAL NERVE (C6, C7, C8, T1)

Innervation of muscle • Before the radial groove: Long and medial heads of triceps. • After the radial groove Before crossing the elbow: Lateral head of triceps, anconeus brachioradialis, external carpi radialis longus. • After crossing the elbow Before piercing the supinator: Extensor carpi radialis brevis, supinator. After piercing the supinator Other extensor muscles of the forearm and hand. Sensory distribution: Posterior aspect of arm, forearm and radial side of posterior hand.

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Clinical features: Wrist drop (loss of elbow, wrist, finger and thumb extension). MEDIAN NERVE (C6, C7, C8, T1)

Innervation of muscle: In the forearm Proximal 1/3: All flexor muscles of the forearm (except the flexor carpi ulnaris and medial half of the flexor digitorum profundus). Distal 1/3: Nil. In the hand: Flexor pollicis brevis, opponens pollicis, abductor pollicis, first two lumbricals. Sensory distribution: Palmar aspect of thumb, second, third and fourth (radial half) fingers. Clinical features: Ape hand (loss of thumb opposition, flexion and abduction). ULNAR NERVE (C8, T1)

Innervation of muscles In the forearm Proximal 1/3: Flexor carpi ulnaris, medial half of flexor digitorum profundus. Distal 1/3: Nil. In the hand Superficial branch: Hypothenar muscles. Deep branch: Adductor pollicis, all interossei and medial two lumbricals.

NEUROLOGY

Sensory distribution: Fourth finger (medial portion), fifth finger. Clinical features: Loss of wrist ulnar deviation. Also affect flexion of wrist and finger Pope’s blessing—weakened fourth and fifth finger flexion, thumb abduction loss, claw hand. FEMORAL NERVE (L2, L3, L4)

Innervation of muscle: Iliopsoas, sartorius, pectineus, quadriceps femoris. Sensory distribution: Anterior and medial thigh, medial leg and foot. Clinical features: Loss of knee extension, also affect hip flexion. OBTURATOR NERVE (L2, L3, L4)

Innervation of muscle: Hip adductors, obturator externus. Sensory distribution: Medial thigh (middle part) Clinical features: Loss of hip adduction, also affect lateral rotation of hip. SCIATIC NERVE (L4, L5, S1, S2, S3)

Innervation of muscle: Hamstring. Sensory distribution: Nil. Clinical features: Loss of knee flexion, also affect hip extension.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS TIBIAL NERVE (L4, L5, S1, S2, S3)

Innervation of muscle: Popliteus, ankle plantar flexors tibialis posterior, intrinsics muscles of foot. Sensory distribution: Medial side of ankle. Clinical features: Loss of toe flexion and ankle plantar flexion, also affect ankle inversion. COMMON PERONEAL NERVE (L4, L5, S1, S2)

Innervation of muscle: Superficial branch: Peroneals. Deep branch: Tibialis anterior, toe extensors. Sensory distribution: Anterolateral aspect of leg and foot. Clinical features: Foot drop (loss of ankle dorsiflexion). Loss of toe extension and ankle eversion. SPLINTS USED FOR VARIOUS NERVE INJURIES Nerve injured Splint Axillary nerve Shoulder abduction splint Radial nerve palsy Cock-up splint Ulnar nerve palsy Knuckle-bender splint Sciatic nerve palsy Foot drop splint

NEUROLOGY

VERTEBRAE AND CORRESPONDING SPINAL SEGMENT RELATIONSHIP Vertebrae Spinal segments C1 to C4 (upper cervical) Same C4 to C7 (lower cervical) +1 T1 to T7 +2 T7 to T9 +3 T10 L1,L2 T11 L3, L4 T12 L5 S1 L1 Sacral and coccygeal nerve DESCENDING TRACTS (FIG. 4.10)

Corticospinal tract: Voluntary movements, finger finer movements. Rubrospinal tract: Inhibits extensor muscles, facilitates flexors movements. Vestibulospinal tract: Inhibits flexors, facilitates extensors. Reticulospinal tract: Control muscle activity. Tectospinal tract: Vision reflex. ASCENDING TRACTS (FIG. 4.10)

Medial lemniscus: Kinesthetic, touch and vibration sense. Lateral spinothalamic: Temperature, pain. Anterior spinothalamic: Crude touch, pressure.

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CHAPTER

4

Fig. 4.10: Ascending and descending spinal cord tracts

Spinocerebellar: Kinesthetic sensation Spino-olivary: Carries message to fascia, tendon and ligaments. Spinoreticular: Works on conscious level. Spinotectal: Vision. NEUROLOGICAL TESTS ALTERNATE NOSE-TO-FINGER TEST

Procedure: Keep your finger away about an arm’s length from the patient. Ask the patients to touch

NEUROLOGY

your finger with his index finger and then touch his nose. Repeat the movement. Response: Patient missing your finger or intention tremor. Indicates: Possible cerebellar dysfunction. FINGER-TO-NOSE TEST

Procedure: Keep the patient shoulder in 900 abduction with elbow extension. Ask the patient to touch the tip of the nose with the help of the tip of the index finger. Response: Patient missing your finger or intention tremor. Indicates: Possible cerebellar dysfunction. FINGER-TO-FINGER TEST

Procedure: Keep the patient both shoulders in 90° abduction with the elbow extension. Ask the patients to bring both the hand towards the midline and approximate the index fingers from opposing hand. Response: Patients missing your finger or intention tremor. Indicates: Possible cerebellar dysfunction. HEEL-SHIN TEST

Procedure: Patient lying down. Ask him to place one heel on the opposite knee and then drag the

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THE POCKETBOOK FOR PHYSIOTHERAPISTS

heel down or the shin towards the ankle and back again. Response: Inability to keep the heel on the shin or uncoordinated movement or intention tremor. Indicates: Possible cerebellar dysfunction. ALTERNATE HEEL-TO-KNEE TEST

Procedure: With supine position, ask the patients to touch the knee and big toe alternately, with the heel of opposite extremity. Response: Uncoordinated movement or intention tremor. Indicates: Possible cerebellar dysfunction. HOFFMANN REFLEX

Procedure: Flick the distal phalanx of the patient’s third or fourth finger. Response: Reflex flexion of the patient’s thumb. Indicates: Possible upper motor neuron lesion. JOINT POSITION SENSE (KINESTHESIA)

Procedure: The test is generally performed at distal joint of the limb. Demonstrate the movement with patient’s eye open. Then ask the patient to close his eyes to test. Grasp the joint to be tested between two fingers and move it up and down. Ask the patient to identify the direction of movement.

NEUROLOGY

Response: Inability to identify. Indicates: Loss of proprioception. LIGHT TOUCH

Procedure: Take a wisp of cotton wool. Demonstrate the procedure with the patient’s eye open. Then ask the patient to close his eyes. Stroke the patient’s skin with the cotton wool at random point, ask him to indicate every time they feel the touch. Response: Inability to indicate every time. Indicates: Altered touch sensation. PIN-PRICK (PAIN)

Procedure: Demonstrate the procedure with patient’s eyes open. Then ask him to close his eyes. Test random areas of limb by using sharp end object and ask the patient to tell, which sensation they feel. Response: Inability to identify the type of sensation of pain. Indicates: Altered pain sensation. RAPIDLY ALTERNATING MOVEMENT

Procedure: Ask the patients to hold out one hand palm up and then alternately slap it with the palmar and then dorsal aspects of the fingers of the other hand. For the lower limbs get the patient to tap first one foot on the floor and then the other.

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Response: Loss of rhythm. Indicates: Possible cerebellar dysfunction. TEMPERATURE

Procedure: Take cold and warm water and ask the patients to distinguish between the two sensation. Or A cold tuning fork is taken and ask the patient to identify the sensation, when applied to various parts of the body. Response: Inability to differentiate the temperature. Indicates: Altered temperature sensation. VIBRATION SENSE

Procedure: Ask the patient to close his eyes. Put the vibrating tuning fork (128 Hz) over bony prominence or on the finger tips or toes. Response: Unable to report the feeling of vibration. Indicates: Altered vibration sense. TWO-POINT DISCRIMINATION

Procedure: Demonstrate the procedure with patient’s eye open. Ask the patient to close his eyes, with either one prong or two touches the patient alternately and reduces space between two prongs. Response: Inability to discriminate. Indicates: Indicates sensory dysfunction.

NEUROLOGY ROMBERG’S TEST

CHAPTER

Procedure: Patient stand with feet parallel to each other with a normal width between the feet and then close eyes for 20-30 seconds. Response: Excessive postural sway or loss of balance. Indication: Proprioceptive or vestibular deficit. SHARPENED ROMBERG’S TEST

Procedure: Ask the patient to stand with the feet in a tandem stance with arm folded across the chest and stand for about a minute. Response: Excessive postural sway or loss of balance. Indication: Proprioceptive or vestibular deficit. OTHER BALANCE TESTS

One leg stance, timed stance, postural sway test, functional reach test, nudge test, get up and go test, Berg balance test. CRANIAL NERVES ORIGINATION OF NERVE

Forebrain Midbrain Pons Medulla

169

I, II III, IV V, VI, VII, VIII IX, X, XI, XII

4

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THE POCKETBOOK FOR PHYSIOTHERAPISTS TYPES OF NERVE

Motor Sensor Mixed

III, IV, VI, XI, XII I, II, VIII V, VII, IX, X

Name

Function

Assessment

Abnormal signs

I Olfactory

Smell

Tested by use of non irritating volatile oils or liquids

Inability to detect smell

II Optic

Vision

– Tested for visual acuity by Snellen’s chart (distance vision) and Jaeger’s (near vision) – Tested for color vision by Ishihara’s chart – Tested for visual field by perimetry or comfrontation test

Loss of visual acuity

Test pupillary light reflex

Papillary dilatation

Test accommodation reflex

Loss of accommodation reflex Diplopia Ptosis, squint

III Oculomotor

Pupil constriction accommodation of lens, movement of eyeball and eyelid

Test eyeball and eyelid movements

Color blindness Defects visual fields

Contd...

NEUROLOGY

171

Contd...

Name

Function

Assessment

Abnormal signs

IV Trochlear

Movement of eyeball in upward direction

Assess the eye movement

Diplopia, Adductor paralysis

V Trigeminal

Mastication, Somatosensation: face cornea, anterior tongue

Ask the patient to clench jaws, hold against resistance test sensation: forehead, cheeks, chin test corneal reflex

Weakness and wasting of mastication muscle, loss of sensation in eye face, sinuses and teeth, trigeminal neuralgia

VI Abducent

Movement of eyeball in outward direction

Test eye movement

Diplopia with gaze palsy, convergent strabismus

VII Facial

Facial movement, Tearinglacrimal gland Salivary secretionsSubmandibular, Sublingual Taste for anterior two-thirds of tongue Somatosensation

Ask the patients to raise eye frows, show teeth, smile, close eyes, tightly puff cheeks

Test for tastesweet, salty, sour, bitter

Bells palsy, loss of taste, inability to close eye

Contd...

CHAPTER

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Contd...

Name

Function

Assessment

VIII Vestibulocochlear

Hearing

Test for hearing: Deafness, Rinne (sensoriTinnitus neural) and Weber test (conduction) Assess the Vertigo, balance, nystagnystagmus mus and eye head co-ordination

Equilibrium

IX Glossopharyngeal

X Vagus

XI Accessory

Abnormal sign

Elevation of pharynx Salivary secretion: parotid, sensation of test for posterior third of tongue reflexes

Assess taste— sweet, salty, sour, bitter

Dysphagia, Dry mouth, loss of tongue sensation and taste, dysphonia

Phonation and deglutition, secretion of digestive fluid, cardiac depressor, reflexes, somatosensations

Assess phonation and articulation Observe movement of soft palate

Dysphonia

Test gag reflex Test for pharyngeal sensation

Loss of gag reflex

Deglutition and phonation, Movement

Test for muscle strength and tone

Muscle weakness

Test gag reflex

Dysphagia

Contd...

NEUROLOGY

173

Contd...

Name

XII Hypoglossal

Function

Assessment

Abnormal sign

of sternocleidomastoid and trapezius (spinal part)

Test for muscle strength and tone

Muscle weakness

Movement of tongue

Test for strength of tongue movement

Dysphagia, dysarthria, wasting of tongue

REFLEXES DEEP TENDON REFLEXES Reflex

Nerve

Mode of elicitation

Response

Biceps C5-6

Musculocutaneous

Striking over the biceps tendon

Elbow flexion

Supinator Radial C5-6

Striking over the Brachioradialis tendon at the distal end of radius

Forearm flexion with supination

Triceps C7–8

Radial

Striking over the tendon of triceps

Arm extension

Finger flexion C7-8

Median and ulnar

Striking over the palmar surface of the semiflexed fingers

Finger and thumb flexion

Contd...

CHAPTER

4

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Contd...

Reflex

Nerve

Mode of elicitation

Response

Knee L2-4

Femoral

Striking over the tendon of quadriceps

Knee extension

Ankle S1-2

Sciatic

Striking over the tendocalcaneous

Ankle plantar flexion

SUPERFICIAL REFLEXES Reflex

Mode of elicitation

Response

Plantar S1

Flexor response— slightly scratching the lateral border of the sole Extensor response— slightly scratching the lateral border of the sole

All toes flexion

Abdominal T6-12

Slightly scratching the abdomen with blunt object

Homolateral contraction of the abdominal muscles, retraction of linea alba and umbilicus

Cremasteric L1

Slightly scratching the skin on the upper, inner aspect of the thigh from above downwards with a blunt object

Cremasteric muscle contraction with homolateral elevation of testicle

Small toe fanning, ankle and big toe dorsiflexion

Contd...

NEUROLOGY

175

Contd...

CHAPTER

Reflex

Mode of elicitation

Response

Bulbocavernous S2-4

Pressing the glans penis

Bulbocavernous muscle contraction

Anal S4-5

Pricking the skin on mucous membrane in the perianal region

External anal sphincter muscle contraction

PATHOLOGICAL REFLEXES Reflex

Mode of elicitation

Positive response

Babinski (UMN Lesion)

Scratching the lateral border of sole of foot and across the footpad

Big toe extension and other toes fanning

Clonus (UMN Lesion)

Sudden dorsiflexion of foot passively

Three or more then three rhythmic contraction of plantar flexors

DIFFERENCES OF UPPER MOTOR NEURON AND LOWER MOTOR NEURON LESIONS UMNL

LMNL

Origin

Cerebral cortex

Cranial nerve motor nuclei or spinal cord anterior horn

Termination

Cranial nerve nuclei Motor unit of or spinal cord anterior skeletal muscle horn Contd...

4

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Contd...

UMNL

LMNL

Affects

Muscle group

Individual muscle

Muscle tone

Increased

Decreased

Paralysis

Spastic

Flaccid

Wastage of muscle

Do not occur

Occur

Involuntary movements

Flexor spasms sometimes

Fasciculation sometimes

Superficial reflexes

Lost

Lost

Deep reflexes

Exaggerated

Lost

Plantar reflex

Abnormal (Babinski’s sign)

Lost

Clonus

Present

Lost

Electrical activity

Normal

Absent

Fasciculation twitch in EMG

Absent

Present

Speech

Aphasia, aphonia

Normal, unless Laryngeal Muscles are affected

Posture and gait

Hemiplegic or scissoring

High stepping

Palpation

Hard

Soft

NEUROLOGY

177

GLASGOW COMA SCALE

CHAPTER

EYE OPEN

Spontaneous To speech To pain None

4 3 2 1

BEST VERBAL RESPONSE

Oriented Confused Inappropriate words Incomprehensible sound None

5 4 3 2 1

BEST MOTOR RESPONSE

Obeys commands Localize the pain Withdrawal to pain Flexion to pain Extension to pain None

6 5 4 3 2 1

SCORE

Total Minimum Coma

15 3 7 or less than 7

4

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MODIFIED ASHWORTH SCALE FOR GRADING SPASTICITY 0

No increase in muscle tone

1

Slight increase in muscle tone manifested by a catch and release or by a minimal resistance at the end of the range of motion when the affected part or parts are moved in flexion or extension

1+

Slight increase in muscle tone manifested by a catch, followed by minimal resistance through the reminder (less then half) of the ROM, but affected parts are easily moved

2

Marked increase in muscle tone through most of the ROM, but affected parts are easily moved

3

Considerable muscle tone passive increases, passive movement difficult

4

Affected part(s) rigid in flexion or extension

NEUROLOGICAL PATHOLOGIES ALZHEIMER’S DISEASE

Commonest form of dementia characterized by slow, progressive mental deterioration. Neuritic plaques (primarily in the hippocampus and parietal lobes) and neurofibrillary tangles (mainly affecting the pyramidal cells of the cortex) are present. Clinical Features

Memory loss both in short and long-term apraxia, aphasia, visuospatial impairment, aggressive behavior.

NEUROLOGY ARACHNOIDITIS

Chronic inflammation of the nerve root sheath in the spinal canal with or without nerve root symptoms. Chronic arachnoiditis occurs as a result of meningitis, myelography or spinal surgery. Clinical Features

Severe low back pain, radicular pain, leg weakness, gait disorder, incontinence. ANTERIOR CORD SYNDROME

Occurs due to the flexion injury at the cervical region resulting into damage of anterior portion of spinal cord or its vascular supply. Clinical Features

Loss of motor function, loss of sense of pain and temperature. BELL’S PALSY

Lower motor neuron paralysis of the face, related to inflammation and swelling of the facial nerve (VII) within the facial canal or at the stylomastoid foramen. Usually unilateral. Good recovery is common. Clinical Features

Asymmetry of face, weakness or paralysis of facial muscle, unable to close eye of affected side,

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difficulty in chewing, drooling of saliva from affected side, verbal communication is affected. BROCA’S DYSPHASIA

Caused due to lesion or damage of Broca’s area on the inferior frontal cortex. Broca’s area is near the motor cortex for the face and arm and so may be associated with weakness in these areas. Clinical Features

Difficulty in speaking, non-fluent speech, difficulty in writing, reducing word output. BROWN-SEQUARD SYNDROME

It occurs due to damage to one side of the spinal cord commonly caused by stab injuries. Clinical Features

Loss of sensory sensation on same side, loss of sense of pain and temperature on the opposite side. BULBAR PALSY

Occurs due to lower motor neuron lesion, may be unilateral or bilateral. The nerve supplying the bulbar muscles of head and neck are mainly affected.

NEUROLOGY Clinical Features

Paralysis or weakness of muscles of face, jaw, pharynx, larynx and palate, impairment in swallowing, coughing, speaking and gag reflex. CEREBRAL PALSY

Group of condition characterized by motor dysfunction due to nonprogressive brain damage early in life classified into various types: 1. Topographical classification: Quadriplegia, triplegia, paraplegia, diplegia, hemiplegia monoplegia 2. According to types: Spastic, athetoid, ataxic, floppy, mixed Common causes include intrauterine cerebrovascular insult, intrauterine infection, birth asphyxia, postnatal meningitis and postnatal cerebrovascular insult. Clinical Features

Retarded development, the performance of various movements in pattern, there will be persistence of infantile behaviour in all function including primitive reflexes. CENTRAL CORD SYNDROME

Occurs from hyperextension injury to the cervical region, associated with congenital or degenerative narrowing of spinal canal, resulting due to

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compressive force causing hemorrhage and edema. Clinical Features

Sensory impairment, neurological deficit of upper and lower extremity. CHARCOT-MARIE-TOOTH DISEASE

Progressive disorder of peripheral nerve which is hereditary, characterized by gradual progressive distal weakness and wasting, mainly affecting the peroneal muscle in the leg. In the later stages arm muscles can also be involved. This is also known as hereditary motor sensory neuropathy (HMSN). Clinical Features

Difficulty in running, foot deformity, muscle wasting, lower extremity weakness. DISSEMINATED ENCEPHALOMYELITIS

Occurs due to prevascular CNS demyelination resulting due to viral infection. Myelin loss is followed by axonal degeneration and then by cell body degeneration (irreversible). Clinical Features

Neurological and motor dysfunction, limb weakness.

NEUROLOGY GUILLAIN-BARRÉ SYNDROME (GBS)

An acute or subacute symmetrical predominantly motor neuropathy involving more than one peripheral nerve, frequently it may involve the facial and other cranial nerve, does not have any known etiology, and reaches a peak of disability by one to four weeks. There is distruction of myelin sheath and inflammatory cell. Infiltration of nerve mostly affects the proximal part of nerve root. In most of the cases, onset of symptoms is preceded by a mild gastrointestinal or respiratory infection. GBS usually ends up with recovery. Clinical Features

Neurological dysfunction, lower limb weakness, difficulty in walking, muscle weakness, facial paralysis, diminished reflexes, pain and autonomic disturbances. In severe cases, respiratory problems are seen. HEMIPLEGIA

Paralysis of half side of the body, i.e. it affects both upper and lower limbs of same side. It may be due to thrombosis, embolism, hemorrhage, hypertension, intracranial infections, trauma or hysteria. Clinical Features

Upper and lower limb weakness, facial paralysis, in some cases there may be sensory loss.

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A group of symptoms occurring due to lesion of the sympathetic pathways in the brainstem, spinal cord, hypothalamus, superior cervical ganglion, internal carotid sheath or C8-T2 ventral spinal roots. Clinical Features

Pupil constrictions of same side, loss of facial sweating on affected side of face, drooping of the upper eyelid. HUNTINGTON’S DISEASE

Disease caused by a defect in chromosome IV, which can be transmitted by either of the parent. It can be hereditary in nature. Onset is insidious and occurs between 35 and 50 years of age. Clinical Features

Chorea, progressive dementia, changes in behavior. HYDROCEPHALUS

An increase in cerebrospinal fluid (CSF) volume, usually resulting from impaired absorption, rarely from excessive secretion. Classified into two types: communicating and non-communicating. Causes includes congenital, intrauterine infection,

NEUROLOGY

intracranial bleeding, hemorrhage, congenital malformation, etc. Clinical Features

Vomiting, nausea, irritability, behavioural changes, bradycardia, delayed milestone development, drowsiness, papilledema. LOCKED-IN SYNDROME

This is a neurological disorder in which there occurs total paralysis of all the voluntary muscles except those of face. Caused due to trauma of demyelinating diseases and vascular diseases. Clinical Features

Inability in speaking, difficulty in hearing. MENINGITIS

It is the inflammation of the leptomeninges and underlying subarachnoid C and F, caused by bacteria or viral infections, commonly occurs in children under 5 years of age and adults over 15 years of age. Classified into acute and chronic meningitis. Acute due to meningococcal, Pneumococcal Haemophilus influenzae, gram-negative meningitis, chronic neoplasm infection, AIDS, syphilis.

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Headache, high fever, cold hands and feet, lethargy, change in level of alertness, respiratory distress, apnea, cyanosis. MOTOR NEURON DISEASE

This is a pathological progressive degenerative disease. Changes are more marked in anterior horn cell of spinal cord, motor nuclei of medulla and the corticospinal tracts. Clinical Features

Wasting of muscles especially upper limbs and those innervated from the medulla, combined with symptoms of corticospinal tract degeneration various types are: Amyotrophic lateral sclerosis: Occur due to lower motor neuron lesion. There is weakness of limbs and face muscular atrophy may also be seen. Progressive bulbar palsy: Caused due to damage of motor nuclei is area of brainstem. There is pain and spasm, dyspnea, dysphagia, sore eyes and dysarthria, paralysis of muscles of face, larynx, pharynx and muscle wasting. MULTIPLE SCLEROSIS

This is a slow progressive CNS disease characterized by disseminated patches of demyelination in the brain and spinal cord resulting in multiple

NEUROLOGY

and varied neurologic symptoms and signs with remission and exacerbation. Women are affected more; age of onset is 20 to 40 years. Clinical Features

Ataxia, motor and sensory disturbance, visual disturbances, fatigue, bowel and bladder dysfunction, pain and spasm, behavioural changes, bulbar dysfunction. MUSCULAR DYSTROPHY

This is a group of inherited and progressive muscle disorder. There is selective distribution of weakness. Muscle fibers are replaced by fat and connective tissue. Commonly affected are boys below four years of age and the disease is further classified as: • Duchenne’s muscular dystrophy • Becker’s muscular dystrophy • Facioscapulohumeral muscular dystrophy • Limb girdle muscular dystrophy. Clinical Features

Pseudohypertrophy of proximal muscles, difficulty in walking, postural abnormalities diminished reflexes, Gower’s sign. MYASTHENIA GRAVIS

A disorder of the neuromuscular junction caused by an impaired ability of the neurotransmitter

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acetylcholine to induce muscular contraction, most likely due an autoimmune destruction of the post synaptic receptors for acetylcholine. Male: female ratio is 2:3. Age of onset – neonates, 2030 years or 50 years. Clinical Features

Muscle weakness, ptosis in bulbar muscle, respiratory distress,weakness of facial muscles and jaw-slack, face expressionless. PARKINSONISM

This is the degenerative disease of substantia nigra, because of which there is decreased amount of dopamine in the basal ganglia. It has a gradual and incidious onset that affects the age group between 50 to 60 years. Syndrome is characterized by tremor, muscular rigidity, bradykinesia, postural instability. Clinical Features

Poor posture reflexes, resting tremor, depression, mask like face, shuffling gait, difficulty in speaking, slowness of voluntary movements. POLIOMYELITIS

Is an infectious disease usually affecting children under five year of age. It is caused by three types of poliovirus. It enters feco-oral route. It destroys

NEUROLOGY

the motor neuron of anterior horn, showing the symptoms of lower motor neuron lesion. Divided into various stages according to the involvement. They are acute stage/pre-paralytic/paralytic stage/convalescent stage/stage of early/recovery residual stage/post-polio residual phase. Clinical Features

Weakness or paralysis of lower limb is more than upper limb, difficulty in speaking and swallowing, respiratory complications due to paralysis of muscles of thorax and abdomen. POSTERIOR CORD SYNDROME

It is very rare and occurs when there is any deficits in function served by posterior column. This is usually seen with tabes dorsalis, a late stage syphilis condition. Clinical Features

Loss of proprioception and two point discrimination of stereognosis. Gait pattern is wide based. POSTPOLIO SYNDROME

Persistence of symptom like paralysis or weakness after two years of illness. In this the symptoms progresses after the recovery from acute paralytic stage.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Clinical Features

Pain in muscles and joints, neurological dysfunctions, progressive muscular weakness, severe fatigue. PSEUDOBULBAR PALSY

It occurs when the corticomotor neuron pathways are affected due to upper motor neuron lesion resulting in spasticity and weakness of the pharyngeal and oral musculature. Clinical Features

Dysphagia and slurring of speech, emotional incontinence, inability to control the expressions like laughing or crying. SACRAL SPARING

Incomplete lesion in it the centrally located sacral tracts are preserved or remains unaffected. The differing level of innervations remains intact. Clinical Features

Loss of acute contraction of toe flexors supplied by sacral nerve, cutaneous sensation is lost, rectal/ sphincter contraction is affected, perianal sensation is lost.

NEUROLOGY SPINAL MUSCULAR ATROPHIS (SMA)

Degenerative disorders of the anterior horn cells, that are inherited and cause muscle atrophy. This is classified according to the age of onset and is of three types: SMA I: Also known as Werdnig-Hoffmann disease. This is the most severe, one in onset and cause weakness and hypotonia. SMA II: It is of intermediate type. It progresses a bit slower and has same features age of onset of 6 to 15 months. SMA III: Wohlfart-Kugelberg-Welander disease has late onset, leads to progressive limb weakness and occurs between one year. STROKE/CEREBROVASCULAR ACCIDENT

It is an acute onset of neurological dysfunction, because of abnormality in circulation in cerebral area with resulting signs and symptoms and it also involves the focal areas of brain. Two mechanisms resulting in stroke—ischemic and hemorrhagic. Major risk factors causing stroke are atherosclerosis, hypertension, smoking, endocarditis and cardiac disease. Clinical Features

Headache, nausea, vomiting, dizziness, papilledema, shallow respiration and increased heart rate.

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It is a syndrome not a disease in which acute inflammation affectes gray and white matter in one or more adjacent thoracic segments. Etiology is unknown, but in some cases there is viral infection, vasculitis. Clinical Features

Ascending weakness and numbness of feet and legs, sensorimotor, paraplegia below the lesion, urinary retention and loss of bowel control, local back pain, headache and stiff neck. TRIGEMINAL NEURALGIA

Characterized by paroxysmal attack of severe, short, sharp, stabbing pain affecting one or more divisions of the trigeminal nerve. It can be caused by degeneration of the nerve or compression on it, though often the cause is unknown. Paroxysmal attacks last for several days or weeks, they are often superimposed on a more constant ache. When the attacks settle, the patient may remain pain free for many months. Clinical Features

Chewing, speaking, washing the face, toothbrushing, cold winds or touching a trigger point, e.g. upper lip or gum, may all precipitate an attack of pain.

NEUROLOGY WERNICKE’S DYSPHASIA

Occurs due to the lesion of posterolateral left temporal and inferior parietal region of the left cortex, i.e. the Wernicke’s area. The person suffering from unaware of the language problem. Clinical Features

Fluent but nonsensical speech, impairment of comprehension and writing. NEUROLOGICAL ASSESSMENT Reg. No. Name Age/sex Date of admission Address Occupation Referred by (consultant) and hospital Consultant’s probable diagnosis Type of operation/illness Date of discharge Discharge summary Instruction for physiotherapist Subjective examination History of present condition Past medical history Drug history Social situation Normal daily routine

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GENERAL EXAMINATION

• • • • •

Pulse rate Respiratory rate Temperature Blood pressure State of consciousness—Glasgow Coma Scale

On Observation

• • • •

Attitude of limbs Facial expression Deformity Posture – Lying – Sitting – Standing • Pain – Type – Onset – Nature – Radiation – Intensity – Aggravating/relieving factor – Associated symptoms – Severity: Visual analog scale On Palpation

• Temperature • Tenderness • Edema: Pitting/non-pitting

NEUROLOGY

• Inflammatory sign • Muscle wasting • Contractures On Examination

• • • • • •

• •

Range of movement Muscle girth Limb length End feel – Capsular – Noncapsular Differential tests Gait – Pattern – Distance – Velocity – Walking aids – Orthoses MMT Reflexes – Superficial – Deep

STATES OF HIGHER FUNCTION

• • • • •

Orientation Consciousness Behavior Memory Intelligent capacity

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• • • • • • •

Counting and calculation Speech Reading and writing Vision Speech and articulation Cranial nerve examination Muscle tone – Spasticity – Rigidity – Flaccidity

SENSORY ASSESSMENT

• • • • • • • •

• •

Pain Temperature Vibration Touch – Light – Crude Pressure Two-point discrimination Spine – Tenderness – Deformity Limb attitude – Lying – Sitting – Standing Co-ordination (UL/LL) Balance

NEUROLOGY

• • • • •

Bladder and bowel Dermatomes and myotomes Exercise tolerance test Fatigue Specific investigations/blood test/X-rays/CT scan/MRI

GLOSSARY OF NEUROLOGICAL TERMS Acalculia: Inability to calculate Agnosia: Inability to interpret sensations (types— auditory, tactile, visual) Agraphia: Inability to write Akinesia: Difficulty in initiating movement Alexia: Inability to read Amnesia: Partial or total loss of memory Amusia: Impaired recognition of music Amyotrophy: Muscle wasting Aneurysm: An expanded segment of an artery Anomia: Inability to name objects Anosmia: Loss of ability to smell Anosognosia: Existence of a hemiplegic limb Aphasia: Inability to generate and understand language Astereognosis: Inability to perceive shape by touch

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Ataxia: Incoordinated voluntary movements Athetosis: Involuntary writhing movements Bradykinesia: Slowed voluntary movements Catatonia: Freezing of movements Charcot’s joint: Damaged joints with neurological involvement Chorea: Jerky, irregular, involuntary movement Clonus: Rhythmic, rapid, repetitive muscle contraction associated with increased tone Dementia: Loss of mental function Diplegia: Weakness and spasticity, affecting all limbs but legs more than arms Diplopia: Double vision Dysesthesia: Abnormal burning or aching sensations Dysarthria: Difficulty in articulating speech Dysdiadochokinesia: Impaired ability to perform rapid alternating movement Dysmetria: Impaired ability to judge the distance Dysphagia: Difficulty in swallowing Dysphasia: Difficulty in understanding language Dysphonia: Difficulty in producing the voice Dyspraxia: Inability to perform skilled movements

NEUROLOGY

Dyssynergia: Impaired ability to complex movements Dystonia: Abnormal postural movements caused by mainly co-contraction of agonists and antagonists group of muscles. Embolism: Cerebral-blood clot in the circulation blocking an artery in the brain Encephalopathy: Disorder of brain substances Ependymoma: Tumor of brain and spinal cord Euphoria: An exaggerated felling of wellbeing Fasciculation: Visible involuntary contraction of bundles of muscle fibers Fibrillation: Involuntary contraction of individual muscle fibers Glioma: One type of brain tumor Gliosis: Proliferation of neurological tissue Graphesthesia: Inability to recognize number, figures or letter traced onto the skin with blunt object Hemianopia: Loss of half of field of vision Hemiballismus: Violent involuntary movements of a limb Hemiparesis: Weakness of one side of the body Hemiplegia: Paralysis of one side of the body Homonymous: Affecting the same side

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Hyperacusis: Increased sensitivity to sound Hyperreflexia: Increased reflexes Hypertonia: Increased muscles tone Hypertrophy: Increased size Hypotonia: Decreased muscles tone Kinesthesia: Perception of body position and movements Miosis: Contraction of pupil Monoparesis: Weakness of one limb Myoclonus: Brief shock like involuntary muscular contraction Myopathy: Disorder of muscle Myotonia: State of persistence of muscle contraction Nystagmus: Jerk, involuntary movement of eye Paresthesia: Tingling sensation Paraparesis: Weakness of both legs Paraphasia: Inappropriate or incorrect word during speech Paraplegia: Paralysis of both legs Paresis: Muscles weakness Photophobia: Intolerance to light Prosopagnosia: Inability to recognize the person Ptosis: Drooping of upper eyelid

NEUROLOGY

Quadrantanopia: Loss of quarter than normal visual field Quadriparesis: Weakness of all four limbs Quadriplegia: Paralysis of all four limbs Scotoma: Area of defective vision Stereognosis: Tactile perception of shape Tetraparesis: Quadriparesis Tetraplegia: Quadriplegia Tremor: Quivering or continuous shaking Vertigo: Sensation of movements of one’s body or of object’s moving about or spinning.

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CHAPTER

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Musculoskeletal •

Muscles listed by function

•

Manual muscle testing grading

•

Alphabetical listing of the muscles

•

Joint range of movement

•

Common musculoskeletal tests

•

Musculoskeletal pathologies

•

Grades of sprain and treatment

•

Stages of fracture healing

•

Fractures with eponyms

•

Musculoskeletal assessment

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MUSCLES LISTED BY FUNCTION SHOULDER

Flexors: Pectoralis major, deltoid (anterior fibers), biceps brachii (long head), coracobrachialis. Extensors: Latissimus dorsi, teres major, pectoralis major, deltoid (posterior fibers), triceps (long head). Abductors: Supraspinatus, deltoid (middle fibers). Adductors: Coracobrachialis, pectoralis major, latissimus dorsi, teres major. Medial rotators: Subscapularis, teres major, latissimus dorsi, pectoralis major, deltoid (anterior fibers). Lateral rotators: Teres minor, infraspinatous, deltoid (posterior fibers). ELBOW

Flexors: Biceps brachii, brachialis, brachioradialis, pronator teres. Extensors: Triceps brachii, anconeus. Pronators: Pronator teres, pronator quadratus. Supinators: Supinator, biceps brachii. WRIST

Flexors: Flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis,

MUSCULOSKELETAL

flexor digitorum profundus, flexor pollicis longus. Extensors: Extensor carpi radialis brevis, extensor carpi radialis longus, extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, extensor pollicis longus, extensor pollicis brevis, extensor indicis. Radial deviation: Flexor carpi radialis, extensor carpi radialis longus, extensor carpi radialis brevis, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis. Ulnar deviation: Extensor carpi ulnaris, flexor carpi ulnaris. FINGERS

Flexors: Flexor digitorum profundus, flexor digitorum superficialis, lumbricals, Flexor digiti minimi brevis. Extensors: Extensor digiti minimi, extensor digitorum, extensor indicis, lumbricals. Abductors: Abductor digiti minimi, opponens digiti minimi, dorsal interossei. Adductors: Palmaris interossei. THUMB

Flexors: Flexor pollicis longus, flexor pollicis brevis.

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Extensors: Extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus. Abductors: Abductor pollicis longus, abductor pollicis brevis. Adductors: Adductor pollicis. Opposition: Opponens pollicis. HIP

Flexors: Psoas major, iliacus, rectus femoris, sartorius, pectineus. Extensors: Gluteus maximus, semitendinosus, semimembranosus, biceps femoris. Abductors: Gluteus maximus, gluteus medius, gluteus minimus, sartorius, tensor fasciae latae, piriformis. Adductors: Adductor longus, adductor magnus, adductor brevis, gracilis, pectineus. Medial rotators: Gluteus medius, gluteus minimus, tensor fasciae latae. Lateral rotators: Gluteus maximus, piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, sartorius. KNEE

Flexors: Semitendinosus, semimembranosus, biceps femoris, gastrocnemius, gracilis, sartorius, plantaris, popliteus.

MUSCULOSKELETAL

Extensors: Rectus femoris, vastus medialis, vastus lateralis, vastus intermedius, tensor fasciae latae. Medial rotators: Semitendinosus, semimembranosus, sartorius, gracilis, popliteus. Lateral rotators: Biceps femoris. ANKLE

Dorsiflexors: Tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius. Plantar flexors: Gastrocnemius, soleus, plantaris, peroneus longus, tibialis posterior, flexor digitorum longus, flexor hallucis longus, peroneus brevis. Invertors: Tibialis anterior, tibialis posterior. Evertors: Peroneus longus, peroneus brevis, peroneus tertius. TOES

Flexors: Flexor digitorum longus, flexor digitorum accessorius, flexor digitorum brevis, flexor hallucis longus, flexor hallucis brevis, flexor digiti minimi brevis, interossei, lumbricals, abductor hallucis. Extensors: Extensor hallucis longus, extensor digitorum longus, extensor digitorum brevis, lumbricals, interossei. Abductors: Abductor hallucis, abductor digiti minimi, dorsal interossei. Adductors:Adductor hallucis, plantar interossei.

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Protractors: Serratus anterior, pectoralis minor. Retractors: Rhomboid major, rhomboid minor, trapezius, levator scapulae. Elevators: Trapezius, levator scapulae. Depressors: Trapezius. Medial rotators: Rhomboid major, rhomboid minor, pectoralis minor, levator scapulae. Lateral rotators: Trapezius, serratus anterior. HEAD AND NECK

Flexors: Longus colli, longus capitis, anterior sternocleidomastoid, scalenus anterior. Lateral flexors: Erector spinae, rectus capitis lateralis. Scalene (anterior, middle and posterior), splenius cervicis, splenius capitis, trapezius, levator scapulae, sternocleidomastoid. Extensors: Splenius cervicis, levator scapulae, trapezius, splenius capitis, semispinalis, superior oblique, sternocleidomastoid, erector spinae, rectus capitis posterior major, rectus capitis posterior minor. Rotators: Semispinalis, multifidus, scalenus anterior, splenius cervicis, sternocleidomastoid, splenius capitis, rectus capitis posterior major, inferior oblique.

MUSCULOSKELETAL TRUNK

CHAPTER

Flexors: Rectus abdominis, external oblique, internal oblique, psoas major, psoas minor, iliacus. Rotators: Multifidus, rotatores, semispinalis, internal oblique, external oblique. Lateral flexors: Quadratus lumborum, intertransversarii, external oblique, internal oblique, erector spinae, multifidus. Extensors: Quadratus lumborum, multifidus, semispinalis, erector spinae, interspinales, rotatores. MANUAL MUSCLE TESTING GRADING Grade

Response

0

No movement

1

Flicker of contraction

2

Active movement with gravity eliminated

3

Active movement against gravity

4

Active movement against resistance but not to full strength Normal in power

5

209

Note Grade 4 may be divided into 4 – Movements against slight resistance. 4 + Movements against strong resistance.

5

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ALPHABETICAL LISTING OF THE MUSCLES ABDUCTOR DIGITI MINIMI (FOOT)

Origin: Medial and lateral process of the calcaneal tuberosity, plantar aponeurosis, intermuscular septum. Insertion: Lateral side of base of proximal phalanx of fifth toe. Nerve: Lateral plantar nerve (S1–S3). Action: Abducts fifth toe. ABDUCTOR DIGITI MINIMI (HAND)

Origin: Pisiform, tendon of flexor carpi ulnaris, pisohamate ligament. Insertion: Ulnar side of base of proximal phalanx of little finger. Nerve: Ulnar nerve (C8, T1). Action: Abducts little finger. MMT: Place the palm over a table and try to abduct the little finger in full abduction without resistance shows grade III power. ABDUCTOR HALLUCIS

Origin: Flexor retinaculum, calcaneal tuberosity, plantar aponeurosis, intermuscular septum. Insertion: Medial side of the base of proximal phalanx of great toe.

MUSCULOSKELETAL

Nerve: Medial plantar nerve (S1, S2). Action: Abduct and flexes great toe. MMT: Stand erect with equal body weight on both legs. Try to abduct the great toe. Full abduction shows grade III power. ABDUCTOR POLLICIS BREVIS

Origin: Flexor retinaculum, tubercles of scaphoid and trapezium, tendon of abductor pollicis longus. Insertion: Radial side of base of proximal phalanx of thumb. Nerve: Median nerve (C8, T1). Action: Abducts thumb. Manual muscle testing (MMT): Put your palm in mid prone position over a table, abduct your thumb. Full abduction shows grade III power. ABDUCTOR POLLICIS LONGUS

Origin: Upper part of posterior surface of ulna, middle third of posterior surface of radius, interosseous membrane. Insertion: Radial side of first metacarpal base, trapezium. Nerve: Posterior interosseous nerve (C7, C8). Action: Abducts and extends thumb, abducts wrist.

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MMT: Put your palm in mid-prone position over a table, try to abduct and extend your thumb. Full range of motion shows grade III power. ADDUCTOR BREVIS

Origin: External aspect of body and inferior ramus of pubis. Insertion: Upper half of linea aspera. Nerve: Obturator nerve (L2, L3). Action: Adducts hip. MMT: Same as for adductor longus. Stretching: Patient lies supine, therapist stand at right side of patient with his left hand at patient’s right hip and right hand over patient’s right ankle. Then he abducts the leg with his right hand upto a full range, where the person feels stretching at the medial aspect of the right thigh. ADDUCTOR HALLUCIS

Origin: Oblique head—base of second to fourth metatarsal, sheath of peroneus longus tendon; transverse head-plantar metatarsophalangeal ligaments of lateral three toes. Insertion: Lateral side of base of proximal phalanx of great toe. Nerve: Lateral plantar nerve (S2, S3). Action: Adducts great toe.

MUSCULOSKELETAL

MMT: Stand erect over a platform with your great toe in abducted position. The therapist keep his index finger at the lateral side of the toe and resist your adduction of great toe. Full range of motion shows grade III power. ADDUCTOR LONGUS

Origin: Front of pubis. Insertion: Middle third of linea aspera. Nerve: Anterior division of obturator nerve (L2–L4). Action: Adducts thigh. MMT: Patients in side lying. Uppermost limb in 25° abduction supported by examiner. Therapist standing behind patient at knee level, his hand give resistance to the lowermost limb at the medial surface of distal femur, just proximal to the knee resistance is directed straight downward towards the table. Full range of action against gravity shows grade III power while against resistance show grade V power. ADDUCTOR MAGNUS

Origin: Inferior ramus of pubis, conjoined ischial ramus, inferolateral aspect of ischial tuberosity. Insertion: Linea aspera, proximal part of medial supracondylar line.

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Nerve: Obturator nerve and tibial division of sciatic nerve (L2–L4). Action: Adducts thigh. MMT: Same as above. ADDUCTOR POLLICIS

Origin: Oblique head: Palmar ligaments of carpus, flexor carpi radialis tendon, base of second to fourth metacarpals, capitate, transverse headpalmar surface of third metacarpal. Insertion: Base of proximal phalanx of thumb. Nerve: Ulnar nerve (C8, T1). Action: Adducts thumb. MMT: Forearm in pronation, wrist in neutral and thumb relaxed and hanging down in abduction. Therapist stabilize the all metacarpals by grasping the patient’s hand around the ulnar side, ask patient to adduct the thumb. Full range of motion with no resistance shows grade III power. ANCONEUS

Origin: Posterior surface of lateral epicondyle of humerus. Insertion: Lateral surface of olecranon, upper quarter of posterior surface of ulna. Nerve: Radial nerve (C6–C8). Action: Extends elbow.

MUSCULOSKELETAL

MMT: Patients prone on table with arm in 90° abduction and forearm flexed and hanging vertically over the side of the table. Therapist provides support just above the elbow. Patients extend elbow to end of available range. Full range of motion with no resistance shows grade III power. BICEPS BRACHII

Origin: Long head: Supraglenoid tubercle of scapula and glenoid labrum. Short head: Apex of coracoid process. Insertion: Posterior part of radial tuberosity, bicipital aponeurosis into deep fascia over common flexion origin. Nerve: Musculocutaneous nerve (C5, C6). Action: Flexes shoulder and elbow, supinate forearm. MMT: Patient in short sitting, with forearms at side and testing forearm in supination. Therapist cups the test elbow. Patient flexes elbow through range of motion. Full range of motion without resistance shows grade III power. Stretching: Patient in supine lying with right upper limb fully extended and hanging by the side of bed. Therapist right hand over the patient wrist and left hand at back of elbow to prevent flexion put the limb in the full extension starting from

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wrist, then elbow and upto shoulder till a stretch is felt over anterior arm. BICEPS FEMORIS

Origin: Long head: Ischial tuberosity, sacrotuberous ligament. Short head: Lower half of lateral lip of linea aspera, lateral supracondylar line of femur, lateral intramuscular septum. Insertion: Head of fibula, lateral tibia condyle. Nerve: Sciatic nerve (L5–S2). Long head—tibial division. Short head—common peroneal division. Action: Flexes knee and extends hip, laterally rotates tibia on femur. MMT: Prone with knee flexed to less than 90°. Leg is in external rotation (toe pointing laterally). Patient flexes knee, maintaining leg in external rotation (heel away from examiner, toes pointing toward examiner). Full range of motion without resistance shows grade III power. BRACHIALIS

Origin: Lower half of anterior surface of humerus, intermuscular septum. Insertion: Coronoid process and tuberosity of ulna.

MUSCULOSKELETAL

Nerve: Musculocutaneous nerve (C5, C6) radial nerve (C7). Action: Flexes elbow. MMT: All is same as for biceps brachii except forearm in pronation. Stretching: Same as for biceps brachii. BRACHIORADIALIS

Origin: Upper two-third of lateral supracondylar ridge of humerus lateral intermuscular septum. Insertion: Lateral side of radius above styloid process. Nerve: Radial nerve (C5, C6). Action: Flexes elbow. MMT: All same as for biceps brachii except forearm in mid-position between pronation and supination. CORACOBRACHIALIS

Origin: Apex of coracoid process. Insertion: Midway along medial border of humerus. Nerve: Musculocutaneous nerve (C5–C7). Action: Adducts shoulder and acts as weak flexor. MMT: Patient in short sitting, arm at side with elbow slightly flexed and forearm pronated.

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Patient flexes shoulder to 90°. Complete test range (90°) shows grade III power. DELTOID

Origin: Clavicle (anterior superior border of lateral 1/3 of shaft). Insertion: Humerus (deltoid tuberosity on shaft). Nerve: Axillary nerve (C5, C6). Action: Anterior fibers: Flex and medially rotate shoulder. Middle fibers: Abduct shoulder. Posterior fibers: Extend and laterally rotate shoulder. MMT: • For anterior deltoid, the test is same as for coracobrachialis. • For middle fibers—position of hand is sideway and action is to abduct the shoulder upto 90°. • For posterior fibers—hand in side way and action is extension upto 90° with lateral rotation. • Full range (test range 90°) of function shows grade III power. DIAPHRAGM

Origin: Posterior surface of xiphoid process, lower six costal cartilages and adjoining ribs on each

MUSCULOSKELETAL

side, medial and lateral arcuate ligament, anterolateral aspect of bodies of lumbar vertebrae. Insertion: Central tendon. Nerve: Phrenic nerve (C3–C5). Action: Draw central tendon inferiorly, changes volume and pressure of thoracic and abdominal cavities. MMT: Patient lies supine. Therapist standing next to patient at approximately waist level. One hand is placed lightly on the abdomen in the epigastric area just below the xiphoid process. Patient inhales with maximal effort and holds maximum inspiration. Completion of maximal inspiratory expansion shows grade III power. DORSAL INTEROSSEI (FOOT)

Origin: Proximal half of sides of adjacent metatarsals. Insertion: Bases of proximal phalanges and dorsal digital expansion (first attaches medially to second toe; second, third and fourth attach laterally to second, third and fourth toes respectively). Nerve: Lateral plantar nerve (S2, S3). Action: Abducts toes, flexes metatarsophalangeal joints.

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Origin: Adjacent side of two metacarpal bones (four bipennate muscles). Insertion: Bases of proximal phalanges and dorsal digital expansions (first attaches laterally to index finger; second and third attach to both sides of middle finger; fourth attaches medially to ring finger). Nerve: Ulnar nerve (C8, T1). Action: Abducts index, middle and ring fingers, flexes metacarpophalangeal joints and extends interphalangeal joints. EXTENSOR CARPI RADIALIS BREVIS

Origin: Lateral epicondyle via common extensor tendon. Insertion: Posterior surface of base of third metacarpal. Nerve: Posterior interosseous branch of radial nerve (C7, C8). Action: Extends and abducts wrist. MMT: Patient in short sitting. Elbow is flexed, forearm is fully pronated, and both are supported on the table. Therapist supports the patient’s forearm. The patient then extends and abducts the wrist. Completion of full range of motion with no resistance shows grade III power.

MUSCULOSKELETAL EXTENSOR CARPI RADIALIS LONGUS

Origin: Lower third of lateral supracondylar ridge of humerus, intermuscular septa. Insertion: Posterior surface of base of second metacarpal. Nerve: Radial nerve (C6, C7). Action: Extends and abducts wrist. MMT: Same as for extensor carpi radialis brevis, but the patient will only extend the wrist. EXTENSOR CARPI ULNARIS

Origin: Lateral epicondyle via common extension tendon. Insertion: Medial side of fifth metacarpal base. Nerve: Posterior interosseous nerve (C7, C8). Action: Extends and adducts wrist. MMT: All is same as for extensor carpi radialis longus except that patient will extend the wrist with ulnar deviation. EXTENSOR DIGITI MINIMI

Origin: Lateral epicondyle via common extensor tendon, intermuscular septa. Insertion: Dorsal digital expansion of fifth digit. Nerve: Posterior interosseous nerve (C7, C8). Action: Extends fifth digit and wrist.

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MMT: Patient’s forearm in pronation, wrist in neutral, MP joints and IP joints are in relaxed flexion position. Therapist stabilizes the wrist in neutral. Patient extends the MP joint of 5th digit. Complete active range with no resistance shows grade III power. EXTENSOR DIGITORUM

Origin: Lateral epicondyle via common extensor tendon, intermuscular septa. Insertion: Lateral and dorsal surface of second to fifth digits. Nerve: Posterior interosseous branch of radial nerve (C7, C8). Action: Extends fingers and wrist. MMT: Position same as for extensor digiti minimi, patient extends MP joint (all finger simultaneously), allowing the IP joints to be in slight flexion. Complete active range, with no resistance shows grade III power. EXTENSOR DIGITORUM BREVIS

Origin: Calcaneus (anterior superolateral surface), lateral talocalcaneal ligament. Extensor retinaculum (inferior). Insertion: Base of proximal phalanx of great toe, lateral side of dorsal hood of adjacent three toes. Nerve: Deep peroneal nerve (L5, S1).

MUSCULOSKELETAL

Action: Extends great toe and adjacent three toes. MMT: Patient in short sitting, with foot on examiner’s lap. Alternate position supine. Ankle in neutral position, therapist sitting on low stool in front of patient, or standing beside table near the patient’s foot. One hand stabilizes the metatarsals with the fingers on the plantar surface and the thumb on the dorsum of foot. If patient can extend the toes to complete range without resistance, it shows grade III power. EXTENSOR DIGITORUM LONGUS

Origin: Upper three quarter of medial surface of fibula, interosseous membrane, lateral tibial condyle. Insertion: Middle and distal phalanges of four lateral toes. Nerve: Deep peroneal nerve (L5, S1). MMT: Same as for extensor digitorum brevis. EXTENSOR HALLUCIS LONGUS

Origin: Fibula (shaft, middle ½ of medial aspect), interosseous membrane. Insertion: Hallux (distal phalanx, dorsal aspect of bases), expansion to proximal phalanx. Nerve: Deep peroneal nerve (L5). Action: Extends great toe, ankle dorsiflexor.

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MMT: Patient’s and therapist’s position same as for extensor digitorum longus and brevis. Therapist stabilizes the metatarsal area by contouring the hand around the plantar surface of the foot, with the thumb curving around to the base of the hallux. The other hand stabilizes the foot at the heel. If the patient can extend the great toe upto full range without resistance, it shows grade III power. EXTENSOR INDICIS

Origin: Lower part of posterior surface of ulna, interosseous membrane. Insertion: Dorsal digital expansion on back of proximal phalanx of index finger. Nerve: Posterior interosseous nerve (C7, C8). Action: Extends index finger and wrist. MMT: Patient’s forearm in pronation, wrist in neutral, MP joint and IP joint are in relaxed flexion posture. Therapist stabilizes the wrist in neutral, patient extends the MP joint of the index finger. Complete range of extension shows grade III power. EXTENSOR POLLICIS BREVIS

Origin: Radius (posterior surface), interosseous membrane.

MUSCULOSKELETAL

Insertion: Dorsolateral base of maximal phalanx of thumb. Nerve: Posterior interosseous nerve (C7, C8). Action: Extends thumb and wrist, abducts wrist. MMT: Patient’s forearm in mid-prone position and wrist in neutral; CMC and IP joints of thumb are relaxed and in slight flexion. The MP joint of the thumb is in abduction and flexion. Therapist stabilizes the first metacarpal firmly, allowing motion to occur only at the MP joint. If the patient moves proximal phalanx of the thumb through full range of extension, it shows grade III power. EXTENSOR POLLICIS LONGUS

Origin: Ulna (middle 3rd of posterior surface), interosseous membrane. Insertion: Dorsal surface of distal phalanx of thumb. Nerve: Posterior interosseous nerve (C7, C8). Action: Extends thumb and wrist, abducts wrist. MMT: Same as for extensor pollicis brevis. EXTERNAL OBLIQUE

Origin: Ribs 5–12 (interdigitating on external and inferior surface). Insertion: Iliac (rest outer border) thoracolumbar fascia, linea alba, aponeurosis from 9th costal

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cartilage to ASIS, both sides meet at midline to form linea alba, pubic symphysis (upper border). Nerve: Ventral rami of lower six thoracic nerve (T7–T12). Action: Flexes, laterally flexes and rotates trunk. MMT: Patient in supine with arms outstretched above plane of body. Ask the patient to lift your head and shoulders from the table taking your right elbow toward your left knee. Then lift the shoulder from the table, taking your left elbow towards right knee. The patient is able to perform this at full range, it shows grade III power. FLEXOR CARPI RADIALIS

Origin: Medial epicondyle via common flexor tendon. Insertion: Front of base of second and third metacarpals. Nerve: Median (C6, C7). Action: Flexes and abducts wrist. MMT: Patient in short sitting forearm is supported on its dorsal surface in a table. To start, forearm is supinated and wrist is in neutral position. The therapist supports the patient’s forearm under the wrist. The patient flexes the wrist in radial deviation. Full range of motion without resistance shows grade III power.

MUSCULOSKELETAL FLEXOR CARPI ULNARIS

Origin: Humeral head: Medial epicondyle via common flexor tendon. Ulnar head: Medial border of olecranon and upper 2/3rd of border of ulna. Insertion: Pisiform, hook of hamate and base of fifth metacarpal. Nerve: Ulnar nerve (C7–T1). Action: Flexes and adducts wrist. MMT: Patient’s and therapist’s position same as for flexor carpi radialis. Patient flexes the wrist in ulnar deviation. Full range of motion without resistance shows grade III power. FLEXOR DIGITI MINIMI BREVIS (FOOT)

Origin: Plantar aspect of base of fifth metatarsal, sheath of peroneus longus tendon. Insertion: Lateral side of base of proximal phalanx of fifth toe. Nerve: Lateral plantar nerve (S2, S3). Action: Flexes fifth metatarsophalangeal joint, supports lateral longitudinal arch. FLEXOR DIGITI MINIMI BREVIS (HAND)

Origin: Hook of hamate, flexor retinaculum. Insertion: Ulnar side of base of proximal phalanx of little finger.

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Nerve: Ulnar nerve (C8, T1). Action: Flexes little finger. FLEXOR DIGITORUM ACCESSORIUS

Origin: Medial head—medial tubercle of calcaneus, lateral head—lateral tubercle of calcaneus and long plantar ligament. Insertion: Flexor digitorum longus tendon. Nerve: Lateral plantar nerve (S1–S3). Action: Flexes distal phalanges of lateral fourth toes. FLEXOR DIGITORUM BREVIS

Origin: Calcaneal tuberosity, plantar aponeurosis, intermuscular septa. Insertion: Tendons divide and attach to the both sides of the middle phalanges of second to fifth toes. Nerve: Medial plantar nerve (S1, S2). Action: Flexes proximal interphalangeal joints and metatarsophalangeal joints of lateral four toes. MMT: Patients in short sitting with foot on examiner’s lap or supine. Therapist sitting on short stool in front of patient or standing at side of table near patient’s foot. His one hand grasp the anterior foot with the finger’s placed across the dorsum of the foot and the thumb under the

MUSCULOSKELETAL

proximal phalanges or digital phalanges. Patient is asked to flex the toes. Full range of flexion without resistance shows grade III power. FLEXOR DIGITORUM LONGUS

Origin: Medial part of posterior surface of tibia, deep transverse fascia. Insertion: Plantar aspect of base of distal phalanges of second to fifth toes. Nerve: Tibial nerve (L5–S2). Action: Flexes lateral four toes, plantar flexes ankle. MMT: Same as for flexor digitorum brevis. FLEXOR DIGITORUM PROFUNDUS

Origin: Ulna (proximal 3/4th of anterior and medial shaft, medial coracoid process), interosseous membrane (ulnar). Insertion: Four tendons to digits 2–5 (distal phalanges, at the base of palmar surface). Nerve: Medial part—ulnar nerve (C8, T1). Lateral part—anterior interosseous branch of median nerve (C8,T1). Action: Flexes fingers and wrist. MMT: Patient’s forearm in supination, wrist in neutral and PIP joint in extension. Therapist stabilizes middle phalanx in extension by

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grasping in on either side. Patient flexes distal phalanx of each finger individually. Full range of motion without resistance shows grade III power. FLEXOR DIGITORUM SUPERFICIALIS

Origin: Humero-ulnar head—humerus (medial epicondyle via common flexion tendon). Ulna (medial collateral ligament of elbow joint); coronoid process (medial side). Intermuscular septum. Radial head—radius (oblique line on anterior shaft). Insertion: Four tendon arranged in two pairs: Superficial pair—middle and ring fingers (side of the middle phalanges). Deep pair—index and little fingers (side of middle phalanges). Nerve: Median (C8, T1). Action: Flexes fingers and wrist. MMT: Patient’s forearm supinated, wrist at neutral, finger to be tested is in slight flexion at the MP joint. Therapist holds all fingers (except one being tested) in extension at all joints. Isolation of the index finger may not be complete. Each of four fingers is tested separately. Patient flexes the PIP joint without flexing the DIP joint. Do not allow motion of any joint of the other fingers. Flick the terminal end of the finger being tested with the thumb to make certain that the

MUSCULOSKELETAL

flexor digitorum profundus is not active; that is the DIP joint goes into extension. The distal phalanx should be floppy. Ask the patient “bend your index [then long, ring or little] finger, hold it. Full range of motion without resistance shows grade III power. FLEXOR HALLUCIS BREVIS

Origin: Medial side of plantar surface of cuboid, lateral cuneiform. Insertion: Medial and lateral side of base of proximal phalanx of great toe. Nerve: Medial plantar nerve (S1, S2). Action: Flexes metatarsophalangeal joint of great toe. MMT: Patient in short sitting, with legs hanging over edge of table. Ankle is in neutral position, therapist sitting on low stool infront of patient. Test foot rests on examiner’s lap. One hand is contoured over the dorsum, of the foot just below the ankle for stabilization. The index finger of the other hand is placed beneath the proximal phalanx of the great toe alternatively, the tip of the finger is placed up under the proximal phalanx. Patient flexes great toe. Full range of great toe flexion shows grade III power. GASTROCNEMIUS

Origin: Medial head—femur (posterior part of medial condyle).

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Lateral head—femur (lateral surface of lateral condyle). Insertion: Posterior surface of calcaneus. Nerve: Tibial nerve (S1, S2). Action: Plantar flexes ankle, flexes knee. MMT: The patient stands over testing limb with one or two fingers supported over a table. Patient attempts to raise heel from base consecutively through full range of plantar flexion. Ask him to “stand on your right leg. Go up on your tiptoes. Now down. Repeat this 20 times”. If the patient completes nine times or above and one heel raise correctly with no rest or fatigue it shows grade III power. Stretching: Standing on the steps with the ball of the toes. GEMELLUS INFERIOR

Origin: Upper part of ischial tuberosity. Insertion: With obturator internus tendon into medial surface of greater trochanter. Nerve: Nerve to quadratus femoris (L5, S1). Action: Laterally rotates hip. MMT: Patient is in short sitting. The therapist sit over a low stool towards the testing limb. One hand is contoured over the distal thigh (lateral

MUSCULOSKELETAL

aspect). Patient attempts to externally rotate the hip. If the patient can hold the end position, it shows grade III power. Stretching: Patient is supine, lying with hip and knee joint of testing limb in 90°. Therapist is standing beside the patient and facing the hip joint. His left hand stabilizes the thigh of the patient, while his right hand is grasping the lower leg. Therapist performs medial rotation. GEMELLUS SUPERIOR

Origin: Ischial spine (gluteal surface). Insertion: Greater trochanter (with obturator internus tendon into medial surface). Nerve: Nerve to obturator internus (L5, S1). Action: Laterally rotates hip. MMT and stretching: Same as G. inferior. GLUTEUS MAXIMUS

Origin: Ilium (posterior gluteal line, posterior border, adjacent part of iliac crest), aponeurosis of erector spinae, sacrum (posterior aspect) side of coccyx, sacrotuberous ligament, gluteal aponeurosis. Insertion: Iliotibial tract of fascia lata, femur (gluteal tuberosity). Nerve: Inferior gluteal nerve (L5–S2).

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Action: Extends, laterally rotates and abducts hip. MMT: Patient is on prone lying. Therapist stands at side of testing limb at the level of pelvis. Ask patient to lift the leg towards ceiling. If the patient can hold the full range of motion, it shows grade III power. Stretching: (Passive): Patient lies supine. Therapist stands beside the patient and facing the limb. Therapists right hand grasping the ankle while his left hand holds the knee posteriorly. The leg is lifted with hip and knee flexed, towards the cranial side of the patient. Self-stretching Position: Knee sitting. Procedure: Patient flexing hip and knee himself, in supine with the help of both hands. GLUTEUS MEDIUS

Origin: Gluteal surface of ilium between posterior and anterior gluteal line. Insertion: Greater trochanter (anterolateral ridge). Nerve: Superior gluteal nerve (L4–S1). Action: Abducts and medially rotates hip. MMT: Patient in side-lying with testing leg in uppermost position. The therapist stands behind patient. For palpating the muscle, he puts his hand just proximal to the greater trochanter of the femur. Ask him to abduct hip through complete

MUSCULOSKELETAL

range of motion without flexed hip or rotation. Full range of motion and holds at end position, shows grade III power. Stretching: Patient lies supine. Therapist stands beside the patient and faces the hip joint. Therapist left hand stabilizes the opposite leg of patient, while his right hand grasping lower thigh, therapist right hand pushes the leg inside. GLUTEUS MINIMUS

Origin: Ilium (gluteal surface between anterior and inferior gluteal lines). Insertion: Anterior lateral ridge on greater trochanter. Nerve: Superior gluteal nerve (L4–S1). Action: Abducts and medially rotates hip. MMT and stretching: Same as G. medius. GRACILIS

Origin: Pubis (interior ramus and lower half of body), adjacent ischial ramus. Insertion: Tibia (upper part of medial surface). Nerve: Obturator nerve (L2, L3). Action: Flexes knee, adducts hip, medially rotates tibia on femur. MMT: Same as for hip adductors. Stretching: Patient in supine lying. Therapist stand

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beside the patient and facing the hip joint. His left hand stabilizes the opposite leg, while his right hand grasping the lower thigh and the leg is placed on the therapist forearm. Leg is pulled apart by the therapist’s right hand. ILIACUS

Origin: Iliacus fossa (superior 2/3), iliac crest (inner lip), ala of sacrum, sacroiliac and iliolumbar ligaments. Insertion: Blends with insertion of psoas major into lesser trochanter. Nerve: Femoral nerve (L2, L3). Action: Flexes hip and trunk. MMT: Patient in short sitting with thigh over table and leg hanging at the edge. Therapist stands at the testing side. Ask the patient to lift off his leg. Full range of motion, shows grade III power. Stretching: Patient in side-lying. Therapist is standing beside the patient, facing the hip joint. Therapist’s left hand stabilizes the patient pelvis, while his right hand grasping the upper thigh and the leg is resting on the forearm of the therapist. Patients thigh is lifted by the therapist’s right hand and performing the extension movement of the hip. ILIOCOSTALIS CERVICIS

Origin: Angles of third to sixth ribs.

MUSCULOSKELETAL

Insertion: Posterior tubercles of transverse process of C4 to C6. Nerve: Dorsal rami. Action: Extends and laterally flexes vertebral. MMT: Patient in prone with head off at the edge of table. Therapist puts one hand below patient’s forehead. Ask patient to extend neck without tilting chin, or looking up full range of motion, shows grade III power. ILIOCOSTALIS LUMBORUM

Origin: Sacral crest (medial and lateral) spines of T 11 , T 12 and lumbar vertebrae and their supraspinous ligament, medial part of iliac crest. Insertion: Angle of lower six or seventh ribs. Nerve: Dorsal rami. Action: Extends and laterally flexes vertebral column. MMT: Patient in prone with arms at side. Therapist stands at side of table, stabilizing lower extremities just above the ankle. Ask patient to raise his head, arms, and chest from the table as high as he can. Full range of motion, shows grade III power. Stretching: Patient in long sitting. Ask him to put his hands together in front of his foot and try to cross the toes by his finger as much as he can, looking towards his lower legs.

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Origin: Angle of lower six ribs. Insertion: Angle of upper six ribs, transverse process of C7. Nerve: Dorsal rami. Action: Extend and laterally flexes vertebral column. MMT: Same as for iliocostalis lumborum. INFERIOR OBLIQUE

Origin: Lamina of axis. Insertion: Transverse process of atlas. Nerve: Dorsal ramus (C1). Action: Rotates atlas and head. INFRASPINATUS

Origin: Infraspinous fossa and its medial 2/3. Insertion: Humerus (middle facet on greater tubercle), shoulder joint (posterior aspect of capsule). Nerve: Suprascapular nerve (C5, C6). Action: Laterally rotates shoulder. MMT: Patient prone with head turned towards test side. Abduct the shoulder to 90° with arms supported on table. Forearm hanging vertically over the edge. Place folded towel under the arm

MUSCULOSKELETAL

at the edge. Ask patient to move forearm upwards through the range of external rotation. Full range of motion, shows grade III power. Stretching: Patient in supine lying. Therapist stands beside patient and faces the limb. The therapist now grasps the lower arm of the patient with his left hand and with right hand grasping the wrist and applying the stretch force towards the medial rotation. INTERCOSTALIS EXTERNI

Origin: Lower border of the rib above. Insertion: Upper border of the rib below. Nerve: Intercostal nerves. Action: Elevate ribs below towards rib above to increase thoracic cavity volume for inspiration. MMT: Patient lies supine. Therapist stands at the side. Tape measure placed lightly around thorax at level of xiphoid. Ask patient to hold maximal inspiration for measurement and then hold maximal expiration for a second measurement. The difference between the two measurements is recorded as chest expansion. INTERCOSTALIS INTERNI

Origin: Lower border of costal cartilage and costal groove of rib above. Insertion: Upper border of rib below.

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Nerve: Intercostal nerves. Action: Draw ribs downwards to decrease thoracic cavity volume for expiration. MMT: Same as for I. externi. INTERNAL OBLIQUE

Origin: Inguinal ligament (lateral 2/3), iliac crest (anterior 2/3 of intermediate line), thoracolumbar fascia. Insertion: Lower four ribs and their cartilages, pubic crest, abdominal aponeurosis to linea alba. Nerve: Ventral rami of lower six thoracic nerves, first lumbar nerve. Action: Flexes, lateral flexes and rotates trunk. MMT: Patient is supine with arms outstretched in full extension above the plane of body. Ask patient to raise his head, shoulders and arm off the table. Full range of motion, shows grade III power. Stretching: Patient lies prone on table. Ask him to lift his head, shoulder and upper trunk as much as possible and turn towards one side to look at the ceiling of that side. The opposite side of the muscle will feel stretch. INTERSPINALIS

Origin and insertion: Extend between adjacent spinous processes.

MUSCULOSKELETAL

Nerve: Dorsal rami of spinal nerves. Action: Extend and stabilize vertebral column. MMT: Same as for iliocostalis muscles. INTERTRANSVERSARII

Origin: Cervical and lumbar vertebrae (transverse process). Insertion: Transverse process of vertebra, superior to origin. Nerve: Ventral and dorsal rami of spinal nerve. Action: Laterally flex lumbar and cervical spine, stabilize vertebral column. ISCHIOCAVERNOSUS In the female

Origin: Ischium (tuberosity and ramus), crus clitoridis (surface). Insertion: Aponeurosis inserting into side and inferior surface of crus clitoridis. Nerve: Pudendal nerve (S2–S4). Action: Compress crus clitoridis, retarding venous return and thus assisting erection. In the male

Origin: Ischium (tuberosity, medial aspect dorsal to crus penis and ischial rami).

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Insertion: Aponeurosis into the sides and under surface of the body of the penis. Nerve: S 2–S 4 spinal nerves (pudendal nerve, perineal branch, ventral rami). Action: Compression of crus penis, maintaining erection by retarding return of blood through the veins. LATERAL CRICOARYTENOID

Origin: Cricoid cartilage (cranial border of arch). Insertion: Arytenoid cartilage on same side (front of muscular process). Nerve: Vagus (X) nerve (recurrent laryngeal branch). Action: Closes glottis by rotating arytenoid cartilages medially, approximating (adducting) the vocal folds for speech. LATISSIMUS DORSI

Origin: Spinous process of lower six thoracic and all lumbar and sacral vertebrae, intervening supra and interspinous ligament, outer lip of iliac crest, outer surface of lower three or four ribs, inferior angle of scapula. Insertion: Intertubercular sulcus of humerus. Nerve: Thoracodorsal nerve (C6–C8).

MUSCULOSKELETAL

Action: Extends, adducts and medially rotates shoulder. MMT: Patient prone with head turned to one side. Arms at side; test arm is internally rotated (palm up). Therapist stands at test side. Ask the patient to push his arm towards feet (reach down toward your feet). If the patient completes full range of motion, with no resistance, it shows grade III power. Stretching: Patient in supine lying. Therapist stands beside the patient and facing the limb. Therapist left hand grasps the lower arm region and the patient’s forearm resting over the therapist forearm. Therapists right hand apply opposite force on the scapular region to prevent scapular movement. Stretch force is given towards the flexion of the shoulder with the therapists left hand. LEVATOR SCAPULAE

Origin: C1–C3/C4 (transverse processes). Insertion: Scapula (medial border between superior angle and base of spine). Nerve: Ventral rami (C3, C4) dorsal scapular nerve (C5). Action: Elevates, medially rotates and retracts scapula, extends and laterally flexes neck.

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Origin: T 1–T 4,5 (transverse process) articular process of C4/5–C7. Insertion: Posterior aspect of mastoid process. Nerve: Dorsal rami. Action: Extends, laterally flexes and rotates head. MMT: Patient prone with head off the end of table. Arm at side. Therapist standing next to patient’s head with one hand supporting the forehead. Ask the patient to lift your forehead from my hand and keep looking at the floor. Full range of motion, shows grade III power. LONGISSIMUS CERVICIS

Origin: Transverse process of T1–T4/5. Insertion: Transverse process of C2–C6. Nerve: Dorsal rami. Action: Extends and laterally flexes vertebral column. MMT: Same as for L. capitis. LONGISSIMUS THORACIS

Origin: Transverse and accessory process of lumbar vertebrae and thoracolumbar fascia. Insertion: Transverse processes of T1–T12 and lower nine or ten ribs.

MUSCULOSKELETAL

Nerve: Dorsal rami. Action: Extends and laterally flexes vertebral column. MMT: Same as for iliocostalis thoracic. LONGUS CAPITIS

Origin: Occipital bone. Insertion: Anterior tubercles of transverse processes of C3–C6. Nerve: Anterior primary rami (C1–C3). Action: Flexes neck. MMT: Patient in supine with head supported on table. Arm at side. Therapist stands at head of the table facing patient. Ask patient to tuck his chin into his neck. Do not raise his head from table. If patient completes available ROM without resistance, it shows grade III power. LONGUS COLLI

Origin: T1–T2/3 (inferior oblique part, front of bodies). T1–T3 and C5–C7 (vertical intermediate part front of bodies). C3–C5 (superior oblique part—anterior tubercles of transverse process). Insertion: C5 and C5 (inferior oblique part–anterior tubercles of transverse process), C2–C4 (vertical

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intermediate part: front of bodies); superior oblique part—anterior tubercle of atlas. Nerve: Anterior primary rami (C2–C6). Action: Flexes neck. MMT: Patient supine with arms at side. Patient flexes neck, keeping eyes on the ceiling. If the patient completes available range of motion, it shows grade III power. LUMBRICALS (FOOT)

Origin: Tendon of flexor digitorum longus. Insertion: Medial side of extensor hood and base of proximal phalanx of lateral four toes. Nerve: First lumbrical-medial plantar nerve (S2, S3), Lateral three lumbrical-lateral plantar nerve (S2, S3). Action: Flexes metatarsophalangeal joint and extends interphalangeal joint of lateral four toes. MMT: Patient short sitting with foot on examiner’s lap. Therapist sitting on low stool in front of patient, his hand grasps the dorsum of the foot just below the ankle to provide stabilization. The index finger of the other hand is placed under the MP joints of the four lateral toes to provide resistance to flexion. Ask the patient to bend your toes over my finger. Full range of motion without resistance, shows grade III power.

MUSCULOSKELETAL LUMBRICALS (HAND)

Origin: Tendons of flexor digitorum profundus. Insertion: Lateral margin of dorsal digital expansion of extensor digitorum. Nerve: I and II—median nerve (C8, T1). III and IV—ulnar nerve (C8, T1). Action: Flexes metacarpophalangeal joint and extends interphalangeal joints of fingers. MMT: Patient short sitting with forearm in supination. Wrist is maintained in neutral. The MP joints are flexed. Therapist stabilizes the metacarpals proximal to the MP joints, resistance is given on the palmar surface of the proximal row of phalanges in the direction of MP extension. Ask patient to simultaneously flex the MP joint and extend the IP joints. If the patient completes both motions correctly and simultaneously without resistance, it shows grade III power. MULTIFIDUS

Origin: Back of sacrum, aponeurosis of erector spinae, posterior superior iliac spine, dorsal sacroiliac ligaments, mamillary processes in lumbar region, all thoracic transverse process, articular process of lower four cervical vertebrae. Insertion: Spines of all vertebrae from L5 to axis. Nerve: Dorsal rami of spinal nerves.

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Action: Extends, rotates and laterally flexes vertebral column. MMT: Same as for interspinales and intertransversarii. OBTURATOR EXTERNUS

Origin: Outer surface of obturator membrane and adjacent bone of pubic and ischial rami. Insertion: Trochanteric fossa of femur. Nerve: Posterior branch of obturator nerve (L3, L4). Action: Laterally rotates hip. MMT: Patient in short sitting. Therapist sits on a low stool or kneels beside limb to be tested. Ask the patient to turn his leg in full range of motion, shows grade III power. OBTURATOR INTERNUS

Origin: Internal surface of obturator membrane and surrounding bony margin. Insertion: Medial surface of greater trochanter. Nerve: Nerve to obturator internus (L5, S1). Action: Laterally rotates hip. MMT: Same as for O. externus. OPPONENS DIGITI MINIMI

Origin: Hook of hamate; flexor retinaculum. Insertion: Medial border of fifth metacarpal.

MUSCULOSKELETAL

Nerve: Ulnar nerve (C8, T1). Action: Abducts fifth digit, pulls it forwards and rotates it laterally. MMT: Patient’s forearm supinated, wrist in neutral. He raises the thumb away from the palm and rotates it, so that its distal phalanx opposes the distal phalanx of the little finger. Opposition must be pad to pad. It the patient moves thumb and 5th digit through full range of opposition with no resistance, it shows grade III power. OPPONENS POLLICIS

Origin: Flexor retinaculum, tubercles of scaphoid and trapezium, abductor pollicis longus tendon. Insertion: Radial side of base of proximal phalanx of thumb. Nerve: Median nerve (C8, T1). Action: Rotates thumb into opposition with fingers. MMT: Patient forearm supinated, wrist in neutral position, thumb in adduction with MP and IP flexion. Therapist stabilizes the hand by holding the wrist on the dorsal surface. If the patient moves thumb and 5th digit through full range of opposition with no resistance, it shows grade III power.

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Origin: Shaft of metacarpal of digit on which it acts. Insertion: Dorsal digital expansion and base of proximal phalanx of same digit. Nerve: Ulnar nerve (C8, T1). Action: Adducts thumb, index, ring and little finger. MMT: Patient’s forearm pronated, wrist in neutral and fingers extended and adducted. MP joints are neutral; avoid flexion. Ask patient to hold his fingers together. If the patient can adduct finger towards middle finger, but cannot hold against resistance, it shows grade III power. PALMARIS LONGUS

Origin: Medial epicondyl via common flexor tendon. Insertion: Flexor retinaculum, palmar aponeurosis. Nerve: Median (C7, C8). Action: Flexes wrist. Stretching: Patient is sitting on stool. Therapist is standing beside the patient and facing his wrist. Therapist left hand grasping the lower forearm of the patient, while his right hand grasps the palm and fingers.The therapist extends the wrist of the patient with his right hand.

MUSCULOSKELETAL PECTINEUS

Origin: Pecten pubis, iliopectineal eminence, pubic tubercle. Insertion: Along a line from lesser trochanter to linea aspera. Nerve: Femoral nerve (L2,3) occasionally accessory obturator (L3). Action: Flexes and adducts hip. MMT: Same as for adductors of hip. PECTORALIS MAJOR

Origin: Clavicular attachment—sternal half of anterior surface of clavicle sternocostal attachment—anterior surface of manubrium, body of sternum, upper six costal cartilages, sixth rib, aponeurosis of external oblique muscle. Insertion: Lateral lip of intertubercular sulcus of humerus. Nerve: Medial and lateral pectoral nerve (C5-T1). Action: Adducts, medially rotates, flexes and extends shoulder. MMT: Patient lies supine, shoulder at 90° of abduction and elbow 90° of flexion. Therapist stands at side of testing shoulder. For testing both heads of P. major, ask the patient to move his arm across his chest and hold it. Full range of motion, without resistance shows grade III power.

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Origin: Outer surface of third to fifth ribs and adjoining intercostal fascia. Insertion: Upper surface and medial border of coracoid process. Nerve: Medial and lateral pectoral nerves (C5–T1). Action: Protracts and medially rotates scapula. PERONEUS BREVIS

Origin: Lower 2/3 of lateral surface at fibula, intermuscular septa. Insertion: Lateral side of base of fifth metatarsal. Nerve: Superficial peroneal nerve (L5, S1). Action: Everts and plantar flexes ankle. MMT: Patient in short sitting with ankle in neutral position. Therapist sitting on low stool in front of patient or standing at end of table, if patient is supine. His one hand grips the ankle just above the malleoli for stabilization. Ask patient to turn your foot down and out, hold it. If the patient completes available range of eversion, it shows grade III power. Stretching: Assisted full range of inversion in sitting or supine position.

MUSCULOSKELETAL PERONEUS LONGUS

Origin: Lateral tibial condyle, upper 2/3 of lateral surface of fibula, intermuscular septa. Insertion: Lateral side of base of first metatarsal, medial cuneiform. Nerve: Superficial peroneal nerve (L5, S1). Action: Everts and plantar flexes ankle. MMT: Same as for peroneus brevis. PERONEUS TERTIUS

Origin: Distal third of medial surface of fibula, interosseous membrane, intermuscular septum. Insertion: Medial aspect of base of fifth metatarsal. Nerve: Deep peroneal nerve (L5, S1). Action: Everts and dorsiflexes ankle. MMT: Same as for peroneus longus. PIRIFORMIS

Origin: Front of second to fourth sacral segment, gluteal surface of ilium, pelvic surface of sacrotuberous ligament. Insertion: Medial side of greater trochanter. Nerve: Anterior rami of sacral plexus (L5–S2). Action: Laterally rotates and abducts hip. MMT: Same as for obturators internus and externus.

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Origin: Base and medial side of lateral three toes. Insertion: Medial side of base of proximal phalanx of same toes and dorsal digital expansions. Nerve: Lateral plantar nerve (S2, S3). Action: Adduct third to fifth toes, flex metatarsophalangeal joints of lateral three toes. PLANTARIS

Origin: Lateral supra condylar ridge, oblique popliteal ligament. Insertion: Tendocalcaneus. Nerve: Tibial nerve (S1, S2). Action: Plantar flexes ankle, flexes knee. POPLITEUS

Origin: Outer surface of lateral femoral condyle. Insertion: Posterior surface of tibia above soleal line. Nerve: Tibial nerve (L4–S1). Action: Medially rotates tibia, flexes knee. Stretching: Patient on side lying, with testing limb (right) upward. Therapist stands behind the patient’s left hand over anterior thigh just proximal to knee. His right hand just around the posterior side of the ankle joint from his left hand,

MUSCULOSKELETAL

he pushes the knee joint towards himself and with his right hand, he attempts to pull the leg away from him and rotates it upwards, so that the toes face towards ceiling. PRONATOR QUADRATUS

Origin: Ulna (lower quarter of anterior surface). Insertion: Radius (lower quarter of anterior surface). Nerve: Anterior interosseous branch of median nerve (C7, C8). Action: Pronates forearm. MMT: Patient short sitting over a table. Arms at side with elbow flexed to 90° and forearm in supination. Therapist standing at side or in front of patient. Support the elbow, ask the patient to turn the palm down and hold it. If the patient completes available range of motion it shows grade III power. PRONATOR TERES

Origin: Humeral head—medial epicondyle via common flexor tendon, intermuscular septum, antebrachial fascia, ulnar head—medial part of coronoid process. Insertion: Middle of lateral surface of radius. Nerve: Median nerve (C6, C7).

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Action: Pronates forearm, flexes elbow. MMT: Same as for pronator quadratus. PSOAS MAJOR

Origin: Bodies of T12 and all lumbar vertebrae, bases of transverse processes of all lumbar vertebrae, lumbar intervertebral disks. Insertion: Lesser trochanter. Nerve: Anterior rami of lumbar plexus (L1–L3). Action: Flexes hip and lumbar spine. MMT: Same as for iliacus. PSOAS MINOR (NOT ALWAYS PRESENT)

Origin: Bodies of T12 and L1 vertebrae and intervertebral disks. Insertion: Pecten pubis, iliopubic eminence, iliac fossa. Nerve: Anterior primary ramus (L1). Action: Flexes trunk (weak). MMT: Same as for psoas major. QUADRATUS FEMORIS

Origin: Ischial tuberosity. Insertion: Quadrate tubercle midway down intertrochanteric crest. Nerve: Nerve to quadratus femoris (L5, S1).

MUSCULOSKELETAL

Action: Laterally rotates hip. MMT: Same as for obturator and piriformis. QUADRATUS LUMBORUM

Origin: Iliolumbar ligament, posterior part of iliac crest. Insertion: Lower border of 12th rib, transverse process of L1–L4. Nerve: Ventral rami of T12 and L1–L3,4. Action: Laterally flexes trunk, extends lumbar vertebrae, steadies 12th rib during deep inspiration. MMT: Same as for interspinales lumborum. RECTUS ABDOMINIS

Origin: Symphysis pubis, pubic crest. Insertion: 5th–7th costal cartilages, xiphoid process. Nerve: Central rami T6,7–T12. Action: Flexes trunk. MMT: Patient supine with arms outstretched in full extension above plane of body. Instruct the patient to raise your head, shoulders and arms off the table. Full range of motion till inferior angle of scapulae are off the table, shows grade III power.

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Origin: Anterior surface of lateral mass of atlas and root of its transverse process. Insertion: Occipital bone. Nerve: Anterior primary rami (C1, C2). Action: Flexes neck. MMT: Same as for longus capitis. RECTUS CAPITIS LATERALIS

Origin: Atlas (transverse process). Insertion: Jugular process of occipital bone. Nerve: Ventral rami (C1, C2). Action: Laterally flexes neck. MMT: Same as for rectus capitis anterior. RECTUS CAPITIS POSTERIOR MAJOR

Origin: Axis (spinous process). Insertion: Occipital bone (lateral part of inferior nuchal line). Nerve: Dorsal ramus (C1). Action: Extends and rotates neck. MMT: Same as for longissimus capitis. RECTUS CAPITIS POSTERIOR MINOR

Origin: Atlas (posterior tubercle).

MUSCULOSKELETAL

Insertion: Medial part of inferior nuchal line of occipital bone. Nerve: Dorsal ramus (C1). Action: Extends neck. MMT: Same as for longissimus capitis. RECTUS FEMORIS

Origin: Straight head—anterior inferior iliac spine; Reflected head—area above acetabulum, capsule of hip joint. Insertion: Base of patella, then forms part of patellar ligaments. Nerve: Femoral nerve (L2–L4). Action: Extends knee, flexes hip. MMT: MMT of rectus femoris is carried out jointly as for quadriceps femoris. Patient in short sitting place wedge under the distal thigh to maintain the femur in the horizontal position. Patient should lean backward to relieve hamstring muscle tension. Therapist standing at side of testing limb. Ask patient to extend his knee through available range of motion, but not beyond 0°. If patient completes available range of motion and holds the position without resistance, its shows grade III power. Stretching: Patient is in side lying with stretching limb in side. Therapist stand behind the patient at the level of his pelvis, keeping his one hand

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over pelvis to stabilize and one hand to support the knee. He then gradually pulls the limb in backward direction till a stretch is felt over anterior part of the thigh. RHOMBOID MAJOR

Origin: T 2 –T 5 [spines and supraspinous ligaments]. Insertion: Medial border of scapula between root of spine and inferior angle. Nerve: Dorsal scapular nerve [C4, C5]. Action: Retracts and medially rotates scapula. MMT: Patient on prone lying. Shoulder is internally rotated and arm is adducted across the back with elbow flexed and hand resting on the back. Ask the patient to lift his hand and hold it. Full range of motion shows grade III power. RHOMBOID MINOR

Origin: C7–T1 (spine and supraspinous ligaments), lower part of ligamentum nuchae. Insertion: Medial end of spine of scapula. Nerve: Dorsal scapular nerve [C4, C5]. Action: Retracts and medially rotates scapula. MMT: Same as for rhomboid major. ROTATORES

Origin: Transverse process of each vertebra.

MUSCULOSKELETAL

Insertion: Lamina of vertebra above. Nerve: Dorsal rami of spinal nerves. Action: Extends vertebral column and rotates thoracic region. SARTORIUS

Origin: Anterior superior iliac spine and area just below. Insertion: Upper part of medial side of tibia. Nerve: Femoral nerve [L2, L3]. Action: Flexes hip and knee, laterally rotates and abducts hip, medially rotates tibia on femur. MMT: Short sitting with thigh supported on table and legs hanging over side. Ask Patient to side your heel up the shin of your other leg. Complete range of motion with hold at end position shows, grade III power. SCALENUS ANTERIOR

Origin: C3–C6 [anterior tubercles of transverse process]. Insertion: Scalene tubercle on inner border of first rib. Nerve: Ventral rami [C4–C6]. Action: Flexes, laterally flexes and rotates neck, raises first rib during respiration.

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MMT: Patient supine lying with head on table. Ask the patient to bring your head off the table, keeping your eyes on ceiling. Keep your shoulders completely on the table. Full range of motion without resistance, show grade III power. SCALENUS MEDIUS

Origin: Atlas and axix (transverse process), C3–C7 (posterior tubercles of transverse processes). Insertion: Upper surface of first rib. Nerve: Ventral rami (C3–C8). Action: Laterally flexes neck, raises first rib during respiration. MMT: Patient supine with cervical spine in neutral. Ask patient to turn your head and face the ceiling and hold it. If the patient rotates head through full range to both right and left without resistance, it shows grade III power. SCALENUS POSTERIOR

Origin: C4–C6 [posterior tubercles of transverse process]. Insertion: Outer surface of second rib. Nerve: Ventral rami [C6–C8]. Action: Laterally flexes neck, raises second rib during respiration. MMT: Same as for scalenus medius.

MUSCULOSKELETAL SEMIMEMBRANOSUS

Origin: Ischial tuberosity Insertion: Posterior aspect of medial tibial condyle. Nerve: Tibial division of sciatic nerve [L5–S2]. Action: Flexes knee, extends hip and medially rotates tibia on femur. MMT: Patient in prone lying. Therapist stands beside the patient. Ask the patient to lift the leg off the table, as high as without bending the knee. If the patient completes full range of motion and hold the position without resistance, it shows grade III power. Stretching: Patient in supine lying. Therapist stands beside the patient and facing the hip joint. Therapist grasps lower leg region of the patient with his right hand, while his left hand grasps the patient’s knee. He flexes the patients hip and knee with his both hands. SEMISPINALIS CAPITIS

Origin: C7–T6/7 (transverse process). C4–C6 (articular process). Insertion: Between superior and inferior nuchal lines of occipital bone. Nerve: Dorsal rami of spinal nerve. Action: Extends and rotates head.

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MMT: Patients prone with head off end of table. Arm at sides. Therapist standing next to patients head with one head supporting (or ready to support the forehead). Ask the patient to look at the wall in front. If the patient completes range of motion, but takes no resistance, it shows grade III power. SEMISPINALIS CERVICIS

Origin: T1–T5/6 (transverse processes). Insertion: Spinous process of C2–C5. Nerve: Dorsal rami of spinal nerve. Action: Extends and rotates vertebral column. MMT: Patient in prone lying with head off end of table. Arm at side. Therapist standing next to patient’s head with one hand supporting the forehead. Ask the patient to lift forehead and keep looking at floor. If the patient completes the full range without resistance, it shows grade III power. SEMISPINALIS THORACIS

Origin: T6–T10 (transverse processes). Insertion: C6–T4 spinous processes. Nerve: Dorsal rami of spinal nerve. Action: Extends and rotates vertebral column.

MUSCULOSKELETAL

MMT: Prone with arm at sides. Therapist standing at side of table. Lower extremities are stabilized just above the ankle. Ask the patient to raise your head arm and chest from the table as high as you can. SEMITENDINOSUS

Origin: Ischial tuberosity. Insertion: Tibia (upper part of medial surface). Nerve: Tibial division of sciatic nerve (L5–S2). Action: Flexes knee, extends hip and medially rotates tibia on femur. MMT: Same as for semimembranosus. Stretching: Same as for semimembranosus. SERRATUS ANTERIOR

Origin: Outer surface and superior border of upper eight, nine or ten ribs and intervening intercostal fascia. Insertion: Costal surface of medial border of scapula. Nerve: Long thoracic nerve (C5–C7). Action: Protracts and laterally rotates scapula. MMT: Patient in short sitting over end or side of table. Hands on lap. Therapist standing at test side of patient. Hand giving resistance is on the arm proximal to the elbow. The other hand uses the

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webspace along with the thumb and index finger to palpate the edges of the scapula at the inferior angle and along the vertebral and axillary borders. Ask the patient to raise arm forward over head, keep the elbow straight; hold it, do not let push your arm down. If patient’s scapula moves through full range of motion without winging but can tolerate no resistance other than the weight of the arm. SOLEUS

Origin: Soleal line and middle third of medial border of tibia, posterior surface of head and upper quarter of fibula, fibrous arch between tibia and fibula. Insertion: Posterior surface of calcaneus. Nerve: Tibial nerve (S1, S2). Action: Plantar flexes ankle. MMT: Patient standing on testing limb with knee slightly flexed. Use one or two finger for balance assist. Therapist standing or sitting with clear lateral view of test limb. Ask patient to stand on right leg with knee bent. Keep knee bent and go up and down on toes atleast 20 times. If the patient completes between nine and one correct heel rises, with the knee flexed then it shows grade III power. Stretching: Patient in supine lying. Therapist standing beside the patient. The therapist holds

MUSCULOSKELETAL

the lower thigh region with his left hand and flexing the knee. The therapist’s right hand holds the heel in neutral position. Slowly dorsiflex the ankle to full range. SPINALIS (CAPITIS, CERVICIS, THORACIS)

Origin: Spinalis thoracis-spinous processes of T11–L2. Insertion: Spinalis thoracis-spinous processes of upper four to eight thoracic vertebrae. Nerve: Dorsal rami. Action: Extends vertebral column. MMT: Spinalis capitis and spinalis cervicis are poorly developed. So test is done for only spinalis thoracis. The test is same as for semispinalis thoracis. SPLENIUS CAPITIS

Origin: Ligamentum nuchae (lower half), spinous processes of C 7 –T 3/4 and their supraspinous ligaments. Insertion: Mastoid process of temporal bone, lateral third of superior nuchal line of occipital bone. Nerve: Dorsal rami (C3–C5). Action: Extends, laterally flexes and rotates neck. MMT: Same as for semispinalis capitis.

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Origin: T3 T6 (spinous processes). Insertion: Posterior tubercles of transverse processes of C1–C3/4. Nerve: Dorsal rami (C5–C7). Action: Laterally flexes, rotates and extends neck. MMT: Same as for semispinalis cervicis. STERNOCLEIDOMASTOID

Origin: Sternal head-anterior surface of manubrium sterni, calvicular head—upper surface of medial third of clavicle. Insertion: Mastoid process of temporal bone, lateral half of superior nuchal line of occipital bone. Nerve: Accessory nerve (XI). Action: Laterally flexes and rotates neck; anterior fibers flex neck, posterior fibers extend neck. MMT: Same as for scalenus anterior. SUBSCAPULARIS

Origin: Medial 2/3 of subscapular fossa and tendinous intramuscular septa. Insertion: Lesser tubercle of humerus, anterior capsule of shoulder joint. Nerve: Upper and lower subscapular nerve (C5, C6).

MUSCULOSKELETAL

Action: Medially rotates shoulder. MMT: Patient prone with head turned towards test side. Shoulder is abducted to 90° with folded towel placed under distal arm and forearm hanging vertically over edge of table. Ask patient to move your forearm up and back and hold it. If the complete range is achieved, it shows grade III power. Stretching: Patient is supine lying. Therapist is standing beside the patient and facing the limb. The therapist grasps the lower arm of patient with his left hand while his right hand grasping the wrist of the patient and applying the stretch force towards lateral rotation. SUPERIOR OBLIQUE

Origin: Atlas (upper surface of transverse process). Insertion: Superior and inferior nuchal lines of occipital bone. Nerve: Dorsal ramus (C1). Action: Extends neck. SUPINATOR

Origin: Lateral epicondyle (inferior aspect), radial collateral ligament, annular ligament, supinator crest and fossa of ulna. Insertion: Posterior, lateral and anterior aspects of upper third of radius.

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Nerve: Posterior interosseous nerve (C6, C7). Action: Supinates forearm. MMT: Patient in short sitting. Arm at side and elbow flexed to 90° forearm in pronation. Therapist stands at side and supports the elbow. Ask patient to turn your palm up. If the patient completes available range of motion without resistance, it shows grade III power. Stretching: Patient in supine lying. Therapist is standing beside the patient and facing the limb. Therapist’s left hand stabilizing the anterior aspect of proximal humerus of the patient. Therapist’s right hand grasping the lower forearm, wrist and hand of the patient and elbow is in 90° flexed position. Therapist’s right hand supinates and pronates the forearm and stretches the structures. SUPRASPINATUS

Origin: Supraspinous fossa (medial 2/3) and supraspinous fascia. Insertion: Capsule of shoulder joint, greater tubercle of humerus. Nerve: Suprascapular nerve (C5, C6). Action: Abducts shoulder. MMT: Patient in short sitting with arm at side and elbow slightly flexed. Ask the patietnt to lift arm out to the side to shoulder level and hold it. If the

MUSCULOSKELETAL

patient completes the range of motion (90°), it shows grade III power. TENSOR FASCIAE LATAE

Origin: Outer lip of iliac crest between iliac tubercle and anterior superior iliac spine. Insertion: Iliotibial tract. Nerve: Superior gluteal nerve (L4–S1). Action: Extends knee, abducts and medially rotates hip. MMT: Patient in side-lying, with testing limb in upper side and flexed to 45° and lies across the lowermost limb with the foot resting on the table. Ask the patient to lift your leg and hold it. If the patient completes the movement and holds it without resistance, then it shows grade III power. TERES MAJOR

Origin: Dorsal surface of inferior scapular angle. Insertion: Medial lip of intertubercular sulcus of humerus. Nerve: Lower subscapular nerve (C5, C7). Action: Extends, adducts and medially rotates shoulder. MMT: Patient in prone with head turned to one side, arm at side, test arm is internally rotated

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(palm up). Ask the patient to lift arm as high as you can. If the patient completes available range of motion without resistance, it shows grade III power. Stretching: Patient in supine lying, therapist is standing beside the patient and facing the limb. The therapist grasps the lower arm region with his left hand and the patient forearm resting over the therapist forearm. Therapist right hand apply opposite force on the scapular region to prevent scapular movement. Stretch force is given towards the flexion of the shoulder with the therapist left hand. TERES MINOR

Origin: Upper 2/3 of dorsal surface of scapula. Insertion: Lower facet on greater tuberosity of humerus, lower posterior surface of capsule of shoulder joint. Nerve: Axillary nerve (C5, C6). Action: Laterally rotates shoulder. MMT: Same as for infraspinatous. Stretching: Patient in supine lying. Therapist is standing beside the patient and facing the limb. Therapist grasps the lower arm of the patient with his left hand and his right hand grasps the wrist and applying the stretch force towards the medial rotation.

MUSCULOSKELETAL TIBIALIS ANTERIOR

Origin: Lateral tibial condyle and upper 2/3 of lateral surface of tibia, interosseous membrane. Insertion: Medial and inferior surface of medial cuneiform, base of first metatarsal. Nerve: Deep peroneal nerve (L4,5). Action: Dorsiflexes and inverts ankle. MMT: Patient in short sitting. Therapist sitting on stool in front of patient with patient’s heel resting on thigh. Ask the patient to bring foot up and holds it. If the patient completes the available range of motion and holds it, shows grade III power. Stretching: Patient in supine lying. Therapist is standing beside the patient and facing the ankle joint. The therapist left hand grasps the lower leg region and his right hand palm holding the heel of the patient. Therapist’s right hand plantar flexes the ankle and stretches the tightened structures. TIBIALIS POSTERIOR

Origin: Tibia (lateral aspect of posterior surface, below soleal line, interosseous membrane, upper half of posterior surface of fibula, deep transverse fascia). Insertion: Tuberosity of navicular, medial cuneiform, sustentaculum tali, intermediate cuneiform, base of second to fourth metatarsals.

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Nerve: Tibial nerve (L4,5). Action: Plantar flexes and inverts ankle. MMT: Patient in short sitting with ankle in slight plantar flexed. Therapist sitting on low stool in front of patient or on side of test limb. One hand is used to stabilize the ankle just above the malleoli. Ask the patient to turn your foot down and in and hold it. If the patient is able to invert the foot through the full available range of motion, it shows grade III power. Stretching: Patient in supine lying, therapist is standing beside the patient and facing the ankle joint. He then grasps the ankle joint of the patient with his left hand while his right hand grasps the foot region. Therapist’s right hand is applying stretch force towards the inversion and eversion movement and stretches the tightened structure. TRANSVERSUS ABDOMINIS

Origin: Lateral third of inguinal ligament, anterior two-third of inner lip of iliac crest, thoracolumbar fascia between iliac crest and 12th rib, lower six costal cartilages where it interdigitates with diaphragm. Insertion: Abdominal aponeurosis to linea alba. Nerve: Ventral rami of lower six thoracic and lumbar spinal nerve. Action: Compresses abdominal contents, raises intra-abdominal pressure.

MUSCULOSKELETAL TRAPEZIUS

Origin: Medial 1/3 of superior nuchal line, external occipital protuberance, ligament nuchae, C7 spine, T1–T12 spines, corresponding supraspinous ligament. Insertion: Upper fibers—posterior border of lateral third of clavicle; middle fibers—medial border of acromion, superior lip of crest of spine of scapula; lower fibers—tubercle at medial end of spine of scapula. Nerve: Accessory nerve (XI) ventral rami (C3, C4). Action: Upper fibers elevate scapula, middle retract scapula, lower fibers depress scapula. MMT: 1. For upper fibers: Patient in short sitting over end of table hands relaxed on lap. Ask patient to raise his shoulder towards his ear. 2. For middle fibers: Patient in prone lying with shoulder at the edge of table and 90° abducted elbow is flexed to 90°. Ask patient to lift elbow towards ceiling and hold it. 3. For lower fibers: Patient in prone with arms over head to about 145° of abduction. Forearm is in midposition with the thumb pointing towards the ceiling. Therapist stands at test side. His finger tip of one hand palpate below the spine of scapula and across to the thoracic vertebrae, following the muscle as it curves down to the lower thoracic vertebrae. Ask

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patient to raise your arm from the table as high as possible and hold it. If the patient completes the available ROM in all above 3 tests, then the muscle is in grade III. TRICEPS BRACHII

Origin: Long head: infraglenoid tubercle of scapula, shoulder capsule. Lateral head: Above and lateral to spiral groove on posterior surface of humerus. Medial head: Below and medial to spiral groove on posterior surface of humerus. Insertion: Upper surface of olecranon, deep fascia of forearm. Nerve: Radial nerve (C6, C8). Action: Extends elbow and shoulder. MMT: Patient in prone on table. His shoulder of testing limb is in 90° of flexion and forearm hanging vertically at the edge of the table. Ask patient to straighten your elbow and hold it. If the patient completes the available ROM with no resistance, it shows grade III power. Stretching: Patient in supine lying or sitting. Therapist is standing beside the patient. Therapist left hand hold’s the patient hand and flexes the elbow after the hand reaches the shoulder. Therapist left hand stabilizes the shoulder also. Therapist right hand grasping the elbow, lifts up to gain shoulder flexion.

MUSCULOSKELETAL VASTUS INTERMEDIUS

Origin: Upper 2/3 of anterior and lateral surface of femur, lower part of lateral intermuscular septum. Insertion: Deep surface of quadriceps tendon, lateral border of patella, lateral tibial condyle. Nerve: Femoral nerve (L2–L4). Action: Extends knee. MMT: Done along with quadriceps femoris. Stretching: Done along with quadriceps femoris. VASTUS LATERALIS

Origin: Intertrochanteric line, greater trochanter, gluteal tuberosity, lateral lip of linea aspera. Insertion: Tendon of rectus femoris, lateral border of patella. Nerve: Femoral nerve (L2, L4). Action: Extends knee. MMT: Done along with quadriceps femoris. Stretching: Done along with quadriceps femoris. VASTUS MEDIALIS

Origin: Intertrochanteric line, spiral line, medial lip of linea aspera, medial supracondylar line, medial intermuscular septum, tendon of adductor longus and adductor magnus.

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Insertion: Tendon of rectus femoris, medial border of patella, medial tibial condyle. Nerve: Femoral nerve (L2–L4). Action: Extends knee. MMT: Done along with quadriceps femoris. Stretching: Done along with quadriceps femoris. JOINT RANGE OF MOVEMENT TYPES OF GONIOMETER

1. Universal goniometer (by Mr Moore) 2. Gravity depended or fluid goniometer (by Mr Schenkar) 3. Pendulum goniometer (by Mr Fox and van Breemen) 4. Electrogoniometer (by Mr Karpovich and Karpovich) RANGE OF MOTION FOR VARIOUS JOINTS Shoulder

Flexion Extension Abduction Adduction Internal rotation External rotation

0–180° 0–45° 0–180° 0 0–90° 0–90°

(150°–180°) (40°–60°) (150°–180°) (70°–90°) (70°–90°)

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Elbow

Flexion Extension

CHAPTER

0–130° (120°–150°) 135°–0

Forearm

Supination Pronation

0–90° 0–90°

Wrist

Flexion Extension Ulnar deviation Radial deviation

0–90° 0–70° 0–40° 0–20°

(10°–90°) (50°–70°) (25°–40°) (15°–25°)

MCP

Flexion Extension Abduction Adduction

0–90° 0–20° 0–20° 0

(15°–30°)

PIP

Flexion Extension

0–110° (90°–120°) 0

DIP

Flexion Extension

0–90° 0

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MCP flexion

0–45°

HIP

Flexion Extension Abduction Adduction External rotation Internal rotation

0–120° 0–35° 0–55° 0 0–45° 0–35°

(110°–130°) (25°–40°) (35°–50°) (30°–45°)

Knee

Flexion Extension

0–120° 0

Ankle

Plantar flexion Dorsi flexion Inversion Eversion

0–45° 0–20° 0–45° 0–15°

MTP

Flexion Extension Abduction

0–40° 0–80° 0–15°

(10°–90°)

Intraphalangeal

Flexion Extension

0–60° 0

(50°–70°)

MUSCULOSKELETAL Cervical Spine

Flexion Extension Lateral flexion Rotation

CHAPTER

0–45° 0–45° 0–45° 0–60°

Thoracic and Lumbar Spine

Flexion Extension Lateral flexion Rotation

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0–80° 0–25° 0–35° 0–45°

Note: MCP: Metacarpophalangeal joint PIP: Proximal interphalangeal joint DIP: Distal interphalangeal joint MEASURING PROCEDURES Shoulder Joint

Flexion Axis: Greater tuberosity of humerus Moving arm: On the midline of lateral aspect of arm Fixed arm: Straight to the moving arm. Extension Axis: Greater tuberosity of humerus Moving arm: Midline of the lateral aspect of arm Fixed arm: Straight to the moving arm.

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Abduction Axis: One inch below the acromion process of the scapula Moving arm: Midline of the anterior aspect of arm Fixed arm: Horizontally on the clavicle. Medial and lateral rotation Axis: Olecranon process of the ulna Moving arm: Midline of the posterior aspect of forearm Fixed arm: Straight to moving arm. Elbow Joint

Flexion Axis: Lateral epicondyle of humerus Fixed arm: Lateral midline of humerus Moving arm: Lateral midline of forearm. Radioulnar Joint

Pronation Axis: Ulnar styloid process Fixed arm: Perpendicular to the moving arm without any body contact Moving arm: Anterior aspect of wrist Supination Axis: Ulnar styloid process

MUSCULOSKELETAL

Fixed arm: Perpendicular to the movable arm without any body contact Moving arm: Posterior aspect of wrist. Wrist Joint

Flexion and extension Axis: Medial margin of wrist Fixed arm: Lateral midline of forearm Moving arm: Lateral midline of little finger. Ulnar and radial deviation Axis: Middle of the posterior aspect of wrist Fixed arm: Middle of posterior aspect of forearm Moving arm: Midline of posterior aspect of the middle finger. MCP

Flexion Axis: Midline of the posterior aspect of the joint line of the MCP Fixed arm: Midline of the posterior aspect of wrist and forearm Moving arm: Midline of the posterior aspect of the metacarpal. Extension Axis: Middle of the anterior aspect of the joint line of MCP.

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Fixed arm: Midline of the anterior aspect of wrist and forearm Movable arm: Midline of the anterior aspect of the metacarpal and phalanx. Abduction and adduction Axis: Middle of the posterior aspect of the joint line of the MCP Fixed arm: Midline of the posterior aspect of wrist and forearm Moving arm: Midline of the posterior aspect of the metacarpal. PIP

Flexion and extension Axis: Middle of the posterior aspect of the joint line of the PIP Fixed arm: Midline of the posterior aspect of the MC, wrist and forearm Moving arm: Midline of the posterior aspect of phalanx. Hip Joint

Flexion Axis: Greater trochanter of the femur Fixed arm: Midline of the lateral aspect of lower trunk Moving arm: Midline of the lateral aspect of thigh.

MUSCULOSKELETAL

Extension Axis: Greater trochanter of femur Fixed arm: Midline of the lateral aspect of lower trunk Moving arm: Midline of lateral aspect of the thigh. Adduction Axis: Two inches below the ASIS Moving arm: Midline of the anterior aspect of the thing Fixed arm: 90° to the movable arm. Medial and lateral rotation Axis: Tip of patella Moving arm: Midline of the anterior aspect of the leg Fixed arm: Straight to moving arm. Knee Joint

Flexion Axis: Lateral joint line Moving arm: Midline of lateral aspect of leg Fixed arm: Midline of the lateral aspect of thigh. Ankle Joint

Plantar and dorsiflexion Axis: Tip of medial malleolus.

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Fixed arm: Midline of the medial aspect of the leg Moving arm: 90° to stable arm. Subtalar Joint

Inversion Axis: Medial joint line of the head of the first metatarsal Fixed arm: Parallel to the medial aspect of the ankle and lower leg Moving arm: Perpendicular to the fixed arm. Eversion Axis: Lateral aspect of the head of the fifth metatarsal Fixed arm: Parallel to the lateral aspect of the lower leg Moving arm: Perpendicular to the fixed arm. Cervical Spine

Atlanto-occipital and atlanto-axial joint Flexion—Extension Axis: External auditory meatus Fixed arm: Perpendicular to the ground Moving arm: Base of nares. Lateral flexion Axis: Spinous process of C7 vertebrae

MUSCULOSKELETAL

Fixed arm: Perpendicular to the ground Moving arm: Midline of head. Rotation Axis: Center of cranial aspect of head Fixed arm: Parallel to the line joining both acromion process Moving arms: Along the line of the tip of the nose. Thoraco-lumbar Spine

Flexion—extension 1. Measure distance between C7 and S1 spinous process and then ask the patient to bend forward. 2. Again take measurement and calculate difference between first and final measurement. Lateral flexion Axis: Posterior aspect of S1 spinous process Fixed arm: Perpendicular to the ground Moving arm: Parallel to the spine with reference to the spinous process of C7 vertebra. Rotation Axis: Center of the cranial aspect of the head Fixed arm: Parallel to the imaginary line between the tubercles of the iliac crest Moving arm: Parallel to the imaginary line between acromion process.

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COMMON MUSCULOSKELETAL TESTS CERVICAL SPINE Distraction Test

Tests: Nerve root compression. Patient’s position: Sitting. Procedure: Put one hand under chin and other hand under occiput, then gently lift patient’s head. Positive sign: Relief or decrease in pain. Quadrant Test

Tests: Vascular involvement in spine. Patient’s position: Sitting or supine lying. Procedure: Examiner passively takes patient’s head and neck in extension and side. Flexion and rotation, hold it for 30 seconds. Positive sign: Dizziness, nausea, headache, nystagmus. Romberg’s Test

Tests: Cervical neuropathy, UMNL. Patient’s position: Standing. Procedure: Ask the patient to close his eyes and hold the position for 20 to 30 seconds. Positive sign: Body sways, patients looses balance.

MUSCULOSKELETAL Sharp-Purser Test

Tests: Cervical instability (subluxation). Patient’s position: Sitting. Procedure: Examiner’s one hand over forehead while thumb of other hand over spinous process of axis, patient is asked to flex his head. Positive sign: The head slides backward during the movement. Spurling’s Test

Tests: Nerve root compression. Patient’s position: Sitting. Procedure: Neck of unaffected side in side flexion, apply gentle pressure on the top of patient’s head. Test is repeated on affected side. Positive sign: Onset or increase in pain radiating into shoulder or arm on fixed side. Upper Limb Tension Test

Tests: Brachial plexus tension. Procedure: Test should be done in sequence given below: ULTT 1 • Depress and abduct (110°) shoulder • Elbow extension • Forearm supination

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• Wrist extension • Finger and thumb extension • Contralateral side flexion of cervical spine. ULTT 2 • Depress and abduct (10°) shoulder • Elbow extension • Forearm supination • Wrist extension • Finger and thumb extension • Shoulder lateral rotation • Contralateral side flexion of cervical spine. ULTT 3 • Depress and abduct (10°) shoulder • Elbow extension • Forearm pronation • Wrist flexion and ulnar deviation • Finger and thumb flexion • Shoulder medial rotation • Contralateral side flexion of cervical spine. UTLL 4 • Depress and abduct (10°–90°) shoulder • Elbow extension • Forearm supination • Wrist extension and radial deviation • Finger and thumb extension • Shoulder lateral rotation • Contralateral side flexion of cervical spine. Positive sign: Radiculating pain and stress over the nerve of brachial plexus.

MUSCULOSKELETAL THORACIC SPINE Slump Test

Tests: Dural stretch. Patient’s position: Sitting. Procedure 1. Patient sits on table, slumps so that spine flexes, shoulder sags forward, examiner holds the chin and head erect. If no symptoms, then in continuation. 2. Examiner flexes patient’s neck and holds the head down, if again no symptoms then in continuation. 3. Examiner passively extends patients knee and dorsiflexes the foot. Positive sign: Sciatic pain, impingement of dura and spinal cord or nerve roots. LUMBAR SPINE Brudzinski-Kernig Test

Tests: Neurodynamic dysfunction. Patient’s position: Supine. Procedure: Hands cupped behind the head. Patient actively flex the head onto chest. Patient raises the extended leg with hip flexion until pain is felt, patient then flexes the knee. Positive sign: Pain disappears.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Farfan Torsion Test

Tests: Lumbar instability. Patient’s position: Prone. Procedure: Examiner stabilizes ribs and spine by a hand and other hand on ilium. Anteriorly pulls the ilium backward, results in rotation of spine on opposite side. Positive sign: Reproduce all the symptoms in patient. Quadrant Test

Tests: Joint dysfunction. Procedure: Patient standing with examiner standing behind. Patient extends spine, patient holds the occiput on her/his shoulder and takes weight of head. Over pressure is applied, when patient side flexes and rotates. Positive sign: Pain in the back and sometimes stress fracture. Slump Test

Tests: Neurodynamic dysfunction. Procedure ST1: Supine lying • Cervical spine flexion • Thoracic and lumbar spine flexion • Hip flexion (90°)

MUSCULOSKELETAL

• Knee extension • Ankle dorsiflexion. ST2: Supine lying • Cervical spine flexion • Thoracic and lumbar flexion • Hip (90°), abduction • Knee extension • Ankle dorsiflexion. ST3: Side lying • Cervical spine flexion • Thoracic and lumbar spine flexion • Hip flexion (20°) • Knee flexion • Ankle plantar flexion. ST4: Long sitting • Cervical spine flexion, rotation • Thoracic and lumbar spine flexion • Hip flexion (90°) • Knee extension • Ankle dorsiflexion. Positive sign: Reproduce the patient’s symptoms, cause discomfort or pain on neurological tissues. Straight Leg Raise Test

Tests: Neurodynamic dysfunction. Patient’s position: Supine lying. Procedure: Stabilize the unaffected leg, patient actively raise the leg (hip flexion, with knee extension and ankle neutral).

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Positive sign: Pain and stretch below the range of 65°–70°. SHOULDER JOINT Anterior Drawer Test

Tests: Anterior shoulder instability. Patient’s position: Supine. Procedure: Hold shoulder in 80°–120° abduction, 0–20° forward flexion and 0–30° lateral rotation. Perform flexion with stabilized scapula. Positive sign: Click sound or/and apprehension. Clunk Test

Tests: Ligament injury/tear of glenoid labrum. Patient’s position: Supine. Procedure: Ask patient to abduct shoulder over his head. Apply anterior force to posterior aspect of humeral head, while lateral rotation. Positive sign: Clunk or grinding sound and/or apprehension of instability present anteriorly. Crank (Anterior Apprehension) Test

Tests: Anterior shoulder instability. Patient’s position: Supine. Procedure: Slowly abduct the shoulder to 90° with lateral rotation. Positive sign: Apprehension.

MUSCULOSKELETAL Droparm Test/Codman’s Test

Tests: Supraspinatus tendon rupture. Patient’s position: Sitting. Procedure: Examiner on side, put one hand on shoulder girdle and other on forearm. Passively abduction of arm to 90° in prone. Patient lowers down the abducted arm. Positive sign: Pain and lack of motor control. Duga’s Test

Tests: Shoulder dislocation. Patient’s position: Standing, both arms hanging by side. Procedure: Patient is asked to touch the opposite shoulder by flexing the shoulder and elbow of the affected arm. Positive sign: Patient is unable to touch the opposite shoulder. Empty Can Test

Test: Pathology of supraspinatus tendon. Patient’s position: Sitting or standing. Procedure: Shoulder abduction 90°; horizontal flexion 30° and medially rotate the thumb pointing downwards. Positive sign: Weakness or reappearance of symptoms.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Hamilton Ruler Test

Tests: Inferior shoulder instability. Patient’s position: Standing. Procedure: Examiner places straight ruler over affected arm and checks whether the acromion process and lateral epicondyle are touched by the ruler at the same time or not. Positive sign: If the ruler do not touch both at the same time, indicates instability. Hawkins-Kennedy Test

Tests: Supraspinatus tendon impingement. Patient’s position: Sitting or standing. Procedure: Ask the patient to forward flex shoulder to 90° and elbow flexion 90°. Apply medial rotation passively. Positive sign: Reproduction of symptoms. Jerk Test

Tests: Posterior shoulder instability. Patient’s position: Sitting. Procedure: Hold shoulder in 90° forward flexion and medial rotation. Apply longitudinal cephalad force (from head) to humerus and adduct the arm horizontally. Positive sign: Sudden jerk or clunk.

MUSCULOSKELETAL Neer Impingement Test

Tests: Biceps or supraspinatus tendon impingement. Patient’s position: Sitting or standing. Procedure: Forward flex arm and medially rotate it passively. Positive sign: Reappearance of symptoms. Posterior Drawer Test

Tests: Posterior shoulder instability. Patient’s position: Supine. Procedure: Place shoulder in 100°–120° abduction, elbow flexed to 120° and shoulder in 20°–30° forward flexion. Medial rotation and forward flexion of shoulder up to 60°–80° with scapula stabilized. Positive sign: Apprehension and/or significant posterior displacement. Speeds Test

Tests: Pathology of biceps tendon. Patient’s position: Sitting or standing. Procedure: Elbow extension, forearm supination and shoulder forward flexion. Apply resistance when patient performs shoulder flexion. Positive sign: Increased pain in bicipital groove.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Sulcus Sign

Tests: Inferior shoulder instability. Patient’s position: Standing or sitting. Procedure: Arm by side. Hold arm below elbow and pull distally. Positive sign: Reappearance of symptoms and/or apprehension of sulcus under acromion. ELBOW JOINT Cozen’s Test

Tests: Lateral epicondylitis. Patient’s position: Sitting or standing. Procedure: Grip the patient’s forearm distally and ask the patient to make a firm fist and passively flex the wrist. Positive sign: Pain over lateral epicondyle and reappearance of symptoms. Elbow Flexion Test

Tests: Cubital tunnel syndrome. Patient’s position: Sitting or standing. Procedure: Elbow full flexion with extended wrist. Hold it for 5 minutes. Positive sign: Tingling or paresthesia in ulnar nerve distribution.

MUSCULOSKELETAL Jug Test

Test: Lateral epicondylitis. Patient’s position: Standing. Procedure: Ask him to lift a jug full of water holding it from its mouth. Positive sign: Pain and reappearance of symptoms. Lateral Epicondylitis Test (Tennis Elbow)

Tests: Lateral epicondylitis. Patient’s position: Sitting or standing. Procedure Method 1: Passive elbow extension, forearm pronation and flexion fingers and wrist while palpating lateral epicondyle. Method 2: Resist extension of middle finger distal to PIP joint. Positive sign: Pain over lateral epicondyle and reappearance of symptoms. Pinch Grip Test

Tests: Median (anterior interosseous) nerve intrapment. Patient’s position: Sitting or standing. Procedure: Patient pinches the tip of index finger and thumb together. Positive sign: Inability to pinch tip to tip.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Valgus Stress Test

Tests: Stability of medial collateral ligament. Patient’s position: Sitting. Procedure: Stabilize upper arm with elbow flexion in 20°–30° and lateral rotation of humerus in full range. Apply force while abducting forearm. Positive sign: Reappearance of symptoms or increased laxity. Varus Stress Test

Tests: Stability of lateral collateral ligament. Patient’s position: Sitting. Procedure: Stabilize upper arm. Elbow flexion in 20°–30° and humerus in medial rotation. Positive sign: Excessive laxity or reappearance of symptoms. WRIST JOINT AND HAND Finkelstein’s Test

Tests: Tenosynovitis of abductor pollicis longus and extensor pollicis brevis tendons (de Quervain’s tenosynovitis). Patient’s position: Sitting. Procedure: Ask the patient, to make a fist with thumb inside. Move wrist into ulnar deviation passively. Positive sign: Reappearance of symptoms.

MUSCULOSKELETAL Liniburg’s Test

Test: Tendon pathology between flexor pollicis longus and flexor indices. Patient’s position: Sitting. Procedure: Flex thumb towards hypothenar eminence and extend index finger. Positive sign: Limited extension and reappearance of symptoms. Lunotriquetral Ballottement Test (Reagan’s Test)

Tests: Stability of lunotriquetral ligament. Patient’s position: Sitting. Procedure: Stabilize the triquetrum and lunate. Apply posterior and anterior glide. Positive sign: Reappearance of symptoms crepitus or laxity. Murphy’s Sign

Tests: Lunate dislocation. Patient’s position: Sitting. Procedure: Patients makes a fist. Positive sign: 3rd metacarpal lines up with 2nd and 5th metacarpal. Phalen’s (Wrist Flexion) Test

Tests: Median nerve pathology, carpal-tunnel syndrome.

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Patient’s position: Sitting. Procedure: Place the hands together from its dorsal aspect with wrist in flexion. Hold it for one minute. Positive sign: Tingling sensation in distribution. Reverse Phalen’s Test

Tests: Median nerve pathology. Patient’s position: Sitting. Procedure: Place the palms of both hands together with wrist extension. Positive sign: Tingling sensation over median nerve distribution. Sweater Finger Sign

Tests: Rupture of flexor profundus tendon. Patient's position: Sitting. Procedure: Patient makes a fist. Positive sign: Loss of flexion of DIP joint of one of the finger. Thoment’s Sign

Tests: Ulnar nerve paralysis. Patient's position: Sitting or standing. Procedure: Hold piece of paper between thumb and index finger. Pull the paper away. Positive sign: As the paper is pulled away, the IP joint of thumb flexes.

MUSCULOSKELETAL Tinel’s Sign

Tests: Median nerve pathology, carpal-tunnel syndrome. Patient's position: Sitting. Procedure: Tap over carpal tunnel. Positive sign: Tingling sensation or paresthesia over median nerve distribution. Waston (Scaphoid Shift) Test

Tests: Instability of scaphoid. Patient's position: Sitting. Procedure: Stabilize the wrist is full ulnar deviation and slightly extended. Apply pressure to scaphoid tubercle by other hand (palmar aspect) and move wrist into radial deviation and slight flexion. Positive sign: Pain and subluxation of scaphoid. PELVIS Anterior Gapping Test

Tests: Sprain of sacroiliac joint or ligaments. Patient's position: Supine. Procedure: Push right and left ASIS apart. Positive sign: Reappearance of symptoms. Gaenslen’s Test

Tests: Sacroiliac joint involvement, hip pathology or L4 nerve root lesion.

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Patient's position: Side lying on normal side, with leg flexed against chest. Procedure: Affected leg is hyper extended at hip and pelvis is stabilized by examiner. Positive sign: Pain on SI joint, while performing movement. Gillets Test

Tests: Sacroiliac joint dysfunction. Patient's position: Standing. Procedure: Palpate PSIS and sacrum. Patient performs hip flexion and knee on side to be tested (palpated), while standing on opposite leg. Repeat the test and compare both sides. Positive sign: If the PSIS does not move downward to sacrum on side tested, it shows hypomobility of that side. Hibb’s Test

Tests: Movement of sacroiliac joint, stress of posterior sacroiliac ligament. Patient's position: Prone. Procedure: Pelvis is stabilized and patient performs 90° flexion on the knee, hip is medially rotated, while palpating sacroiliac joint on that side. Repeat the test and compare it with other side.

MUSCULOSKELETAL

Positive sign: Range of opening and quality of movement at each sacroiliac joint differ. Laguere’s Sign

Tests: Sacroiliac joint involvement, hip pathology. Patient's position: Supine. Procedure: Examiner flexes, abducts and laterally rotates the patient’s hip to be tested. Over pressure is applied at end range. Pelvis is stabilized. Repeat the test on other side and compare both sides. Positive sign: Pain on SI joint or hip. Piedallu’s Signs (Sitting Flexion)

Tests: Movement of sacrum on ilia. Patient's position: Sitting. Procedure: As the patient forward flexes, palpate the right and left PSIS. Positive sign: Normal side moves higher than other, indicates hypomobility on that side. Posterior Gapping Test

Tests: Sprain of posterior sacroiliac joint or ligament. Patient's position: Side lying or supine. Procedure: Push left and right ASIS towards each other. Positive sign: Reappearance of symptoms.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Standing Flexion

Tests: Movement of ilia on sacrum. Patient's position: Standing. Procedure: Palpate PSIS of both sides, while patient forward flexes the hip. Positive sign: Normal side moves higher than affected side, indicates hypomobility on affected side. Supine-to-Set (Long Sitting) Test

Tests: Pelvic torsion or rotation. Patient's position: Supine. Procedure: Note the level of inferior border of medial malleoli. Patient is asked to sit and changing position of malleoli is noted. Positive sign: One leg moves up more than other. HIP JOINT Anterior Labral Tear Test

Tests: Ligament or labrum tear or injury. Patient's position: Supine. Procedure: Full flexion at hip, lateral rotation and full abduction. Examiner extends, medially rotates and adducts the hip. Positive sign: Pain, reappearance of symptom with/without click.

MUSCULOSKELETAL Ober’s Sign

Tests: Tensor fasciae latae and iliotibial band contractures. Patient's position: Side lying with lower leg flexed. Procedure: Pelvis stabilized. Abduct and extend upper leg with knee extension or flexion to 90° passively and allow it to drop towards plinth. Positive sign: Upper leg remains abducted and does not lower to plinth. Patrick’s Test (Faber’s Test)

Tests: Hip joints and SI joint dysfunction, spasm of iliopsoas muscle. Patient's position: Supine. Procedure: Foot of test leg is placed on opposite knee. Slowly lower knee of test leg. Positive sign: Pain or spasm, knee remains above the opposite leg. Posterior Labral Tear Test

Tests: Ligament injury or labrum tear. Patient's position: Supine. Procedure: Full flexion at hip, adduction and lateral rotation. Examiner extends, abducts and laterally rotates the hip. Positive sign: Resist extension of middle finger distal to PIP joint.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Rectus Femoris Contracture Test

Tests: Rectus femoris contracture. Patient's position: Supine. Procedure: Knee flexed to 90° over edge of plinth. Patient takes other knee to chest. Positive sign: Knee extends over edge of plinth. Thomas Test

Tests: Hip flexion contracture. Patient's position: Supine. Procedure: Patient takes knee on to chest. Positive sign: Opposite leg lifts off plinth. Trendelenburg’s Sign

Tests: Strength of hip abductors, stability of hip. Patient's position: Standing. Procedure: Patient is made to stand on one leg. Positive sign: Pelvis on opposite side drops. KNEE JOINT Abduction (Valgus) Stress Test

Tests: Full knee extension ligament injury (ACL, MCL, POL, PCL), quadriceps and semimembranosus expansion. Patient’s position: Supine.

MUSCULOSKELETAL

Procedure: Ankle is stabilized and medial pressure is applied on knee joint at 0° and then at extension in 20°–30°. Positive sign: Excessive movement is seen as compared to opposite knee. Adduction (Varus) Stress Test

Tests: Full extension ligament injury (LCL), iliotibial band, biceps femoris tendon. Patient’s position: Supine. Procedure: Ankle is stabilized, lateral pressure is applied on knee joint at 20° and then extension at 20°–30°. Positive sign: Excessive movement is seen as compared to opposite knee. Anterior Drawer Test

Tests: Ligament injury (ACL, POL, MCL), iliotibial band, posteromedial and posterolateral capsules. Patient’s position: Supine with 45° hip flexion and 90° knee flexion. Procedure: Foot is stabilized, posteroanterior force is applied on tibia. Positive sign: Movement of tibia, move than 6 mm on femur.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS Apley’s Test

Tests: Compress for meniscus injury and distraction for ligamentous injury. Patient’s position: Prone with 90° knee flexion. Procedure: Medial and lateral rotation of tibia, first with distraction and then with compression. Positive sign: Pain. Brush Test

Tests: Mild effusion. Patient’s position: Long sitting. Procedure: Stroke the patella on medial side, below joint line upto suprapatellar pouch two to three times and stroke down lateral side of patella by using opposite hand. Positive sign: Fluid travels to medial side and bulge appears. External Rotation Recurvatum Test

Tests: Posterolateral rotatory stability in knee extension. Patient’s position: Supine. Procedure: Place the knee in 30° flexion and hold the heel. Extend knee slowly while palpating the knee’s posterolateral aspect. Positive sign: Excessive hyperextension and lateral rotation can be palpated.

MUSCULOSKELETAL Fairbank’s Apprehension Test

Tests: Patellar subluxation or dislocation. Patient’s position: Supine. Procedure: 30° flexion at knee and relaxed quads. Lateral glide to patella passively. Positive sign: Excessive movement. Hughston Plica Test

Tests: Inflammation of suprapatellar plica. Patient’s position: Supine. Procedure: Knee is medially rotated and flexed. Applying medial glide on patella and medial femoral condyle is palpated. Extend and flex knee passively. Positive sign: Popping of plica band over femoral condyle, tenderness. Lachman’s Test

Tests: Ligament injury (ACL, POL), arcuatepopliteus complex. Patient’s position: Supine with 0–30° knee flexion. Procedure: Femur is stabilized and posteroanterior force on tibia is applied. Positive sign: Soft end feel or excessive movement. McMurray Test

Tests: Medial meniscus and lateral meniscus injury.

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Patient’s position: Supine. Procedure: Complete knee flexion. Test medial meniscus: Knee lateral rotation and 90° extension passively, while palpating joint line. Test lateral meniscus: Test is repeated with medial rotation at knee. Positive sign: Click or a snap. Posterior Drawer Test

Tests: Ligament injury (ACL, POL, PCL), arcuate popliteus complex. Patient’s position: Supine. Procedure: 45° flexion at hip and 90° flexion at knee with feet on plinth. Positive sign: Posterior drop of tibia. Posterior Sag Test

Tests: Ligament injury (PCL, POL, ACL) Patient’s position: Supine. Procedure: 45° flexion at hip and 90° flexion on knee with feet on plinth. Positive sign: Tibia drops posteriorly. Slocum Test for Anterolateral Rotatory Instability

Tests: Ligament injury (ACL, PCL, LCL and cruciate), iliotibial band. Patient’s position: Supine.

MUSCULOSKELETAL

Procedure: 45° flexion at hip and 90° flexion at knee, foot is placed in 30° medial rotation and stabilized, posteroanterior force is applied on tibia. Positive sign: Excessive movement on lateral side, when compared with other knee. Slocum Test for Anterolateral Rotary Instability

Tests: Ligament injury (MLC, POL, ACL) Patient’s position: Supine. Procedure: 45° hip flexion, 90° knee flexion, foot is placed in 15° lateral rotation and stabilize it. Then posteroanterior force is applied on tibia. Positive sign: Excessive movement on medial side, when compared with other knee. ANKLE JOINT AND FOOT Anterior Drawer Test

Tests: Medial and lateral ligament integrity. Patient’s position: Prone. Procedure: Flexion at knee, posteroanterior force is applied on talus with dorsiflexion on ankle and then plantar flexion. Positive sign: If movement on one side only (ligament on the affected side). If excessive anterior movement (both ligaments are affected).

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Tests: Syndesmosis injury (fracture, contusion or compartment syndrome). Patient’s position: Supine. Procedure: Examiner grasps leg at mid calf level and squeezes the tibia and fibula together. Positive sign: Pain in the lower leg. Talar Tilt

Tests: Abduction: Integrity of deltoid ligament. Adduction: Integrity of calcaneofibular ligament and also anterior talofibular ligament. Patient’s position: Prone, supine or side lying. Procedure: Flexion at knee. Talus is tilted in adduction and abduction and foot is in neutral position. Positive sign: Excessive movement. Thompson’s Test

Tests: Achilles tendon rupture. Patient’s position: Prone. Procedure: Feet is placed over edge of plinth and then calf muscle is squeezed. Positive sign: Absence of plantar flexion.

MUSCULOSKELETAL

MUSCULOSKELETAL PATHOLOGIES ACHONDROPLASIA

It is a condition which occurs because of failure of normal ossification of bones, specially the long bones, turning into dwarfism. It is a disease with autosomal dominant inheritance, but may also occur by a fresh gene mutation. Clinical Features

Flat nose, short limbs, lumbar lordosis, large skull with bulged vault and forehead, stubby fingers ALBERS-SCHÖNBERG DISEASE

Also known as marble bone disease or osteoporosis. This is a disorder in which the bone are brittle but dense and there is poor formation of protein matrix. It may result due to immobilisation, hormonal imbalance, nutritional deficiency. Clinical Features

Fracture resulting by minimal injury or pressure, weak bone, reduced gaps between bone. ANKYLOSING SPONDYLITIS

This is a chronic disease showing progressive inflammatory stiffening of joint. The SI joint is the first to be involved, the manubrio-sternal, hip and knee joints may also be involved. This mainly

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affects the age group of 15–30 years. M:F—10:1. There may occur cartilage destruction and synovitis. Clinical Features

Pain and stiffness (early morning), deformity of hip and spine (kyphosis), peripheral joints may also be involved, i.e. shoulder hip and knee. ARTHROGRYPOSIS MULTIPLEX CONGENITA

It is a nonprogressive condition in which the infant born with multiple deformities, joint stiffness and soft tissues contractures. Types: Neurogenic—Due to degeneration of anterior horn cells in certain segments of spinal cord. Myogenic—Due to replacement of muscles by fibrofatty tissue. Clinical Features

Flexion, abduction at hips, flexion at knees, equinovarus feet, congenital hip dislocation, joint contractures, genu recurvatum, calcaneovalgus feet, web skins. BAKER’S CYST

This is associated with rheumatoid arthritis and osteoarthritis. There occurs a cyst or a mass or a fluid filled sac at back of knee joint.

MUSCULOSKELETAL Clinical Features

Popliteal bursa gets distended, associated with herniation of synovial membrane of knee joint. BURSITIS

This is the inflammation of bursa. This occurs because of bacterial infection or mechanical irritation. Because of which the bursitis may be infective or irritative caused by excessive pressure or friction. Also sometimes due to gouty deposit. Clinical Features

Pain, swelling, redness, reduced joint range of motion. CONGENITAL TALIPES EQUINOVARUS (CTEV)

This is the commonest congenital feet deformity also known as clubfoot. The etiology is unknown, hence two types: Idiopathic and secondary. The talus neck gets angulated facing downwards and medially, i.e. in inversion. Clinical Features

Postural equinovarus, as age increases difficulty in walking, head is small in size, bilateral foot deformity, creases on back of heel, foot is slight convex.

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This syndrome occurs when the median nerve gets compressed while passing through flexor retinaculum. The causes of this may be inflammatory, post-traumatic, endocrine, idiopathic. The patient affected is usually middle aged. Clinical Features

Numbness, tingling, clumsiness in carrying fine movements, absent in pulse conduction. COMPARTMENT SYNDROME

A rise in pressure in compartments containing muscles, bones, vessels, fascia, because of any reason may affect the blood supply to nerves and muscles resulting in compartment syndrome. This injury leads to swelling resulting into reduced blood supply, further resulting in muscle ischemia. Clinical Features

Necrosis, nerve damage, fibrosis, contractures gangrene. CONGENITAL DISLOCATION OF HIP

This is the sudden dislocation of hip occurring before, during or after the birth. This is one of the commonest disorders in western countries. The factors responsible for this are hereditary, trauma, breech malposition, hormonal changes during pregnancy. F:M—6:1.

MUSCULOSKELETAL Clinical Features

Asymmetry creases on groin, reduces range of motion on the affected side, click sound is heard everytime when movement occurs, child walks with a peculiar gait, i.e. Trendelenburg or waddling gait. DE QUERVAIN’S DISEASE

It results because of inflammation of the tendon sheath of abductor pollicis longus and extensor pollicis brevis at place where it crosses styloid process of radius. Clinical Features

Tenderness on radial styloid process, pain aggravates by adducting the thumb. Thickened sheath can be palpated. DUPUYTREN’S CONTRACTURE

This is a condition occurring due to the flexion deformity of one or more fingers because of thickening and shortening of palmar aponeurosis. The etiology is unknown, but it can be hereditary. The ring finger is commonly affected. Clinical Features

Thickening felt at bases of ring and little finger, flexion deformity of fingers.

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This is the inflammation of the fibrous tissue. There are nodules (firm) mostly on trapezius and spinal muscles. The nodules are mainly the trigger points, respond to ultrasonic therapy and local steroids. Clinical Features

Tenderness, nodules (small, firm), pain, affected movement, reduced range of motion. FIBROMYALGIA

This is disorder which is rheumatological and non-articular in nature associated with joint and myofascial pain. The etiology and pathology is unknown, but it can occur itself or with some other condition. Clinical Features

Pain, tenderness, fatigue, disturbed sleep, anxiety, depression, morning stiffness. GOLFER’S ELBOW (MEDIAL EPICONDYLITIS)

This is the condition in which there is inflammation at the origin of flexor tendon, i.e. at the medial epicondyle of the humerus. Clinical Features

Pain, tenderness, swelling, reduced range of motion.

MUSCULOSKELETAL MYOSITIS OSSIFICANS

In this there is formation of hematoma around a joint due to fracture or severe soft tissue injury, mainly around elbow. It may also be congenital. Clinical Features

Pain, tenderness, stiffness of joint. OSTEOARTHRITIS

This is a degenerative joint disorder mainly affecting the articular cartilage of the joint. It may affect any age group after adolescent. Mainly affects the large joint and the weight bearing joints. Female are more affected than male. Clinical Features

Pain, tenderness, swelling, morning stiffness, reduced range of motion, joint effusion. OSTEOCHONDRITIS

This is the disorder in which there is inflammation of the joint and the cartilages. It may occur due to compression, fragmentation or separation of piece of bone. The various or common types of osteochondritis are: Perthes’ Disease

Also known as coxaplana, pseudocoxalgia. Mainly affects the femoral head or femoral epiphysis affecting the young boys. Occurs due

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to recurrent episodes of ischemia and necrosis. The bone becomes soft and fragmented due to which it appears larger than original size. Osgood-Schlatter Disease

Mainly affect the tibial tubercle seen in teenage boys. Results in detachment of small cartilage, due to vigorous physical activity. Osteochondritis Dissecans

Mainly seen in adult boys. In this, there is separation of fragment of bone and cartilage into a joint. The commonest site are the capitulum of humerus and medial femoral condyle. Scheuermann’s Disease

Mainly affects the vertebral bodies resulting in degeneration of the intervertebral disc into vertebral end plate. Can also lead to kyphosis. OSTEOMALACIA

Occurs due to deficiency of vitamin D, i.e. due to poor nutrition, lack of various types of vitamin D. Due to this, there is softening of bone, because of incomplete calcification. Due to which they become weak and get easily fractured. Mainly seen in long bones.

MUSCULOSKELETAL Clinical Features

Soft fragmented bone, pain, tenderness, swelling, redness, difficulty in weight bearing. OSTEOMYELITIS

This occurs due to infection of the bones by the micro-organisms. This results into destruction of bone and production of inflammatory cells and exudates. Seen commonly because of open fracture or joint surgery. The infection may also spread to other parts of body. Clinical Features

Pain, tenderness, swelling, weight loss, fever. PAGET’S DISEASE

This is a disease characterized by excessive tendency of bony breakdown, gets thickened and spondy. Tibia is affected most commonly. Diseases mostly affects after 40 year of age. This occurs due to osteoclast dysfunction. Clinical Features

Dull pain, thickening of the affected bone. POLYARTERITIS NODOSA

This is a vasculitic syndrome in which, the various size of arteries are attacked by the rogue immune

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cells causing inflammation and necrosis. All the organs or parts of the body supplied by blood or arteries are affected due to impaired blood supply. Clinical Features

Fever, renal failure, hypertension, neuritis, weight loss, muscle and joint pain, skin lesion. POLYMYALGIA RHEUMATICA

This is a vasculitic syndrome, symptoms usually begin at or over the age of 50 and mainly affects women. This is associated with fever, generalized pain and stiffness. Clinical Features

Loss of vision, involvement of cranial arteries, migraines, stroke. POLYMYOSITIS

This is an autoimmune, inflammatory disease of muscle. It causes progressive weakness of skeletal muscle. It has an unknown etiology. The muscles of pelvis, hip and shoulder girdle are mainly affected. The disease occurs sometimes with a skin rash over the body and is known as dermatomyositis. Clinical Features

Pain, tender to touch, difficulty in weight bearing.

MUSCULOSKELETAL RHEUMATOID ARTHRITIS

This is an autoimmune disorder affecting several joints at same times. There is destruction of articular cartilage, capsule, ligament and tendons, leads to deformity. The joints are symmetrically affected. There are nodules, the disease is common in young to middle aged women. Clinical Features

Pain, swelling, morning stiffness, loss of movement and function. SPONDYLOLISTHESIS

This is the forward displacement of one vertebral body over the vertebral body below it, commonly seen in L5/S1, the displacement may be severe, causes compression of cauda equina. I. Dysplastic: Congenital II. Isthmic: Fatigue fracture of the pars interarticularis due to overuse III. Degenerative: Osteoarthritis IV. Traumatic: Acute fracture V. Pathological: Weakening of the pars intra– articularis by a tumor, osteoporosis, tuberculosis or Paget’s disease. Clinical Features

Pain, tenderness, difficulty in bending, sitting and lying down, affected movement.

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This is the defect in the pars interarticularis of the lumbar vertebrae resulting due to fatigue fracture. It can be both uni and bilateral and it may or may not progress to spondylolisthesis. Clinical Features

Pain, difficulty in bending, affected movement. SPONDYLOSIS

This occurs due to degeneration and narrowing of the intervertebral discs which leads to the formation of osteophytes at joint margin and arthritic changes of the facet joint, the cervical joints are commonly affected. The spinal canal causes dysfunction of all four limbs and may be the bladder also. The vertebral artery may also be involved. Clinical Features

Neck pain, stiffness, radiating pain to upper limbs, vertigo. SYSTEMIC LUPUS ERYTHEMATOUS

This is a chronic inflammatory autoimmune connective tissue disorder. It involves the skin, joint and internal organs. Amongst the affected people, 90 percent are women.

MUSCULOSKELETAL Clinical Features

Anemia, hypertension, vasculitis, renal disease, pleurisy, alopecia, polyarthritis vasculitis, butterfly rash on face, Raynaud’s disease. SYSTEMIC SCLEROSIS

This is an autoimmune disorder of the connective tissue that causes increase in metabolism of collagen. Excessive collagen deposits damage the microscopic blood vessels in skin and other organs and leads to fibrosis and degeneration. Middle age women are most commonly affected. Clinical Features

Edema of hands and feet. Alterations of facial features are dry, shiny, tight, skin contractures and finger deformities. TENNIS ELBOW

Also known as lateral epicondylitis, affecting the common extensor origin due to the inflammation of the lateral epicondyle. Clinical Features

Pain, tenderness, affected movement of extension. TENOSYNOVITIS

This is the inflammation of the synovial lining of the tendon sheath caused due to mechanical

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irritation or infection. It may also occur due to overuse and repetitive movements. Clinical Features

Pain, tenderness, swelling, redness affected movement and function. THORACIC OUTLET SYNDROME

It is characterized by compression of neurovascular bundle comprising of subclavian artery/vein, axillary artery/vein and brachial plexus at the thoracic outlet (space between first rib, clavicle and scalene muscles). Causes include hypertrophy of the existing muscles or due to any other cause like trauma, congenital, etc. Clinical Features

Pain, weakness, edema, pallor, paresthesia, venous engorgement, cyanosis involving mainly neck, any affected side shoulder and upper extremity. GRADES OF SPRAIN AND TREATMENT Grade I—Minimal pain and disability, weight bearing not affected. Grade II—Moderate pain and disability, weight bearing difficult. Grade III—Severe pain, swelling and dislocation, no weight bearing possible.

MUSCULOSKELETAL TREATMENT Prices

P—Prevention from further injury R—Rest to the part I—Icing C—Compression E—Elevation of the part S—Support. STAGES OF FRACTURE HEALING HEMATOMA FORMATION

• Duration: Less than 7 days • Essential features: Deposition of blood at the site of fracture, which sensitizes the precursor cells. CELLULAR PROLIFERATION

• Duration: Up to two to three weeks • Essential features: It has two substages: a. Endosteal cellular proliferation—formation of cells in endosteam b. Periosteal cellular proliferation—formation of cells on surface of medullary cavity. STAGE OF CALCIFICATION

This stage includes deposition of lime salt, mainly calcium and phosphorus.

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• Duration: Up to 4 to 12 weeks • Essential features: It has three substages: a. Stage of callus formation: Deposition appears as slit callus, it occurs after two to three weeks of trauma. Callus—It is a new bone formation/ calcification which bridges the fracture site, responsible for healing of fracture. b. Stage of consolidation: — This stage is characterized by more callus formation which bridges the fracture site. — The callus appears to be firm or hard on palpation. This callus consolidates on parent bone. c. Crossing of trabecular pattern: — The trabecular pattern of the fractured bone gets disturbed. — It requires 8–10 weeks for slit alignment of trabecular pattern. — This alignment is not anatomically satisfactory. — It appear to be slit deformed as normal one. The bone gets bended. — To correct it, next stage occurs. REMODELING STAGE

• Duration: One to two years • Essential features: It occurs till the correction of bending.

MUSCULOSKELETAL

• After 6 month, 90 percent bone is formed. Note 1. Angulation and over-riding is not accepted since: • It has longer period of remodeling. • Movement of limb is affected. • Bone may be fixed in rotated position. 2. When fracture is united on bending with remodeling in few months, it is accepted. 3. One of the very important clinical findings of mature union is—no pain on applying angulation force. 4. Radiological criteria to suggest mature union are: • Callus formation • Crossing of trabeculae formation • Remodeling. FRACTURES WITH EPONYMS BARTON’S FRACTURE

It is the fracture of distal articular surface of the radius which extends to either its anterior or posterior cortical. It is thus divided into two types: a. Volar Barton’s fracture (anterior marginal type). b. Dorsal Barton’s fracture (posterior marginal type). This type of fracture is treated by closed manipulation and by a plaster cast. If it fails, the open reduction and internal fixation is done.

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THE POCKETBOOK FOR PHYSIOTHERAPISTS COLLES’ FRACTURE

It is defined as the fracture at the distal end of the radius, at its corticocancellous junction with typical displacement in adults such as: 1. Dorsal tilt 2. Dorsal displacement 3. Fragment impaction 4. Lateral tilt 5. Lateral displacement 6. Supination. Common Injuries Associated Colles’ Fracture

• Fracture of the styloid process of ulna • Rupture of the ulnar collateral ligament • Rupture of the interosseous radioulnar ligament, resulting radioulnar subluxation. Treatment

It is mainly treated conservatively. Undisplaced type of fracture is immobilized in a below-elbow plaster cast for six weeks. Displaced fractures are treated by manipulative reduction and immobilization in Colles’ cast. GALEAZZI FRACTURE—DISLOCATION

This is characterized by fracture of the lower third of the radius with dislocation or subluxation of the distal radioulnar joint. The most common cause is fall on outstretched hand.

MUSCULOSKELETAL

It shows a typical displacement, i.e. the radius fracture is angulated medially and anteriorly. The distal radioulnar joint is disrupted which results in dorsal dislocation of the distal end of the ulna. Treatment: In children, it is treated with closed reduction in a conservative manner. In elder persons, it is mostly treated by open reduction and internal fixation of radius with a plate. MONTEGGIA’S FRACTURE—DISLOCATION

It is defined as ‘ fracture of upper third of the ulna with dislocation of the head of radius.’ Most common cause is fall on outstretched hand with forearm forced in excessive pronation. Types

a. Extension type: Extension type is commoner with the ulna fracture angulates anteriorly and the radial head dislocates anteriorly. b. Flexion type: Flexion type indicates that the ulna fracture angulates posteriorly and the radial head dislocates posteriorly. Treatment

Since, it is very unstable injury, it redisplaces frequently even if it has been reduced once. After proper reduction, close watch is kept by weekly check X-rays for initial three to four weeks.

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Open reduction and internal fixation using a plate is performed in case where a reduction is not possible or if redisplacement occurs. SMITH’S FRACTURE

It is also seen as reverse of Colles’ fracture where the distal fragment displace ventrally and tilts ventrally. It is important to differentiate it from the commoner Colles’ fracture which occurs at the same site. It is treated by closed reduction and plaster cast immobilization for six weeks. BENNETT’S FRACTURE—DISLOCATION

It is a type of an oblique intra-articular fracture of the base of the first metacarpal with subluxation or dislocation of the metacarpal. Most common cause is longitudinal force applied to the thumb. Treatment

As being an intra-articular fracture it requires accurate reduction and reduction, otherwise it leads to incongruity of the articular surface and may prone the bone for osteoarthritis. Mostly used methods are: • Closed manipulation and plaster cast.

MUSCULOSKELETAL

• Closed reduction and percutaneous fixation under X-ray control using an image intensifier. • Open reduction and internal fixation with a K-wire or a screw. MALLET FRACTURE

• It is also called as mallet finger or baseball finger. • This fracture is the result of sudden passive flexion of the distal interphalangeal joint, which causes avulsion of extensor tendon of the distal interphalangeal (DIP) from its insertion at the base of the distal phalanx. Sometimes the avulsion is associated with fragment of bone with it. • It shows the clinical feature of slight flexion of distal phalanx. • Treatment of this fracture is by immobilizing the DIP joint in hyperextension with help of an aluminium splint or plaster cast. ROLADO’S FRACTURE

This is the fracture of base of the first metacarpal, extra-articularly. Being an extra-articular fracture, its perfect reduction is not as important as in Bennett’s fracture dislocation. It is treated clinically by reduction and immobilization in a thumb spica for three weeks.

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It is actually the fracture of condyle of tibia. Mechanism of injury is direct trauma to the upper end of tibia, or an indirect force more often results in unicondylar (by a varus/valgus bending force) or infracondylar fracture (by a hyperextension force). Bumper fracture is more accurately the fracture of the lateral condyle of the tibia, when the bumper of a motorcar strikes the lateral side of the knee. Treatment

It is treated clinically by reduction under anesthesia, followed by below knee skin traction for three weeks. The knee is mobilized as the fracture becomes stickly, few cases need open reduction and joint reconstruction. MUSCULOSKELETAL ASSESSMENT Reg. No. Name Age/sex Date of admission Address Occupation Referred by (consultant) and hospital Consultant’s probable diagnosis Type of operation/illness

MUSCULOSKELETAL

Date of discharge Discharge summary Instructions for physiotherapist History of present illness Past medical history Drug history: Current medication Steroids Anticoagulants allergies. ADL activity Personal history Social history Family history. ON OBSERVATION

Attitude of limb Facial expression Deformity Posture: Lying Sitting Standing. Pain: Type Onset Nature Radiation Intensity Aggravating factor Relieving factor

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Severity Associated symptoms. ON PALPATION

Temperature Tenderness Edema—pitting/non-pitting Inflammatory signs Muscle wasting Contractures. ON EXAMINATION

Range of movement: Active Passive. Joint effusion measurement Muscle girth Limb length End feel: Capsular Noncapsular. Differential test Gait assessment MMT Neurological test: Dermatomes Reflexes Myotomes. Special tests Investigations—Blood/X-ray/CT scan/MRI.

MISCELLANEOUS

6

CHAPTER Miscellaneous •

Diagnostic/electrodiagnostic testing

•

National immunization schedule

•

Proprioceptive neuromuscular facilitation (PNF)

•

Common sports injuries

•

Types of aphasia

•

Gait

•

Levels of amputations

•

Abbreviations

•

Normal reference/lab values

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DIAGNOSTIC/ELECTRODIAGNOSTIC TESTING COMPUTED TOMOGRAPHY (CT)

Imaging procedure where detailed information is obtained from thin section in collimated X-rays. Indications

• Evaluation of bony structure, especially cortical bone. • Useful for diagnosis in compound fracture, dislocations, stress fracture and spinal pathologies. • Structural evaluation of lung, mediastinal pathologies. • Structural analysis of intracranial lesions. • Evaluation and comparison of the normal organ and abdominal tissues. Contraindications

• Restless patient • Pregnancy. MAGNETIC RESONANCE IMAGING (MRI)

Cross sectional image is formed by certain atomic nuclei, which possess unpaired protons or neutrons, possess an inherent spin. Positive charged nucleus generates a small magnetic field

MISCELLANEOUS

around itself, when it spins. Those signals emitted by the nuclei are measured and reconstructed by computer to create an image of soft tissue and bone. T1—Images show anatomical detail with fluid being dark and fat being bright. T2—Images show soft tissue pathology much better with fluid being bright. Advantages

• • • • • •

Noninvasive. Give high intrinsic contrast. No bony or air defect. No known biological hazards. Sagittal, transverse imaging are possible. It does not involve the use of ionizing radiation.

Disadvantages

• Patients may produce artifacts, because imaging time is long. • Expansive. • Require trained technical staff. • Patient with a cardiac pacemaker, brain aneurysm clip or other metallic implants with the exception of those attached to the bone, i.e. prosthetic joints cannot be scanned.

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ULTRASOUND

Based on piezo-electric effect which is the property of certain substances to convert electrical energy to sound energy.These are the active portions of the ultrasonic transducers. Can be used to examine a broad range of soft tissue structures. Advantages

• • • • •

Noninvasive. Cost-effective. Widely available. Also used in wards. Does not involve the use of ionizing radiation and can therefore be safely used in a pregnant women.

Disadvantages

• Limited in thorax. • Cannot image the bone. • Limited use in the abdomen when there is gaseous distension. RADIOGRAPHY

Oldest imaging technique, formed by exposure to short wavelengths of X-rays that pass through the body and hit a photographic receptor placed behind the patient body.

MISCELLANEOUS USES

• • • •

In dentistry Mammography Chest examinations Diagnosis of fractures. Hollow organ can be visualized by filling them with a radiopaque substances. These block the X-rays and visualize the structures. Angiography: Visualization of the blood vessels. Arthrography: Visualize the degenerations of the joints. Discography: Visualize the disc pathology. Myelography: Visualize the compressive lesions of the spinal cord and cauda equine. Tenography: Visualize the tendon pathology and ligaments ruptures. ELECTROENCEPHALOGRAPHY (EEG)

Electroencephalography examines by means of scalp electrode the spontaneous electrical activity of the brain. Tiny electrical potentials, which recorded, amplified and displayed on either 8 or 16 channels of a pen recorder. Mainly used in diagnosis of coma, epilepsy and certain forms of encephalitis. ELECTROMYOGRAPHY (EMG)

Electromyography is a technique used in studying the electrical activity of the muscles for the

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diagnosis of neuromuscular disease. Used in the diagnosis of a broad range of myopathies and neuropathies. NERVE CONDUCTION STUDIES (NCV)

Recording technique of a peripheral nerve impulses at same location, which may distant from the site from where the propagating action potential is induced in that peripheral nerves. Mainly used in the diagnosis of nerve entrapments, peripheral neuropathies, motor and sensory nerve damage and multifocal motor neuropathies. EVOKED POTENTIALS (EP)

An electrical response recorded from the brain, the spinal cord or the peripheral nerve that is evoked by various external stimuli such as visual (e.g. flashing the light), auditory (click sound), somatosensory (electrical stimulation), etc. The recording electrodes are placed over the scalp, neck or spine surface, which vary depending on the type of stimulus modality to be tested. Mainly used for detecting multiple sclerosis, brainstem and cerebellopontine angle lesions, various cerebral metabolic disorders in infants and children.

MISCELLANEOUS

NATIONAL IMMUNIZATION SCHEDULE Time

Vaccine

Birth

BCG and OPV zero dose (for institutional deliveries)

6 weeks

BCG (if not given at birth) DPT-1 and OPV-1

10 weeks

DPT-2 and OPV-2

14 weeks

DPT-3 and OPV-3

9 months

Measles

18-24 months

DPT and OPV (1 booster)

5 years

DT

10 year and 16 years

TT

For pregnant women

Early in pregnancy TT-1, after 1 month TT-2

PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF) TECHNIQUE

To 1. 2. 3.

strengthen muscles: Slow reversals Repeated contractions Rhythmic stabilizations

To 1. 2. 3.

gain relaxation/lengthening of muscles: Hold—relax Contract—relax Rhythmic stabilizations

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To improve coordination 1. Slow reversals 2. Repetitive movements. COMMON SPORTS INJURIES SHOULDER JOINT AND ARM

Rotator cuff tear — Javelin throwers, swimmers, volleyball players, baseball players Glenohumeral — Gymnasts, weight lifters, ballers Glenohumeral — Boxers, hockey players dislocation ELBOW AND FOREARM

Medial epicondylitis — Golf players Lateral epicondylitis — Tennis players Valgus extension — Javelin throwers WRIST AND HAND

Tendon ligament

— Volleyball players, basketball players, boxers Ulnar tunnel syndrome — Cyclist Carpel-tunnel syndrome — Rock-climbers, tennis players, golf players

MISCELLANEOUS HIP AND THIGH

Quadriceps and hamstring injuries—Runners Adductor injuries—Horse riders Fracture of pelvis/hip-dislocation—Footballers KNEE AND LEG

Collateral ligament injury—Footballers Meniscal injury—Footballers, kabaddi players Cruciate ligament injury—Long-jumpers Knee dislocation—Kick boxers IT band syndrome—Long and high jumpers Compartment syndrome—Runners and cyclists ANKLE AND FOOT

Sprain—Basketball player, footballers, baseball players Achilles tendonitis and bursitis—Runners TA rupture—Runners, footballers Metatarsalgia—Runners Stress fracture—Walkers

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TYPES OF APHASIA Fluency Comprehension Repetition 1. 2. 3. 4. 5. 6. 7. 8.

Global Isolation Broca’s Transcortical motor Wernicke’s Transcortical sensory Conduction Normal

– – – –

– – + +

– + – +

+ +

– –

– +

+ +

+ +

– +

– Absent, + present

GAIT GAIT TERMINOLOGY

Traditional Heel strike Foot flat Mid stance Heel off Toe off

Rancho los amigos Stance phase Initial contact Loading response Mid stance Terminal stance Preswing

Acceleration Mid swing Deceleration

Swing phase Initial swing Mid swing Terminal swing

MISCELLANEOUS GAIT ASSESSMENT

Under the headings of: • Type of gait patterns and variations • Length of step and width of base • Abnormal leg movements • Instability • Associated postural movements • Identification of cause • Energy requirement in given pattern • Determination of the functional ambulation capacities. ABNORMAL GAIT

Antalgic/Painful—Stance face on the affected leg is shorter than that on the non-affected leg. Atherogenic/Stiff hip or knee—Patient lifts the entire leg higher than normal to clear the ground because of stiff hip or knee. Ataxic/Drunkers—Staggering and unsteadiness. Patient walks with a wide base and swings the leg unnecessarily and irregularly. High stepping/Foot drop/Slapping—More of the hip and knee flexion to clear the ground. Lordotic—Walking with increased lumber lordosis. Hemiplegic/Circumductory—Rigid lower limb is stiffly dragged sideways and forwards in semicircular fashion.

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Spastic—Toes scraping the floor with pelvis lifting from side to side. Scissoring—Crossed leg pattern, walk on toes, overactive arms to maintain balance, pelvic waddle. Shuffling (Parkinsonian, Festinant, Festinating gait)—Walking on toes but rapid shuffling steps, increased in cadence, lack of heel strike and toe off, decreased arm swing. Jaunty—Jerky and dancing pattern. Waddling—Oscillatory pattern. Kinesia paradoxa—Run better than walks. Tandem walking—Heel-to-toe pattern. Gluteal—Leaning of the trunk to the affected side. Antalgic/Limping—Patient does not put his complete weight on the affected lower limb, step length is very small. Calcaneal—Patient walks on the heel. Hand to knee/Quadriceps—Knee has to be forcibly extended during heel strike and this is done by placing hand on thigh at midstance. Talus/Equinous/Toe—Walks on toes. Valgus—Walks on medial border of the foot and knock knee is present. Varus—Patient walks on the lateral border of the foot and associated bow leg is present.

MISCELLANEOUS

LEVELS OF AMPUTATIONS (FIGS 6.1 AND 6.2)

Fig. 6.1: Levels of amputation in lower limb

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Fig. 6.2: Levels of amputation in upper limb

MISCELLANEOUS

ABBREVIATIONS AAA Abdominal aortic aneurysm Ab Antibody ABG Arterial blood gas ABPA Allergic bronchopulmonary aspergillosis ACBT Active cycle of breathing technique ACE Angiotensin-converting-enzyme ACT Activated clotting time ACTH Adrenocorticotropic hormone AD Autogenic drainage ADH Anti-diuretic hormone ADL Activities of daily living A-aDO2 Alveolar-arterial oxygen gradient ADR Adverse drug reaction AE Air entry AEA Above elbow amputation AF Atrial fibrillation or a febrile AFB Acid fast bacilli AFO Ankle foot orthosis Ag Antigen AGN Acute glomerulonephritis AHRF Acute hypoxemic respiratory failure Ai Aortic insufficiency AIDS Acquired immunodeficiency syndrome AKA Above knee amputation AL Acute leukemia ALD Alcoholic liver disease

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ALI AMBER AML AP APACHE A-aPO2 ARDS ARF AROM AS ASD ATN ATPS AVAS AVF AVR AVSD AXR B/slab BCG BDI BE BEA BiPAP BIVAD

Acute lung injury Advance multiple beam equalization radiography Acute myeloid leukemia Anteroposterior Acute physiology and chronic health evaluation Alveolar-arterial oxygen gradient Acute respiratory distress syndrome Acute renal failure Active range of movement Ankylosing spondylitis Atrial septal defect Acute tubular necrosis Ambient temperature and pressure saturated Absolute visual analog scale Arteriovenous fistula Aortic valve replacement Atrioventricular septal defect Abdominal X-ray Back slab Bacille Calmette-Guerin Baseline and transition dyspnea index Bacterial endocarditis/barium enema/base excess Below elbow amputation Bilevel positive airway pressure Biventricular device

MISCELLANEOUS

BKA BM BMi BO BP BPD BPF Bpm BS BSA BSO BVHF C/O C/W Ca CABG CAD CAH CAL CAO CAPD CBC CBD CBF CCF CCU CDH CF CFA

Below knee amputation Blood glucose monitoring Body mass index Bowels open Blood pressure Bronchopulmonary dysplasia Bronchopleural fistula Beats per minute Bowel sound/breath sound Body surface area Bilateral salpingo-oophorectomy Bi-ventricular heart failure Complains of Consistent with Carcinoma Coronary artery-bypass graft Coronary artery disease Chronic active hepatitis Chronic airflow limitation Chronic airways obstruction Continuous arterial venous hemofiltration Complete blood cell count Common bile duct Cerebral blood flow Congestive cardiac failure Coronary care unit Congenital dislocation of hip Cystic fibrosis Cryptogenic fibrosing alveolitis

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CFMS CHD CHF Ci CK CL CLD CML CMV

Cerebral function monitors Coronary heart disease Chronic heart failure Chest infection Creating kinase Lung compliance Chronic lung disease Chronic myeloid leukemia Controlled mandatory ventilation/ cytomegalovirus CNS Central nervous system CO Carbon monoxide CO Cardiac output CO2 Carbon dioxide COAD Chronic obstructive airways disease CoP Completion of plaster COPD Chronic obstructive pulmonary disease CP Cerebral palsy CPAP Continuous positive airway pressure CPM Continuous passive movement CPN Community psychiatric nurse CPP Cerebral perfusion pressure CPR Cardiopulmonary resuscitation Crash team Cardiac arrest team CRF Chronic renal failure CRP C-reactive protein CRP Conditioning rehabilitation program

MISCELLANEOUS

CRQ C-section CSF CT CVA CVI CVP CVS CVVHF CXR D and C D/C D/W DBE DDD DDH DH DHS DIB DIC DIOS DISH Dl DLCO

Chronic respiratory disease questionnaire Cesarean section Cerebrospinal fluid Computed tomography Cerebrovascular accident Cerebrovascular incident Central venous pressure Cardiovascular system Continuous veno-venous hemofiltration Chest X-rays Dilation and curettage Discharge Discussed with Deep breathing exercises Degenerative disc disease Developmental dysplasia of the hips Drug history Dynamic hip screw Difficulty in breathing Disseminated intravascular coagulopathy Distal intestinal obstruction syndrome Diffuse idiopathic skeletal hyperostosis Deciliter Diffusing capacity for carbon monoxide

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DM DMARD DMD DN DNA DOA DSA DTs DU DVT DXT EBV ECCO2R ECG ECMO EECP EEG EIA ETT EMG ENT EOR Ep EPAP EPP

Diabetes mellitus Disease modifying anti-rheumatic drug Duchenne muscular dystrophy District nurse Deoxyribonucleic acid/did not attend Dead on arrival/date of admission Digital subtraction angiography Delirium tremens Duodenal ulcer Deep vein thrombosis Deep X-ray therapy Epstein-barr virus Extracorporeal carbon dioxide removal Electrocardiogram Extracorporeal membrane oxygenation Enhanced external counter pulsation Electroencephalogram Exercise induced asthma Exercise tolerance test Electromyography Ear, nose and throat End of range Epilepsy Expiratory positive airway pressure Equal pressure points

MISCELLANEOUS

ERCP ERV ESR ESRF ETCO2 ETT EUA FB FBC FDP FET FEV1 FFD FG FGF FH FHF FiO2 FRC FROM Ft FVC FWB G GA Gaw GBS

Endoscopic retrograde, cholangiopancreatography Expiratory reserve volume Erythrocyte sedimentation rate End stage renal failure End-tidal carbon dioxide Endotracheal tube Examination under anesthetic Foreign body Full blood count Fibrin degradation product Forced expiration product Forced expiratory volume in 1 second Fixed flexion deformity French gauge Fibroblast growth factor Family history Fulminating hepatic failure Fractional inspired oxygen concentration Functional residual capacity Full range of movement Feet Forced vital capacity Full weight bearing Gram General anesthetic Airway conductance Guillain-Barré syndrome

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GCS GH GI GIT GOR GPB GTN GU H+ H2 HASO Hb HC Hct HD HDU HF HFCWO HFJV HFO HFOV HFPPV HFV HH HI HIV HLA

Glasgow coma scale General health Gastrointestinal Gastrointestinal tract Gastroesophageal reflux Glossopharyngeal breathing Glycerol trinitrate Gastric ulcer/genitourinary Hydrogen ion Hydrogen Hip abduction spinal orthosis Hemoglobin Head circumference Hematocrit Hemodialysis High dependency unit Heart failure High frequency chest wall oscillation High frequency jet ventilation High frequency oscillation High frequency oscillatory ventilation High frequency positive pressure ventilation High frequency ventilation Hiatus hernia/home help Head injury Human immunodeficiency virus Human leukocyte antigen

MISCELLANEOUS

HLT HME HPC HPOA HR HRR HT Hz IABP IBS IC ICC ICD ICP ICU IDC IDDM IF Ig IHD ILD IM IM/im IMA IMV INH INR IPAP IPPB

Heart-lung transplantation Heat and moisture exchanger History of presenting condition Hypertrophic pulmonary osteoarthropathy Heart rate Heart rates reserve Hypertension Hertz Intra-aortic balloon pump Irritable bowel syndrome Inspiratory capacity Intercostal catheter Intercostal drain Intracranial pressure Intensive care unit Indwelling catheter Insulin dependent diabetes mellitus Interferential therapy Immunoglobulin Ischemic heart disease Interstitial lung disease Intramedullary Intramuscular Internal mammary artery Intermittent mandatory ventilation Inhalation International normalized ratio Inspiratory positive airway pressure Intermittent positive pressure breathing

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IPPV IPS IRQ IRV IS ITU IV/i.v. IVB IVC IVH IVI IVOX IVUS J JVP KAFO KCO KO KPa LA LAP LBBB LBP LCL LDL LED LFA LFT

Intermittent positive pressure ventilation Inspiratory pressure support Inner range quadriceps Inspiratory reverse volume Incentive spirometry Intensive therapy unit Intravenous Intervertebral block Inferior vena cava Intraventricular hemorrhage Intravenous infusion Intravenacaval oxygenation Intravenacaval ultrasound Joule Jugular venous pressure Knee ankle foot orthosis Transfer coefficient Knee orthosis Kilopascal Local anesthetic Left atrial pressure Left bundle branch block Low back pain Lateral collateral ligament Low density lipoprotein Light emitting diode Low friction arthroplasty Liver function test/lung function test

MISCELLANEOUS

LFT × 2 LL LOC LP LRTD LSCS LTOT LVAD LVEF LVF LVRS M MAOI MAP MAS MC and S MCH MCL MCV MDI MDI ME MEFV METs MHz MI MIFV

Lung or liver function test Lower limb/lower lobe Level of consciousness Lumbar puncture Lower respiratory tract disease Lower segment cesarean section Long-term oxygen therapy Left ventricular assist device Left ventricular ejection fraction Left ventricular failure Lung volume reduction surgery Meter Monoamine oxidase inhibitor Mean airway pressure/mean arterial pressure Minimal access surgery Microbiology, culture and sensitivity Mean corpuscular hemoglobin Medical collateral ligament Mean corpuscular volume Multidisciplinary team Metered dose inhaler Metabolic equivalents/myalgic encephalomyelitis Maximum expiratory flow volume Metabolic equivalents Megahertz Myocardial infraction Maximum inspiratory flow volume

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ML MM MMAD mmHg MMV MND MOW Mph MRI MRSA Ms MS MSU MUA MV MVO2 MVR MVV MWM N/S NAD NAG NAI NBI NBL NBM NCPAP NEEP

Middle lobe Muscle Mass median aerodynamic diameter Millimeter of mercury Mandatory minute volume Motor neuron disease Meals on wheels Miles per hour Magnetic resonance imaging Methicillin-resistant staphylococcus aureus Millisecond Mitral stenosis/multiple sclerosis Midstream urine Manipulation under anesthetic Minute volume Myocardial oxygen consumption Mitral valve replacement Maximum voluntary ventilation Mobilization with movement Nursing staff Nothing abnormal detected Natural apophyseal glide Non-accidental injury No bony injury Non-directed bronchial lavage Nil by mouth Nasal continuous positive airway pressure Negative end expiratory pressure

MISCELLANEOUS

NEPV NFR NG NH NICU NIDDM NIPPV NITU NIV Nm Nmol NMR NO NOF NOH NP NPA NPV NR NREM NSAID NSR NWB O/E O2 OA

Negative extra-thoracic pressure ventilation Note for resuscitation Nasogastric Nursing home Neonatal intensive care unit Non-insulin dependent diabetes mellitus Non-invasive intermittent positive pressure ventilation Neonatal intensive care unit Non-invasive ventilation Nanometer Nanomole Nuclear magnetic resonance Nitric oxide Neck of femur Neck of humerus Nasopharyngeal Nasopharyngeal airway Negative pressure ventilation Nodal rhythm Non-rapid eye movement Non-steroidal anti-inflammatory drug Normal sinus rhythm Non-weight bearing On examination Oxygen Oral airway/osteoarthritis

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OB Occ OD Oe OGD OHFO Oi °JACCOL °LKKS OLT OPD ORIF OT PR PA PA PACO2 PaCO2 PADL PAIVM PAO2 PaO2

Obliterative bronchiolitis Occasional Over dose Objective examination Oesophagogastroduodenoscopy Oral high-frequency oscillation Oxygen index No jaundice, anemia, clubbing, cyanosis, edema No liver, kidney, kidney, spleen Orthotopic liver transplantation Outpatient department Open reduction and internal fixation Occupational therapist Per rectum Posteroanterior Pernicious anemia/posteroanterior/pulmonary artery Partial pressure of carbon dioxide in alveolar gas Partial pressure of carbon dioxide in arterial blood Personal activities of daily living Passive accessory intervertebral movement Partial pressure of oxygen in alveolar gas Partial pressure of oxygen in arterial blood

MISCELLANEOUS

PAP PAWP PBC PC PCA PCD PCIRV PCP PCPAP PCV PCWP PD PDA PE PEEP PEF PEFR PEG PeMax PEME PEP PERLA PFC

Pulmonary artery pressure Pulmonary artery wedge pressure Primary biliary cirrhosis Presenting condition/pressure control Patient-controlled analgesia Primary ciliary dyskinesia Pressure-controlled inverted ratio ventilation Pneumocystis carinii pneumonia Periodic continuous positive airway pressure Packed cell volume Pulmonary capillary wedge pressure Parkinson’s disease/peritoneal dialysis/postural drainage Patent ductus arteriosus Pulmonary embolus Positive end expiratory pressure Peak expiratory flow Peak expiratory flow rate Percutaneous endoscopic gastrostomy Peak expiratory mouth pressure Pulsed electromagnetic energy Positive expiratory pressure Pupils equal and reactive to light and accommodation Persistent fetal circulation

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PFO PFY PHC PID PIE PIF PIFR Pimax PIP PMH PMR PN PND POMR POP PPIVM PROM PS PTB PTCA PTFE PTT PU PVC PVD PVH

Persistent foramen ovale Patellofemoral joint Pulmonary hypertension crisis Pelvic inflammatory disease Pulmonary interstitial emphysema Peak inspiratory flow Peak inspiratory flow rate Peak inspiratory mouth pressure Peak inspiratory pressure Previous medical history Percutaneous myocardial revascularization Percussion note Paroxysmal nocturnal dyspnea Problem-oriented medical record Plaster of Paris Passive physiological intervertebral movement Passive range of movement Pressure support/pulmonary stenosis Pulmonary tuberculosis Percutaneous transluminal coronary angioplasty Polytetrafluoroethylene Partial thromboplastin time Passed urine Polyvinyl chloride Peripheral vascular disease Periventricular hemorrhage

MISCELLANEOUS

PVL PVR PWB Px QOL R/O RA RAP Raw RBBB RBC RDS REM RFT RH RhF RIP RMT ROM ROP RPE RPP RR RS RSV RTA RV RVF SC SA

Periventricular leukomalacia Pulmonary vascular resistance Partial weight-bearing Prescribing Quality of life Removal of Rheumatoid arthritis/room air Right atrial pressure Airway resistance Right bundle-branch block Red blood cell Respiratory distress syndrome Rapid eye movement Respiratory function test Residential home Rheumatic home Rest in peace Respiratory muscle training Range of movement Retinopathy of prematurity Rating of perceived exertion Rate pressure product Respiratory rate Respiratory system Respiratory syncytial virus Road traffic accident Residual volume Right ventricular failure Subcuticular Sinoatrial

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SAB SAH SALT SaO2 SB SBE SCI SDH SFL/SFR SGAW SH SHO SIJ SIMV SL SLAP SLE SMA SN SNAG SOA SOB SOBAR SOBOE SOOB SpO2 SpR SPS

Subacromial bursa Subarachnoid hemorrhage Speech and language therapist Arterial oxygen saturation Sinus bradycardia Subacute bacterial endocarditis Spinal cord injury Subdural hematoma Side flex left/right Specific airway conductance Social history Senior house officer Sacroiliac joint Synchronized intermittent mandatory ventilation Sublingual Superior labrum, anterior and posterior Systemic lupus erythematosus Spinal muscular atrophy Swedish nose Sustained natural apophyseal glide Swelling of ankle Shortness of breath Short of breath at rest Short of breath on exertion Sit out of bed Pulse oximetry arterial oxygen saturation Special registrar Single point stick

MISCELLANEOUS

SR SRAW SS ST SUF (c) E SV SVC SVD SVG SVO2 SVR SVT SW SWT T21 TA TAA TAH TAR TATT TAVR TB TBI TCCO2 TCO2 TED TEE TENS TFA

Sinus rhythm Specific airway resistance Social services Sinus tachycardia Slipped upper femoral (capital) epiphysis Self-ventilating Superior vena cava Spontaneous vaginal delivery Saphenous vein graft Mixed venous oxygen saturation Systemic vascular resistance Supraventricular tachycardia Social worker Shuttle walk test Trisomy 21 (Down’s syndrome) Tendon of Achilles Thoracic aortic aneurysm Total abdominal hysterectomy Total ankle replacement Tired all the time Tissue atrial valve repair tuberculosis Traumatic brain injury Transcutaneous carbon dioxide Transcutaneous oxygen Thromboembolic deterrent Thoracic expansion exercises Transcutaneous electrical nerve stimulation Transfemoral arteriogram

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TFT TGA TGV THR TIA TKA TKR TLC TLCO TLCO TLSO TM TMR TMVR TOP TPN TPR TTO TURBT TURP TV TWB Tx U and E UAO UAS UL mm URTI

Thyroid function test Transposition of great arteries Thoracic gas volume Total hip replacement Transient ischemic attack Through knee amputation Total knee replacement Total lung capacity Carbon monoxide transfer factor Transfer factor in lung of carbon monoxide Thoracolumbar spinal orthosis Tracheostomy mask Transmyocardial revascularization Tissue mitral valve repair Termination of pregnancy Total parenteral nutrition Temperature, pulse and respiration To take out Transurethral resection of bladder tumor Trans urethral resection of prostate Tidal volume Touch weight-bearing Transplant Urea and electrolytes Upper airway obstruction Upper abdominal surgery Upper limb/upper lobe Micrometer Upper respiratory tract infection

MISCELLANEOUS

ms USS UTI V V/p shunt V/Q VA VAD VAS VATS VBG VC Vd VE VE VEGF VER VF VR VRE VSD VT Vt W W/R WBC WCC WOB ZEEP

Microsecond Ultrasound scan Urinary tract infection Ventilation Ventricular peritoneal shunt Ventilation-perfusion ratio Alveolar ventilation/alveolar volume Ventricular assist device Visual analog scale Video-assisted thoracoscopy surgery Venous blood gas Vital capacity/volume control Dead space Minute ventilation Ventricular ectopics Vascular endothelial growth factor Visual evoked response Ventricular fibrillation/vocal fremitus Vocal response Vancomycin-resistance Enterococcus Ventricular septal defect Ventricular tachycardia Tidal volume Watt Ward round White blood count White cell count Work of breathing Zero end expiratory pressure

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Acr—across Med—medial Hor—horizontal Incl—inclined Betw—between L—left B—backward D—downward W/c—with Alt—alternate Rhythm—rhythmically Pend—pendulum Stat—stationary Opp—opposite Foll—followed Cont—continuously Rep—repeat Res—resisted >-more than #—fracture —circumduction !!—parallel H—head N—neck T—trunk Abd—abdomen Shbl—shoulder blades A—arm Wr—wrist

O—outward Tow—towards Lat—lateral Obl—oblique Und—under Beh—behind Movt—movement Sup—support Tog—together J—jump Spr—spring Ass—assisted Pass—passive Wd—wide Rev—reverse Reb—rebound Bal—balance