Musculoskeletal
-> Shoulder
1.
2.
3.
4.
5.
6.
7.
-> Special Tests
Empty Can => Supraspinatus MUS/T
Yergason => Bicipital Tendinitis => ER/Sup
Speeds => Bicipital Tendinitis => push down on FA
Ludington’s => Bicep Brachelli long head tendinitis => hands on head
Drop Arm => Rotator Cuff => 90° ABD
Lateral Scapular Slide Test
Apley Scratch Test
a. Inability to touch opposite shoulder => limited GH ADD, IR, horizontal flexion
b. Inability to touch back of neck => limited in GH ABD, ER, upward rotation, elevation
c. Inability to touch back of thorax => limited in GH ADD, IR, Retraction, Downward
Rotation
8. Hawkins – Kennedy => Shoulder impingement (supraspinatus) forward flex GH 90°/Elbow 90°/IR
9. Sternoclavicular Stress Test => Sternoclavicular/Costoclavicular Lig. Sprain
10. Acromionclavicular Compression/Distraction Test => acromioclavicular/coracoclavicular Lig.
Sprain
11. Apprehension Test Posterior/Anterior => dislocation/instability
12. Sulcus SIign => Inferior force/distraction => step inferior to acromion
13. Piano Key Sign => distal clavicle in an inferior direction => instability of acromioclavicular on
involved side
14. Posterior Impingement Test => Maximal ER (crank test) => RTC/Posterior Labral Pathology
15. Cross-over impingement test => horizontal flex/ADD => superior sh. Pain => AC joint pathology
=> Anterior sh. Pain => subscapularis,
supraspinatus,
Biceps long head
=> Posterior sh. Pain => intraspinatus, Teres
minor, Posterior
capsule path.
16. Anterior drawer test => passive ABD GH joint 70 - 80°/forward flex 0° - 10°/ER 0 - 10°
 Increased anterior translation
17. Posterior drawer test => downward pressure => Increased posterior translation
18. Jobe Relocation Test => supine 90° ABD/full ER => posterior force on head of humerus => in
shoulder ER => indicative of anterior instability
19. Feagin Test => 90° ABD rest on PT shoulder => move in atn/inf direction => excessive gliding ->
indicative of anterior and/or inferior GH instability
20. Load and shift test=> compression of humeral head + anterior then posterior shift translation =>
translation greater than 25% of the diameter => instability
21. Grind Test => grinding/clunking => indicative of glenoid labrum tear (overhead)
22. Clunk Test => passive ABD + ER + Anterior force to humerus => grinding clunking => glenoid
labrum
23. O’brien test (Active compression) => 90°forward flex + 30 - 45° ADD + max 1R => pain and/or
popping present in IR position but absent in ER position is indicative of SLAP lesion.
24. Brachial Plexus Stretch Test => lateral flex subject head + downward pressure => Test if cervical
fx or dislocation is suspected => nerve or facet joint impingement
25. Adson Maneuver => palpate radial pulse, rotate arm towards test arm => TDS => Subclavian
Artery
26. Allen’s test => 90° ABD and ER, 90° elbow flex, rotate arm towards test arm => TOS
27. Roo’s test => 90° ABD and ER, 90° elbow flex => rapidly open and close hands for 3min => TOS
28. Military Test => arm extended to 30° and hyperextend head and neck => absent radial pulse TOS
29. Pectoralis major contracture test: Arms clasped behind head, PT pushes elbow to table => (+)
subject is unable to passively have his elbows reach the table
30. Neer impingment => examine passively and maximally forward reflexes => pain, apprehension
=> supraspinatus and long head tendons
-> Elbow
1. Resistive Tennis Elbow Test (cozens) => Resist pronation, RD, Extension, => ECRL/ECRB
=> lateral epicondyle
2. Golfer’s Elbow (Medical Epicondyle) => passively Slip FA, extend elbow, extend worst
3. Hyperextension test => passively extend to 0°
4. Elbow Flexion => maximally flex elbow and hold for 3 – 5 min => Radiating pain in median nerve
distribution (lateral FA, tip of thumb, index and middle finger, lateral half of index) => indicative
of cubital fossa syndrome
5. Varus stress test => pushes laterally => damage radial collateral ligament (LCL)
6. Valgus Stress test => pushes medially => damage UCL/MCL
7. Tinel’s sign => Ulnar notch (btw olecranon process and medial epicondyle) => Ulnar N.
compromise
8. Punch Grip => thumb and index finger: pad to pad => anterior interosseous -> median N.
(trapped between pronator head)
9. Pronator Teres Syndrome => elbow  90° => Resist FA pronation and elbow extension =>
median nerve distribution
-> Wrist and Hand
1.
2.
3.
4.
5.
6.
Tap percussion test => indication of fracture
Compression test => Press, stabilize distal phalanynx => fx
Long finger flexion test => can’t flex PIP => FDP + FDS + nerve => can’t flex DIP = FDP
Finkelstein’s test => identify Dequervain’s (APL/EPB)
Phalen’s => Carpal tunnel of Median N.
Reverse phalens => Median N.
7.
8.
9.
10.
11.
Tinel’s sign => carpal tunnel compression of Median N.
Fromets sign => weakness of adductor pollicis of Ulnar N.
Wrinkle Test => No wrinkle – dennervated tissue. No peripheral regeneration
Allen’s Test => Vascular feeling
Bunnel – Littler test => tight capsule vs tight intrinsic muscle => flexion limited in MCP and PIP =
capsule. If move PIP  with MCP  = Intrinsic tight. If move DIP  with PIP then retinacular
ligament are tight
12. Murphy’s sign: 2nd and 3rd digits are equal when making a fist => dislocated lunate
13. Watson’s test => Ant/post scaphoid while Ulnar and radially => subluxation and reduction of
Scaphoid
-> TMJ
1. Chvostek => taps over masseter muscle and parotid gland => (+) = twitching facial nerve =>
hypoparathyroidism => results of low calcium
2. Loading test => Molase => bites down => Anterior dislocated disc
3. Palpation test => 5th digit in subject ear while open and closes mouth => inflammation of
synovium of TMJ or TMS pathology
Neuromuscular
Neuromuscular / w2
1. SCI: partial or complete disruption results
In paralysis, i loss, altered autonomic reflex activities
-
Thiumatic causes: MVA, jumps, falls
diving, gunshot wounds
-
MOI: Flexion (most common lumbar)
Flexion-Rotation (most common cenical)
Compression
Hyperextension
-
Nonthumatic: disc proplapse,
Vascular unsuits, infections
-
Spinal areas of greatest injury
C5, C7, T12 & L1
-
Pathophysiology: lack of blood supply
Z edme, ischemia, demyelination,
Necrosis, scar tissue formation
-
Lesion level: most distal uninvolved
Nerve not at lease 3+/5 or fair + function
-
Tetbaplegia: C168
-
Paraplegla: btwn T1 T12-L1
-
ASIA scale: A complete
-
Byncomplete: sensory, no motor
-
Ctncomplete: motor presented
Muscle and grade < 3
-
D=incomplete: motor presented
Muscle and grade > 3
E=Normal
Syndromes:
1. Anterior cord – loss of motor fxn,
motor loss sensation good pain, temp preservation of light
touch, proprioception position sense
2. Brown – sequard: UPsilateral awareness
Loss of position vibration below
The level contralateral loss of P!
Temp a few segs below lesion
3. Central: loss of central cenical
loss of ventral home loss of UE motor
thicks / arm fxn preservation
of peripheral located number
sacral tracts / leg fxn. Early loss
of P! temp
4. Calida equine: below L1, LMN
5. Sachi spanng: spring if tracts
to sacral segmenents preservation
of penianal sensation , rectal
sprincter tone or active toe flexion
-
Spinal shock loss of fxn resolves btwn 24 hours
6. Poster: B loss of dosal column,
sensation of ptro fxn, PI light touch,
propnoception, vibration, pressure,
deficits of kinesthesia (sterognesis 2 point discrinination)
2. TBI: 10: Diffuse axonal injury: results
from shear strain of angular acceleration
results in neuronal death petechual
hemormages
-
Focal injury: contusions, lacerators, mass
effect from hemomhage
edema (hematoma)
-
Coup-contricoup: injury at point of impact
Opposite point
-
Closed or open injury: fx of skull
-
Z: hypoxic-ischemic: results
from systemic problems (respiration
or CV) that compromise cerebral
arculation
-
Swelling / edema: intrcronlal
pressure, brain hemuation
(uncal, central, or tonsilkr)
-
Electrolyte imbalance
-
mass release of damaging neuriot
3. Epilepsy: distunaance of CMS:
-
Ground mal: tonic-clonic, tongue
Biting, arrested breathing; after
2-5 min consuousness is gradually
Regrained, full recovery take hours
Some attacks preceeded by a brief
Aura
-
Petit-Mai(absence squee)
Brief lapse of consousness
Followed by immediate full
return of conciousnsess posture
is maintained,; may occur 100x
a day
-
Status sebure: prolonged sebure
(730 mm) very little recovery btwn
Attacks, life threatening, medical
Emergency
-
TX: do not restrain patient
4. Vestibular neurontitis: vestibular synd
acute infection prolonged attack of symptoms
-
Caused by vibal or bacterial infection
5. Meniere: vestubular
-
Recuvent progressive vest.
Disease episodes last from
min -> hrs
-
Tinnitus, deafness, fullness
Of ear, edema of abrynthis
Consistent.
-> Symptoms of concussions

Loss of consciousness, changes in HR, RR, BP
1. Mild concussion: momentary loss of consciousness or confusion
- Retrograde amnesia (loss of memory that goes back in time before injury)
2. Classic: Moderate in severity
- Mostly reversible in 24 hours
- may be retrograde and posttraumatic amnesia (loss of memory for events after the traumatic
event)
3. Severe: loss of consciousness for > 24 hrs
- associated with diffuse axonal injury and coma
-> Standardized Tests and Measure for TBI
1. Glasgow Coma: Mild (13-15)
Mod (9 – 12)
Severe (< 8)
2. Rancho Los Amigos (Recovery): 8 general cognitive and behavioral level
3. Rappaport’s Disability Rating Scale levels of disability of functional behavior
4. Glasgow Outcome Scale: Major Disability Categories for outcome assessment
-> Symptoms of TBI

Increased intracranial pressure, inappropriate physical, verbal, sexual behaviors, poor judgment,
iriitability, low frustration tolerance and aggression, impulsivity, safety issues, depressed mood,
sensory deficits, paresis, apraxia(dyspraxia), reflective behaviors, balance diets, ataxia,
incoordination (cerebellar damage is common)
-> Symptoms of CVA
1. ACA Syndrome: Contralateral sensory loss and hemiparesis
 LE > UE, mental confusion, aphasia
2. MCA Syndrome: contralateral sensory loss and hemi
 UE > LE, motor speech dysfunction (Broca’s), perceptual dysfunction (parietal sensory
cortex), homonymous hemianopsia (optic radiation, internal capsule), loss of conjugate gaze
to opposite side (frontal eyelids), sensory ataxia (parietal lobe)
3. Vertebral Artery (medial medullary): ipsilateral paralysis of tongue, contralateral paralysis of
arm and leg with impaired sen.
4. Lateral Medullary (Wallenberg: PICA, basilar): ipsilateral symptoms (ataxia, vertigo, N/V,
nystagmus, Hornets, dysphagia, impaired speech
 Contralateral loss of pain and temp of half of body, sometimes face.
5. Basilar Artery: locked in syndrome (occlusion in pons): Quadriplegia and bulbar paralysis:
unable to move or speak: full cognitive fxn: sensation may be intact
6. PCA: Contralateral homonymous hemianopsia: contralateral sensory loss, thalamic syndrome,
involuntary mvts, paralysis of vertical eye movement => oculomotor CN III
-> Standardized Test and Measures for CVA
1. Fugi-Meyer: Objective criteria for scoring of movement (O; cant Z; fully performed) UE, LE fxn,
balance, sensation, ROM, pain
2. NIH stroke scale: measures acute cerebral infarction
3. Postural Assessment Scale for stroke (PASS): postural control and balance in patients.
4. Stroke Impact Scale: Brief assessment of physical and social fxn after CVA.
5. Functional Independence Measure (FIM)
(Functional mobility and basic ADL, Physical, Psychological, Social Fxns
6. Functional Assessment Measure (FAM) FIM + community access, IADL, Safety, employability and
adjustment.
-> 10 common disease/congenital conditions
1. ALS: Upper and Lower Motor Neurons
 Affects muscles of reputation
 Dysarthria and dysphagia
 Muscle Atrophy, cramp, fasciculation(LMN)
 Spasticity and hyperreflexive (UMN)
 No sensory changes: ALS functional rating scale
 TX: teach energy conservation
2. Bell’s Palsy: inflammatory response, facial nerve (CN VII) LMN
 Difficulty wrinkling forehead, close eye lid tight and smoking
 Loss of control of salivation, one sided facial muscle weakness or paralysis, normal sensation
 Mouth droops and decrease taste sensation anterior 2/3 tongue
 Tx: Artificial tears of temp. patching to protect cornea
- E-stim
- Teach facial muscle exercises
- Functional retraining (chew on opposite side)
3. Guillain – Barre (GBS) LMN
 Polyneuropathy of probable immune – mediated vital organ symmetric motor paralysis and
progressive muscular weakness
 Affects cranial and peripheral N.
 Stocking/globe sensory loss
 Paresthesias
 Progressive weakness from LE -> UE: from distal -> proximal
 Full tetraplegia with respiratory failure
 Tachycardia, abnormalities in cardiac rhythm and blood pressure changes
 Slow recovery 3% mortality rate
 TX: During Ascending Phase (disease progressing)
- Respiratory function
- PT PROM with tolerance, positioning to prevent contractures, skin care to prevent
breakdown
- Stabilized patient
- Avoid overuse and fatigue, begin gentle stretching and initiate movement in a
controlled environ
During Descending Phase
- Provide muscle reeducation with moderate exercise program
- Improve cardiovascular fitness
- Teach energy conservation
4. Multiple Sclerosis UMN
- demyelinated disease prevalent in colder climates
- sensory disturbances: tigling, numbness, pain
- coordination problems and spasticity
- Fatigue (in p.m.)
- diplopia
- B and B problems
- Psychosocial problems including euphoria/depression
- Adverse rxn to heat
- Standardized test
- Expanded Disability Status Scale
- Minimum Record of Disability
- Modified Impact scale
 TX: Prevention of secondary problems, skin care if sensation is lost or diminished
- Breathing exercises
- PNF tolerance
- Morning treatment preferable
 Meds: Steroids, ACTH
5. Parkinson’s Disease
 Progressive disease affecting basal ganglia with a decrease dopamine production
 TRAP
 Abnormal gait( festigating or slow shuffling)
 Behavior changes including memory loss, decubitus ulcers, muscle atrophy, contractures,
decreased vital capacity and falls
6. Post-polio (LMN)
 new form of muscular dystrophy
 denervation with asymmetrical muscular weakness
 myalgia
 joint pain
 excessive fatigue and decreased endurance
 TX: Low intensity: never to point of fatigue
- Stop exercise with pain or weakness
- Energy conservation
- 2 – 3 min of exercise to 1 min of rest
- Appropriate
target => 60 – 80%
- 3x/week
- Sleep disturbances
7. Cerebral Palsy
 Non-progressive gestational, perinatal or postanatal CNS damage
 Voluntary movement impairments
 Causes: Hemorrhage below lining of ventricles, Hypoxic encephalopathy, Malformations,
Trauma to CNS
 4 main Syndromes
1. Spastic: UMN (most common)
- Hemi, para, or tetraplegia
- Increased DTRs, muscle tone
- Mass patterns of flexion or extension
- Scissors gait and toe walking
- Visual, Auditory, Cognitive and Oral-motor deficits may be present
2. Athetoid:
-
Basal ganglia involvement
Slow, writhing, involuntary movement, may affect extremities
Decreased tone
Poor functional stability in proximal joints, poor visual tracking, speech
delay, and oral motor problems
ATNR, STNR, TLR, may be persistent blocking functional positions and
movement
3. Ataxic: (uncommon)
- Results from cerebellar involvement
- Weakness, poor coordination, intention tremor produce unsteadiness
- Wide base gait
- Difficulty with rapid or fine movement
4. Mixed Forms:
- Most often: spasticity and athetosis
- Less often: ataxia and athetosis
TX for ALL: maxima (I) allowed
-
Motor learning and motor control to facilitate fxn motor skills
Adaptive equipment for posture, trunk control, function and socialization
8. Down Syndrome (Trisomy 21)
 Congenital chromosomal abnormalities: extra chromosome 21




Decreased tone, muscle force, congenital heart defects, visual and hearing losses, laxity
of ligs., cognitive defects
Difficulty in eating and speech
Forceful neck flexion and rotation activities should be limited due to atlantoaxial
ligament laxity and potential for a subluxation and/or SCI
Tx: Facilitate gross and fine motor via positioning, posture and movement activities
o Encourage motor function and avoid hyperextension of elbows and knees
during WB activities
o Encourage conservation (if congenital heart defects are present)
9. Duchenne’s Musuclar Dystrophy
 Affects males, destruction of cells
 Progressive weakness proximal -> distal from ages 3 to 7
 Waddling pattern, toe walking, lordosis, frequent falls, difficulty standing up (Gower’s
sign) and problems climbing stairs
 Contractures and deformities for heel cords and TFL
 As progresses, child develop kyphoscoliosis (after 11 years old)
 Tx: Maintain mobility
o Recreational activities to maintain strength and cardiopulmonary function
o Don’t expect at maximal level
10. Myelomeningocele (Spina Bifida)
 Defect in vertebrae resulting in protrusion of the spinal cord and meninges
 After surgical closure, hydrocephalus may become a problem and require shunt of the
CSF to decrease intracranial pressure
A. Ventriculoatrial shunt: cerebral ventricle -> cardiac atrium
B. Ventriculoperitoneal: Cerebral Ventricle -> peritoneal cavity
 Signs: Increased irritability, decreased muscle tone, seizure, vomit, bulging fontanels,
HA, redness along shunt tract.
 Functional problems depending on level of spinal cord defect:
 Strength deficits
 Hip flexor and adductor tightness
 Foot deformities: club foot or talipes equinovarus (club foot)
 B and B problems
 Low tone and poor head control
 Developmental delays
 Treatment:
Proper positioning
- Standing frame
- Parapodia
- Swivel and rollator walker with low thoracic lesion
- RGO for lumbar lesion
11. Charcot – Marie – Tooth Disease (Peroneal Muscular Atrophy)
 Hereditary disorder of peroneal and distal leg M.
 Foot drop and “stork leg deformity”
12. Legg-Calve – Perthes Disease
 Idiopathic aseptic necrosis of femoral capital epiphysis
 Unilateral: boys ages 5 to 10 years
 Treatment:
o Prolonged Bed rest
o Mobile traction and slings
o Casting
o Special hip abduction orthosis

Common Reflexes Tested and the Scale
o Jaw Reflex: trigeminal CNV
o Biceps: C5 – C6
o Triceps: C7 – C8
o Brachioradialis: C5 – C6
o Hamstrings: L5 – S3
o Quads (knee jerk; patellar): L2 – L4
o Achilles (ankle jerk) S1 – S2

Scale(scoring)
O: absent
1+: Decreased response
2+: Normal
3+: Exaggerated
4+: Hyperactive
DTRs: may be abnormal in CNS lesions (hyporeflexia, hyperreflexia) or PNS lesions (hyporeflexia)

Sensory Pathway (White matter)
A. Ascending fiber systems: (sensory)
1. Dorsal Columns/Medial lemniscal
- sensation of proprioception, vibration and tactile discrimination
- fasciculus cuneatus (UE and laterally located)
- fasiculus gracelis (LE and medially located)
- fibers cross (lemniscal decussation) to form medical lemniscus ascend to thalamus then
to somatosensory cortex
2. Spinothalamic: Sensations of pain and temperature (lateral), and crude touch (anterior) –
ascend 1 or 2 ipsilateral spinal cord (lissauer) synapse and cross in spinal cord to opposite side
3. Spinocerebellar: proprioception information from muscle spindles, GTO, and touch and
pressure receptors to cerebellum for control of voluntary movements
- Dorsal spinocerebellar => ipsilateral -> inferior
-
Ventrospinocerebellar => contralateral and ipsilateral -> superior cerebellar
4. Spinoreticular: Deep and chronic pain to reticular formation of brainstem, polysynaptic
pathways.
B. Descending Fiber Systems (motor)
1. Corticospinal Tract: Arise from primary motor cortex, descend in brainstem, cross in medulla;
important for voluntary motor control.
2. Vestibulospinal: Arise from vestibular nucleus and descend to spinal cord in lateral
(uncrossed) and medial (crossed and uncrossed); important for control of muscle tone,
antigravity muscles and postural reflexes.
3. Rubrospinal: Arise in contralateral red nucleus and descend in lateral white column: assist in
motor function.
4. Reticulospinal: arises in reticular and descends (crossed and uncrossed) in ventral and lateral
columns
- on dorsal gray: modifies transmission of sensation
- on ventral gray: influences gamma motor neurons and spinal reflexes
5. Tectospinal: Arises from superior colliculus (midbrain): assists in head turning response to
visual stimuli
List of 12 Cranial Nerves and How to Test
1. Olfactory (some):
D - Loss of smell
2. Optic (stars):
D – Monocular blindness, loss of papillary constriction, absence of blink reflex
F – Slight, papillary
3. Oculomotor (make):
F – Moves eye and elevates the upper eyelid
D – Ptosis (levator palpebrae), dilation of pupil, loss of accommodation of light reflex; Homer’s
syndrome
4. Trochlear (money):
F – Motor N. for superior oblique muscle
D – Diplopia, failure to rotate eye up and out
5. Trigeminal (but):
F – Mastication and sensory n.
D – Loss of facial sensation, weakness in mastication, deviation of open jaw to ipsilateral side
6. Abducens (my):
F – Abducts eye via nerve supply to lateral rectus muscle
D – Diplopia, convergent squint (medial strabisumus) and abductor paralysis of ipsilateral eye
7. Facial (brother):
F – Facial expression, speech articulation, winking, ingestion of food and drink, taste, salivary
and nasal secretions
D – Ipsilateral facial paralysis, dry mouth, loss of taste anterior third of tongue (Bell’s palsy)
8. Vestibulocochlear (says):
F – maintenance of equilibrium, hearing
D – Vertigo, nystagmus, disequilibrium, tinnitus, loss of hearing
9. Glossophareangeal (bugs):
F – Elevates pharynx, salivary secretion, taste
D – Slight dysphagia, partial dry mouth, loss of taste posterior third of tongue, dysphonia
(hoarseness)
10. Vagus (bunny):
F – Phonation, visceral sensation and reflexes, cardiac depressor, bronchoconstrictor, GI tract
peristalsis and secretion
D – Palpitation, tachycardia, vomiting, slowing of respiration, ipsilateral paralysis of soft palate
and larynx, hoarseness, anesthia of larynx, gag reflex.
11. Accessory (makes):
F – Deglutition and phonation (carotid part), movements of head and shoulder (spinal part)
D – Weakness in shrugging ipsilateral shoulder turning head to opposite side scom
12. Hypoglossal (more):
F – Movements of tongue
D – Unilateral paralysis of tongue, deviation to ipsilateral side with protrusion
UMN
VS
Location
Structures
LMN
CNS
Cortex, brainstem,
corticospinal tract SC
CVA, TBI, SCI
Disorders
Tone
Hypertonia, velocity dependent
Increased
Muscle spasms,
flexor/extensor
Weakness/paralysis
Reflexes
Involuntary Movement
Strength
Muscle bulk
Variable, disuse atrophy
Voluntary Movement
Impaired/absent dyssynergic
pattern
PNS
SC: anterior horn, CN,
peripheral nerve
Polio, GB, Peripheral
neuropathy
Decreased, not velocity
dependent
Decreased
With denervation:
fasiculations
Limited distribution
- segment/focal
- root innervated
Neurogenic atrophy, rapid
focal, severe wasting
Weak or absent if nerve
interrupted
Table 2 – 5



CENTRAL NERVE
PD
ALS
CVA
Conditions vs Peripheral Nerve
 Peripheral nerve injury
 Trigeminal neuralgia
 Bulbar palsy


TBI
SCI




Guillain – Barre
ALS
Postpolio
Bell’s Palsy
Integumentary
 Burn Classification
1. Superficial burn (1°) – only involves outer epidermis area, may be red with slight edema. No scarring,
spontaneous healing 3 – 7 days, delayed pain.
2. Superficial Partial thickness – epidermis and upper layer of dermis, bright pink, blisters, moist surface,
weeping, moderate edema, painful, sensitive to touch, change of temperature, spontaneous healing,
discoloration.
3. Deep partial thickness (2°) – damage to epidermis, dermis, nerve endings, hair follicles, and sweat
glands, mixed red or waxy white appearance, slow capillary refill, broken blisters, wet surface, marked
edema, sensitive to pressure but insensitive to light touch or soft pin prick , slow healing.
4. Full thickness (3°) – destruction of epidermis, dermis, subcutaneous; may extend to muscle. White,
gray, charred or black appearance, no blanching; poor distal circulation, dry leathery surface, little pain,
nerve endings destroyed, removal of infection, hypertrophic scarring and wound contracture.
5. Subdermal (4°) – destruction of epidermis, dermis, subcutaneous with muscle damage, charred
appearance, destruction of vascular system, lead to additional necrosis. From electrical burns;
ventricular fibrillation, acute kidney damage, SCI, heals with skin grafting and scarring, requires
extensive surgery amputation may be necessary.
 Staging of Pressure Ulcers (characteristics)
-
Stage 1: Nonblanchable erythema of intact skin. Skin temperature (warm or cool), tissue consistency
(firm or boggy), and/or sensation (pain, itching) changes.
Stage 2: Partial-thickness skin loss: involves epidermis dermis, or both ulcer is superficial. Presents
clinically as an abrasion, blister, or shallow crater.
Stage 3: Full-thickness skin loss: involves damage to or necrosis of subcutaneous tissues. May extend
down to, but not through, underlying fascia. Presents clinically as a deep crater.
Stage 4: Full-thickness skin loss: involves extensive, destruction, tissue necrosis, or damage to
muscle, bone, or supporting structures undermining and sinus tracts may be present.
 Physical Examination and Documentation
 Size = Clear film grid superimposed on wound
 Depth = sterile cotton tip applicator (tunneling)
 Length = Head to foot

Width = Left to Right or Right to Left
Ulcers
Etiology
Artificial
Arteriosclerosis
obliterans,
Artheroembolism
Venous
Valvular
incompet. Of DVT
venous HTN
Appearance
Irregular, smooth
edges, minimum
to no granulation:
deep
Location
Distal lower leg:
toes, feet, lateral
malleolus, ant.
Tibial area
Decreased or
absent
Painful, especially
leg elevated
Irregular, dark
pigmentation,
fibrotic, good
granulation,
shallow
Distal lower leg
med. malleolus
Pedal Pulses
Pain
Drainage
Gangrene
May be present
Signs
Trophic changes,
pallor on foot
evelation dusky
rubor on
dependency
Usually present
Little pain,
comfort with leg
elevated
Moderate to large
amt of exudate
Absent
Edema status,
dermatitis,
cyanosis on
dependency
Diabetic
Diabetes with
arterial disease
and peripheral
neuropathy
Repetitive trauma
or insensitive skin
Decubitus
Unrelieved
pressure
Plantar aspect of
foot
Bony prominence,
sacrum, heel,
ischial, elbows
Present or
diminished
Not painful,
sensory loss
Red, brown/
black, yellow
Painful if
sensation is intact
Sepsis: may
develop
Absent ankle jerks Hypotension,
with neuropathy
microvascular
inflammatory
with necrotic
tissue, superficial
-> deep erosion of
deep layers,
WBC
Physical Examination and Documentation


Undermining (circumference)
- Deepest area into the wound, document using the face of the clock. Head of the wound is
12. Foot is 6.
Ex. 1.7cm at 10 o’clock (clockwise)
Tunneling
- Deepest area into the wound (depth), document using the face of the clock. Head of the
wound is 12. Foot is 6. (clockwise)
Ex. 1.8cm at 3 o’clock
 Types of Exudate
1. Serous (clear): Watery-like serum, normal in inflammatory and proliferative stage
2. Purulent (yellow): Containing pus, infection
3. Sanguineous (Red): Containing blood, normal or disrupt of BV
4. Serosanguineous (pink): Healthy wound
 Rule of 9s
 Color and Tissues Involved
1. Clean Red wound: healthy granulating (in need of protection), absence of necrotic tissue
2. Yellow wound: include slough (necrotic or dead tissue), fibrous tissue
3. Black wound: Eschar
4. Indolent ulcer: slow to heal; not painful
Genitourinary System
 Symptoms and Types of Urinary Incontinence
 Inability to retain urine: result of loss of sphincter control may be acute (due to transient
causes e.g. cystitis) or persistent (e.g. stroke dementia)
1. Type: Stress – damage to pudendal nerve
 Increased intra-abdominal pressure
o Coughing, laughing, exercise, straining, obesity
 Weakness and laxity of pelvic floor musculature
o Post-partum incontinence, menopause
2. Type: Urge – inability to delay voiding to reach toilet due to:
 Detrusor muscle instability or hyporeflexia (stroke)
 Sensrory instability: hypersensitive bladder
3. Type: Overflow – An overdistended bladder or incomplete emptying of bladder due to:
 Anatomical obstruction: prostate enlarged
 Acontractile Bladder: SCI, DM
 Neurogenic Bladder: MS, Suprasacral Spinal lesion
4. Type: Functional – leakage associated with inability or unwillingness to toilet due to
 Impaired cognition (dementia): depression e.g. Alzheimer’s
 Impaired Physical functioning; stroke
 Environmental barriers
 Bladder Infections (UTI)
 Lower UTI (Urethra and Bladder): Cystitis (inflammation and infection of bladder)
Urethritis (inflammation and infection of the urethra)
- Symptoms of urinary frequency, urgency, burning during urination. Urine may
be cloudy and foul smelling.
- Pain is noted in suprapubic, lower abdominal, or groin area, depending on site
of infection.
 Upper UTI (Ureter and Kidney): Pyelonephritis (inflammation and infection of one or both
kidneys)
- Symptoms of systemic involvement: fever, chills, malaise, HA, tenderness and
pain over kidneys (back pain), tenderness over the costovertebral angle
(Murphy’s sign)


- Symptoms: frequent and burning urination; nausea and vomiting may occur
- Palpation or percussion over kidney causes pain
- Can be acute or chronic; generally more serious than lower UTI
Obstructive disorders
- Prostatic hyperplasia (incontinence for men)
- Renal calculi (kidney stones) => Calcium, Magnesium, Uric Acid, Cystine
 Extracorporeal Shockwave Lithotripsy (ESWL) is used to break up stones
into fragments to allow for easy passage.
- Treatment/prevention: increase fluid intake, thiazide diuretics, dietary
restriction of foods high in oxalate (vegetables, fruits, nuts, grain, seeds),
acidification or alkalinization of urine
Renal failure
A. Acute: Elevation in serum area and creatinine
- Circulatory disruption of kidneys, toxic substances, bacterial toxins, acute
obstruction, trauma.
B. Chronic: Progressive loss of kidney function leading to end-stage failure
- Prolonged acute urinary tract obstruction and infection, DM, SLS, uncontrolled
hypertension.
- Uremia: end-stage toxic condition resulting from renal insufficiency and
retention of nitrogenous waste in blood
- Signs and Symptoms: anorexia, nausea, mental confusion
 Pregnancy
- Postural changes: Kyphosis with scapular protraction, cervical lordosis and forward head;
lumbar lordosis
- Third trimester : limit supine position to avoid inferior vena cava compression bridging
- Balance : COG shifts forward and upward
- Ligament laxity: Joint hypermobility
- Muscle weakness : Stress incontinence
- Respiratory: elevation of diaphragm with widening of thoracic cage; hyperventilation,
dyspnea with mild exercise
- Cardiovascular : Increased blood volume, increased venous pressure in LE, increased HR and
CO, decreased BP due to venous distensibility
- Altered thermoregulation: Increased basal metabolic rate, heat production
 Pregnancy-related Pathologies
1. Diastasis Recti Abdominis
- separation from midline (linea alba), > 2cm is significant
2. Pelvic floor disorders
- Pubococcygeal (PC) muscles
- Weakness or laxity of PC can result in partial or total organ prolapsed ex:
A. Cystocele: Herniated bladder into vagina
B. Rectocele: Herniated rectum into vagina
C. Uterine Prolapse: Bulging uterus into vagina
* Pain can radiate down the posterior thigh
3. Sacroiliac dysfunction
- Posterior pelvic pain
- Pain in buttocks, radiate into posterior thigh/knee
- Associated with prolonged sitting, standing, walking
- Avoid single-limb weight bearing
4. Varicose veins
- Elevate extremities
- Do not cross legs
- Elastic support stockings
5. Preeclampsia
- Acute hypertension after the 24th week of gestation
- Symptoms of HTN, edema, sudden excessive weight gain, HA, visual disturbances,
hyperreflexia
- Initiate prompt physical referral
6. Low Back and pelvic pain
- Emphasize use of firm mattress
- Massage, modalities for pain (no deep heat)
7. Cesarean childbirth
- Post-operative TENS can used for incisional pain: electrodes are placed parallel to
incision
- Assist patient in breathing, coughing
- Postural exercises: precautions about heavy lifting for 4-6 weeks
- Friction massage
 Disorders of the Female Reproductive System
1. Endometriosis
- Ectopic growth and function of endometrial tissue outside of the uterus
- Common sites include ovaries, fallopian tubes, broad ligaments, uterosacral
ligaments, pelvis vagina, intestines
- Back pain, endometrial implants on muscle (Psoas and pelvic floor M)
- Symptoms: dysmenorrheal, dyspareunia (abnormal pain during sexual intercourse)
and infertility
2. Pelvic Inflammatory Disease (PID)
- Inflammation of upper reproductive tract involving uterus (endometritis), fallopian
tubes (salpingitis) or ovaries (oophonitis)
- Symptoms: lower abdominal pain, with mesnstrual cycle, purulent cervical discharge
and painful cervix
- Fever, increased WBC and increased ESR are present
 Disorders of the Male Reproductive System
1. Erectile Dysfunction (ED)
Causes:
-
Neurogenic: CVA, trauma, SCI, MS, PD
Hormonal: decreased androgen level with hypogonadism, hypothyroidism and
hypopituitarism
Vascular: HTN, CHD, hyperlipidemia, smoking, DM, pelvic irradiation
2. Prostatitis
- Inflammation and infection of prostate gland
- Dull acting pain may be found in the lower abdominal, rectal, lower back, sacral, or
groin regions
- Non-bacterial inflammatory prostatitis produces pain in penis, testicles, and
scrotum: painful ejaculation, low back pain or pain in inner thigh, decreased libido
and impotence
- Because the prostate encircles the urethra, obstruction of urinary flow can result.
Cardiovascular
Page - 1
Week 2 : caradovascular/ Pulmonary/ list 10-15 common diseases
1. COPD :
-
Abnormal breath sounds
-
Increased chest size
-
Dry/ productive cough
-
Hx of smoking
2. Astma
-
reactivity of trachea of bronchi
-
Narrowing of away
-
Secretions
-
Dry or productive mucold sputum
-
Wheezing cough
-
Chest wall symmetically decreased
-
Meds ovil or iv stenrds (prednisone)
3. Bronchitis
-
chronic inflammation of tracheobronchlal tree cough
-
sputum lasting at least 3 months for Z convective years
-
Wheezing or Ranchi breath sounds
-
Productive mucold & infection
-
May have fever
-
Tx paced breathing, Endurance, D+ ed about smoking, biancho, pulmonary hygiene
4. Cystic
5.
-
Thickening secretion of all exocrine gland fibrosis
-
Respimtory infection C staph and pseudononas aewgunosa
-
+ sweat test
-
Rales (extrn breath sounds), wheezing
-
May have hemoptysis (cough up blood)
-
Large amt of mucold
-
Tx. Percussion, vibrate, shake endunince exercises
-
Trypsin precursor of prypsnagen
Emphysema
-
Permanent abnormal enlargement distraction of all spaces distal to
-
terminal bronchures
-
barreled chest
-
assessory mussels of vent
-
breath sounds wheeze
-
dyspnea
-
puzed up breathing during exhalation
6. Alternations to pleura fibrotic changes within pulmonary pleura
-
Pulmonary filonosis
-
Asbestosis
-
Radiation pnamonitis
-
Oxygen toxicity
7. Aitenatony to chest wall
-
restricted motion of bory thonix
-
alkylosug spondylitis
-
arithiting
-
scoliosis
-
pectusexcalatum
-
chest wall skin louring
-
scterodorma
8. Alterations un Neuromuscular
-
muscular strength in an unability to expand no cage
-
MS
-
Muscular dystrophy
-
PD
-
SCI
9. Teauma
-
2 or more fixoures in 2 or more adjacent nibs
-
Flail chest shallow breathing
-
Crepitation over fix site
-
Inspination: flail moves inward
-
Exhalation: flail moves outward
-
Tx. gontle breathing, spunt, proper positioning, pain manage
10. Pneumothorix air enters plewal space causing lung to collapse due to loss of negative trauma
pressure
-
Or absent breath sounds
-
Dry cough
-
Local or referred pain
-
Trachear dernation quary from affected side
-
Hyperresonant tympanic percussion sound
-
Tx. chest tube, chest precaution
11. Tuberculosis
infection spread by droplets
-
after 2 weeks of meds, host is non-noninfectious
-
TB in HIV patients
-
Hemoptysis
-
Low grade fever
-
Dyspnea
-
Chest wall pain
12. Pulmory Edema acute Disease
-
excessive seepage if flued from pulmonary vascular system unto
-
interstitial space due to
-
ventricular failure
-
Aovtic valvular disease
-
Mitral valvular disease
-
Unhalation of toxic fumes
-
Naracotic overdose
-
Dyspnea on exertion or paroxysmal noctumal dyspnea
-
Fatgue
-
Pink frothy sputum
-
Circuits
-
Tx. divietics salt intake bed rest (hob elevtel)
13. Rulmonary Acute disease
-
thromlals from peripheral venous circulation (ie)
-
lodges in Embolic pulmonaryarery
-
infarction chest hemoptysis, ploural friction rub, fever and EXR
-
5 infroction pachitinea anxiety restlessness rales wheezing decreasing breath sounds
-
Tx. low dose hepan alalgesies, rilmory vasodilaturs.
Page – 2
4st 10-20
1.
2.
3.
4.
5.
6.
Anti-anhythmic : I docaine, Dilantin, Norpace,
-
Control or prevent cardnic
-
anthythmias that can be fatal
quinidine
Anti-arolinergic (atropine)
-
used & IV for heart block or bbidoavzlia
-
inhibits ACTH, blocking Vagal effects on SA & AV node
-
SE Palpitations, HA, ataxia restlessness, dry mouth, blurred vision
Beta-adrenergic: Propranolol (indetal)
-
HR, BP, conthchloty & SV
-
OZ demand on = in exercise
-
dent use HR to determine tolerance of ex. use RPE
Calcium channel: Vasodilate & relieve coronary antery spasm
-
could reduce blood flow to al muscel creating iocnemic reponse
-
diattizem, cardizen
-
BP, control anthythmias
Digitals: Contractility HR
-
tx of CHF
-
digoxin
Diuretics: myocardial work (Preioad & afferioad)
-
7.
& Lungmeds
Control HTN
Nitrate: Vasodilator
-
BP Preload
-
OZ demand on
8.
10.
11.
Anticoagulants: Coumadin & heparin
-
blood clotting time
-
Could result in hemoptysis during percussion & snacking
-
Pts
DVT
Branchoduators: Epinephine, vention, Alupent
-
Relax smooth muscle
-
open lumen
-
used prior to ex. to reduce
-
negative effect (asthma)
Corticosteriods: Predntson & contisool
-
edema & inflammation
-
COPD
-
SE .OP muscle wasting
-
slow wound healing
1. Lymphatic Deceases
- Lymonadenopathy: enlargement of nodes or stendoness
2. Lymphedema: Chronic-execrate acamuldar of fund
-
results from massacres insufficiency
A) Primary congenital & alonmalyaph
note or lymph vesser (hypoplasia)
B) 2 : acquired; injury of 1 or more pane
-
results from surgery radical mastectomy lymphnode removal radution therapy for
beast cancer,
-
results of panlysis & desuse
-
tropical & subtropical areas from
-
filansis (nematode worm)
-
Chronic venous insufficiency.
3. Acute lymphangtis: bacterial infections spreading throughout lumph system
-
Streptococcal
4. Initiating factors: inactivity / charges in carbon pressure
-
fluctuation in weight gain
-
Hypermia
-
Hypopotonia
Page – 3
Week 2: Musculos kelctal -> Conditions
RA: Systemic disorder, unknown etiology
Dysfunction of synovial tissues and articular cartilage at hands, wrists, elbows, shoulders, knees, ankles,
Ulnar drift and volar subluxation of MCPs
X-rays, lab tests (increased WBCs & erythrocyte sedimentation rate. Hemoglobin/hematocrit show
anemia elevated RF)
Rx:
Antireumatic drugs, NSAIDS( side effect fluid retention and Edema), immunosuppressive
PT Interventions
Joint protection strategies, improve/maintain joint mechanics and CT function
Aerobic fitness
Osteoporosis
Metabolic disease
Depletes bone density (=fractures)
Senile: Decrease in cell activity (genetic or acquired)
Post-menopausal primary: Decrease in estrogen production
CT scan (assess bone density)
Rx:
Calcium, vit D(aids in calcium absorption from the G)I, calcitonin( helps prevent osteoclastic activities
and aids reabsorption), estrogen, biophosphates
PT Intervention
Joint/bone protection strategies, aerobic exercise, improve joint mechanics
Osteomalacia
Decalcification of bones due to vit D deficiency
Severe pain, fractures, weakness, deformities
Diagnosis:
X-ray, bone scans, possibly a bone biopsy
Rx:
Calcium, vit D, calciferol (form of vit D (D2) via injection)
PT Intervention
Joint/bone protection strategies, aerobic exercise, improve joint mechanics
Osteomyelitis
Inflammatory response within bone due to infection
Usually caused by staph aureus
More common in children, immunosuppressed, males
Diagnosis by:
Lab tests for infection, possible bone biopsy
Rx:
Antibiotics for infection, nutrition, possible surgery
PT Intervention
Joint/bone protection strategies, cast care, improve joint mechanics
Arthrogryposis multiplex congenita
Congenital deformity of skeleton and soft tissues
Decreased joint ROM, "sausage-like" limbs
Blue sclera noted and increased contractures and club foot
Diagnosis: X-ray
Rx:
PT intervention
Joint/bone protection strategies, aerobic exercise, improve joint mechanics, education RE
adaptive/assistive/orthotic/supportive devices, flexibility exercises
Oseogenesis imperfecta
Characterized by Abnormal collagen synthesis, imbalance between bone deposition and reabsorption
Thinning of bone - fractures/deform
Genetic autosomal dominant
Bone scan, X-ray, serology
Rx:
Calcium, vit D, estrogen, calcitonin, biophosphonates
Joint/bone protection strategies, aerobic exercise, improve joint mechanics
Osteochondritis dissecans
Separation of articular cartilage from bone (osteochondral #)
Usually medial femoral condyle, occasionally femoral head/talar dome/capitellum
Diagnosis: X-ray, CT
PT intervention
Joint/bone protection strategies, flexibility exercises (for normal joint motion) aerobic exercise,
strength, power, and endurance
Myofacial pain syndrome
Characterized by trigger points
Active TP: Tender, referral pattern
Latent TP: Not tender, can be converted to active
May be due to sudden overload, overstretch, repetitive/sustained muscle activities
No diagnostic tests
Rx:
Dry needling, analgesic/corticosteroid injection (Side effects include infection moon face, striae),
flexibility exercises (for normal joint motion)
Myositis ossificans
Abnormal calcification within muscle belly
Usually due to direct trauma (hematoma-calcification)
CAN BE CAUSED BY EARLY STRETCHING/MOBILIZATION WITH AGGRESSIVE PT FOLLOWING MUSCLE
TRAUMA
Usually occurs in quads, brachialis, biceps
Diagnosis: X-ray, CT, MRI
Acetaminophen( side effects Liver damage), NSAIDS( side effects GI disturbances)
Possible surgery (if non-hereditary and after lesion has matured - 6-24 months. Indicated if lesion
interferes with joint or impinges nerves)
Flexibility (for normal joint motion), massage (reduces guarding/pain), mobilization (correct
biomechanical faults), aerobic exercise
(AVOID BEING OVERLY AGGRESSIVE WITH ALL ABOVE TECHNIQUES)
Complex regional pain syndrome (CRPS)
Dysfunction of sympathetic nervous system including pain, circulation and vasomotor disturbances
Long term: Muscle wasting, trophic skin changes, decreased bone density, decreased proprioception,
contractures
Etiology unknown (thought to be related to trauma)
Two types:
Type 1
1) Triggered by tissue injury; all patients with above symptoms but no underlying nerve injury
Type 2
2) Same symptoms but clearly associated with nerve injury
Rx:
Sympathetic nerve block, sympathectomy, SC stim, intrathecal drug pumps( side effects drowsiness),
topical analgesics, antiseizures Side effects, antidepressants( side effects mood swings, orthostatic
hypotension)corticosteroids, opioids (side effects drowsiness, respiratory depression).
PT interventions
Education to prevent injury, desensitization (focus on RTW), flexibility (for normal joint motion), TENS
Paget's
Metabolic bone disease, abnormal osteoclast/osteoblast activity
Etiology unknown (possibly viral)
Spinal stenosis, facet arthropathy, possible spine
Diagnosis: X-ray, lab tests (look for increased serum alkaline phosphates and urinary hydrogenase)
Rx:
Acetaminophen, calcitonin and etidronate disodium (limit osteoclast activity)
Joint/bone protection strategies, improve mechanics, aerobic
Idiopathic scoliosis
Two types:
Structural: Irreversible lateral curvature with rotation
Nonstructural: Reversible lateral curvature without rotation which straightens with flexion
X-ray, CT, MRI
Rx (Structural):
Bracing, possible surgery depending on degree of curve (<25 conservative, 25-45 orthoses, >45 surgery)
Flexibility, strength, power, endurance, electrical stimulation (for muscle performance), application and
education RE orthoses
Torticollis
Spasm/tightness of SCM
Characterized by Side bend towards, rotation away from affected SCM
Rx:
Acetominophen, muscle relaxants (side effects Drowsiness), NSAIDS
Flexibility, manual therapy - massage, joint oscillations (to decrease muscle guarding/pain),
mobilizations (to corrects biomechanics)
Glenohumeral subluxation/dislocation
Anterior-inferior is the most common direction of dislocation
Occurs with abduction and forceful ER
Tearing of inferior GH ligament, ant capsule, possibly labrum
Posterior: Occurs with horizontal adduction and IR
Complications: Hill-Sachs, SLAP, Bankart, bruising of axillary nerve
AVOID APPREHENSION POSITION POST SURGERY
CT, MRI, apprehension tests
Rx:
Acetaminophen, NSAIDS, biomechanical correction (especially scapulohumeral rhythm, dynamic
stabilization)
Thoracic outlet syndrome (TOS)
Compression of neurovascular bundle (brachial plexus, subclavian artery and vein, vagus and phrenic
nerves, sympathetic trunk) between soft and boney structures
Occurs when size or shape of TO is altered
Areas of compression:
Scalene triangle
Superior TO
Between clavicle and 1st rib
Between pec minor and thoracic wall
Rx:
Surgery, acetaminophen, NSAIDS, postural reeducation, biomechanical restoration, manipulations/mobs
(especially 1st rib)
1. DJD:
Artnntic: P!/stuffness upon rising
-
P! eases through a.m $ c exercise
-
P! bending
-
Soreness / nagging
-
Non theumatic, nonsystemic
Diff Dx: Normal ESR
Abnormal ft ndiographs Problem in WB
-
TX: NSAIDS, education….
2. AAhnogyrposis: non progressive, non genetic congenital
-
symmetrical Rigid joints
-
sausage uke
-
Hip disloc/contric = Frex, ABD,ER
-
Diff Dx: spina bitfida
3. CRPS: Abnormal sympathetic reflex
-
P! edema, circulation, OP, slandriynes, propriception atrophy
-
Tx: modalities, ft mobs, WB, ckc activites
4. Colte’s fx: FOOSH
-
Distal segment of radius moved dorsal
-
Tx: cast -> AROM / PROM -> resistance
>
Mobs -> ckc activities
5. Fibromyalgia:
-
Tendemess, pl stuffness in mus
-
Related to stress, anxiety, fatigue, sleeplessness
-
Achirg burning
-
Diffuse or tenderpoints\
-
Diff Dx: 11 out of 18 tender points
Recognition of typical pattern
of nonrnoumatic symps +
sleep deprivation
-
Tx: ADL +x, stress management
-
Meds: analgesics antidoppresants
6. Gout: level of senium uric acid metabolic disease deposition of unite cyystals
-
Severe ft pain @ night & warmth, enythema extreme tenderness / hypersons
-
Tx: Anti-inflammatory, use of colcnine daily, diet, weight loss, alcohol, allopurinol to
hypeniricamia
7. Hemphilia: Hemownagic disorder (hereditary)
-
PT converns: Hemanthrosis muscle bleeds
8. ITB_Syndrome: nibbing of ITB over lateral epdicondyle of femur
-
Ober test
-
Excessive hupIR
-
TX: stretch, modalities, mobs, shoe orthosis
9. Myositis ossificans: truma to muscle -> Hematoma -> ossity or calcity
-
Quads, bnonialis bicepsionchill
-
Induced ealy mob aggressive PT
-
Tx: conservative gentle A/AAROM
-
Passive stretching NOT undicative
-
No manual stretching over pressure @ end range
10. Osteochondritis dissecans: sopriation of articular cargtibage from bone.
-
Medical femoral condyle
-
Less frequently at femoral head talardome
-
Tx: Gait tx, fxn strengthening, conditioning
11. Osteomalacia: decalcification of bones vitamin D
-
Tx: pain control, fxn mobility tx
12. Oseomyelitis: Bone infection
-
Traumatic injury + infection
-
Child: distal femur, proximal tibla, humens raidus
-
Adult : Pelvis venebias usually result of containination of related
to surger or truma
13. Osteoporosis: Metabolic bone disease
-
Depletes bone mineral density
-
Postmenopausal estrogen
14. Pagets: osteitis deformans metabolic bone distease
-
Intial phase of excessive bone
-
Reabsorption followed by excessive abnormal bone formation
-
New bone is weak fagile
-
Fatal when ass ZCHF bone saroma or giant cell tumore
-
Heals slowly uncomplete
-
Vatebral collapse vascular changes -> paraplegia
-
Osymptomatic = Notx
-
Symptomatic = dng theraphy
15. Patellofemoral dysfxn: patella fails to trick properly into trochelear groove
-
Instability / P! first 30 of knee fexion
-
Stair clumbing, prolonged sitting (moviegoer sign) squal, jump
-
Diff Dx: Q angle > 18
-
+ chondromalacia test.
-
Abnormal tracking of patella
-
During knee
-
Tx – Taping
-
Strengthening
-
Shoe unserts
-
TFM
Page - 4
16. Pattelar position: Patellaya: Lower than normal
-
Patella alta: Higher patella “camel sign”
“less efficient in knee”
-
Tx: inferior glide -> patella alta
Superior glide -> patella baja
17. Progressive systemic sctorosis (sclenderma)
Fibrosis changes in intermalorgan skin
-
Accompanied by Raynauds phenomenon
-
Polyarthralgia is a prominent early symptoms
-
Diff Dx: vneumatold factor
18. Pronator Teres synd: Median N entrap
-
PTS test: resist pronation
from ao of elbow to extension
-
Tx: nerve glides stretch, AROM, ultrasound, NMES
19. RA: systemic inflammatory disease
-
symmetrical pattern
-
eye lessons injection, opare
additional manifestations
-
malaise fatigue
-
symmetrical numbness ->
-
myelopathy => refer to MD!
20. JRA: prior to age 16
-
Characterized by fever rash
-
Fatigue, malaise, weight loss, general ms p!
-
Symmetrical bilateral presentation
-
Deformities: UD swan neck or boutonniere deformities
21. Scaphold fx: navicular: FOOSH
-
Poor vascular supply
-
High risk of a vascular neerosis of proximal fragment
-
Tx: early AROM of distal proximal jounts while UE is casted
-
Latee: foral use of wrist hand
22. Scoliosis: structural alonormalities
(leg length or HNP)
-
Diff Dx: postural analysis
forward flexion test
-
Tx: Bracing: Hamington Rodsctural: stretch, shoe unsers
-
Respiratory care needed if cobb’s angle is > 40
23. Sjogrens syn: meumatold-like by
dyness of mucous membrane, inflamm
anema
-
Diff Dx: Dryness of oyos
Mouth z jt
-
Annentis occute
-
Tx: sipping fluids
-
Chew sugarless gum
-
Mouth wash
24. Smiths fx: FOOSHZ hand suppurated
-
Distal fx of radius volaty
-
Cast -> A/PROM -> Resistance -> mobs -> ckc
25. Systemic lupus: chronic systemic,
Rnematic, unflammatory
Disorder.
-
Diff Dx: malaise, fatigue, anthblge,
Fever, skin rash (over nose) anemia, hair loss,
Raynauds phenomenon
-
Vascullitis, lesion undigit
necrotic legulce
26. TMJ: synontis capsulitis
-
P! anterior to ear (preauricular)
-
Unable to close back teeth
-
Open less than 40mm z p!
-
Pan decreases rest
-
TMJ hpermobility
-
“My jaw feels like its out of place”
-
Ft noises, jaw catching in
fully opened position
-
Mandibular depression > 40 mm
Derviates toward non involved side
-
Disc displacement reduction
“Jant noises, pops or clicks”
-
Disc displacement is limited to
20-25 mm Deflection toward
unvolved side.
-
Lateral excursion limited
Page - 5
 ABI



Test of peripheral arterial circulation
Ratio of Lower Extremity Pressure
Upper Extremity Pressure
Significance
- > 1.0 = Normal; ankle systolic is at least as high as brachial pressure
- 0.8 – 1.0 = Mild peripheral artery disease compression therapy with caution
- 0.5 – 0.8 = Moderate: + for intermittent claudication compression therapy is contraindicated
- < 0.5 = Severe; Critical limb ischemia, + for rest pain compression therapy contraindicated
 Intermittent Claudication


Examine for coldness, numbness, or pallor in legs or feet; loss of hair over anterior tibial area
Leg cramps may also result from diuretic use with hypokalemia
 Diastolic and Systole


Systole
- Ventricular contraction
- End – systolic volume is the amount of blood in the ventricles after systole; about 50mL
Diastole
- Ventricular relaxation and filling of the blood
- End - diastolic is the amount of blood in ventricles after diastole; about 120mL
 Heart Sounds

Auscultation landmark:
1. Aortic Valve: 2nd Right at Sternal Border
2. Pulmonic Valve: 2nd Left Sternal Border
3. Tricuspid: 4th Left at Sternal Bone
4. Mitral: 5th Left at border(midclavical)
5. Erb’s point: 3rd Left Hear S1 and S2 equal
6. PMI: Same as mitral point of max. impulse

S1 sound (lub)
- Normal closure of mitral and tricuspid valve
- Beginning of systole
- Decreased on first degree heart block

S2 sound (dub)
- Normal closure of mitral and tricuspid valve
-
Marks end of systole
Decreased in aortic stenosis
 Bruit
 Indicative of atherosclerosis
 Common in carotid or femoral artery
 Gallop
 S3 (ventricular falling)
o Indicative of congestive heart failure (LV)
 S4 (ventricular filling and atrial contraction)
o Indicative of pathology (CHD, MI, Aortic stenosis, or chronic HTN)
Right-sided Heart Failure
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Increased RAP, CVP
Jugular distention
+ Hepatojugular reflex
Right ventricle heave
Murmur of tricuspid
Hepatomegaly
Peripheral Edema
Nausea/Vomiting
Anorexia
Weight Gain
Ascites
Right upper quadrant pain
 Cystic Fibrosis
 Exocrine glands
 Obstructive, resistive, or mixed disease
 Respiratory infections
vs
Left-sided Heart Failure
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Tachycardia
S3 gallop
Crackles
Increased PAP, PAWP, SVR
Laterally displaced PMI
Left ventricular heave
Pulsus Alternans
Confusion
Decreased Urine Output
Cheyne – stokes respiration (advanced
failure)
Murmur of metal insuff.
Fatigue
Cough
SOB
DOE
Orthopnea
PND
Diaphoresis


Inability to gain weight
Diagnosis by blood test trypsinogen or (+) sweat electrolyte test
 Heart Attack
 Caused by occlusion of one or more coronary arteries
 Factors: atherosclerotic with thrombus function, coronary vasospasm or embolism; cocaine
toxicity

Zones of infarction
1. Central Zone: Pathological Q wave, electrically inert
2. Zone of injury: electrically unstable, elevated ST segments in leads over injured area
3. Zone of ischemia: electrically unstable, see T wave inversion

Infarction sites:
o Transmural (Q wave)
 Full thickness of myocardium
o Nontransmural (no Q wave)
 Subendocardial
 Subepicardial
 Intramural infarctions

Sites of Coronary A. Occlusion
o Inferior MI: Right ventricle infarction = Right coronary artery
o Lateral MI: Ventricular ectopy, Circumflex A
o Anterior MI: disturbances of lower conduction: Left Anterior descending artery

Impaired Ventricular function
o Decreased SV
o Deacreased CO
o Ejection Fraction
o Increased end diastolic ventricular pressures

Electrical Instability
o Arrhythmias present
 Most Common Restrictive Diseases
1. Atelectasis
2. Sarcoidosis
 ECG
 Info about: Rate, rhythm, conduction, areas of infarct, hypertrophy, electrolyte imbalances.
 PVCs: no P wave, bizarre and wide QRS followed by a long compensatory pause.
Serious PVCs: > 6 per minute, paired sequential runs, multifocal, Ron T phenomena
 Ventricular fibrillation: erratic activity without QRS complexes, no effective CO, clinical death
within 4 – 6 minutes.

Atrial arrhythmias: Abnormal P-waves
o Rhythm may be irregular
o Rapid rate with atrial tachycardia
o Cardiac output is maintained, may precipitate ventricular failure
 2 Types of Stress Tests
1. Treadmill and cycle ergometry (leg or arm)
- allow for precise calibration of the exercise workload.
2. Step test (upright or sitting)
- used for fitness screening healthy population
 Diagnostic Imaging for Heart and Lungs
2. Heart
a. Chest X-ray: abnormalities of lung fluids, overall cardiac shape and size aneurysm.
b. Myocardial perfusion: used for MI and ischemic disease; Thalium – 201 scan,
- Radioisotopes concentrate in normal tissue but not in ischemic or infracted tissue,
used to identify myocardial blood flow, areas of stressed – induced ischemia.
c. ECG: Noninvasive to visualize internal structures (size of chambers, movement of valves,
septum, abnormal wall movement)
d. Cardiac Catheterization: Tube passes through heart into blood vessels with intro of a
contrast medium into coronary arteries and subsequent x-ray
- Provides info about anatomy of heart and great vessels, ventricular function,
abnormal wall movements
- Allows determination of ejection fraction (EF)
e. Central line (Swan-Ganz catheter): inserted through vessels into right side of heart
- Measures central venous pressure, pulmonary artery pressure, pulmonary
capillary wedge pressure.
3. Lungs
a. Chest X-ray: 2-dimensional film to detect presence of abnormal material(exudate,
blood) or a change in pulmonary parenchymal (fibrosis, collapse)
b. CT Scan: Cross-sectional plane of the body
c. Ventilation perfusion (v/q): matches the ventilation pattern of the lung to the perfusion
pattern to identify the presence of pulmonary emboli.
d. Fluoroscopy: Continuous x-ray beam allows observation of diaphragmatic excursion
Non-systems
 Therapeutic Modalities
1. Superficial Thermotherapy
- Indications:
 Joint stiffness
 Musculoskeletal pain
 Muscle spasm
 Prepare for e-stim, passive and active
 Subacute and chronic traumatic and inflammatory conditions
-
Contraindications:
 Acute and subacute traumatic and inflammatory
 Decreased circulation and/or sensation
 DVT
 Impaired cognitive function
 Malignant tumors
 Tendency toward hemorrhage or edema
 Very young and very old patients
A. Hot Packs:
- Canvass filled with silica gel immersed between 165 -170°
- 20 – 30 min
B. Paraffin Bath:
- Mixture melt (paraffin wax and oil mixture)
 125° - 127°
- Tx: 15 – 20min
- Indications:
 Painful joints due to arthritis in subacute or chronic phase
 Joint stiffness of hands and wrist
- Contraindications:
 Allergic rash
 Open wounds
 Recent scars and structures
 Skin infections
C. Contrast Bath:
- Alternate hot and cold
- Decreased pain and swelling
- Increased circulation
- Water temp around 40°C (104°F) for hot, 15°C (59°F) for the cold
- In subacute: 3 – 4 min hot to 1 min cold
- Tx: 20-30min end with hot immersion
D. Hydrotherapy
- Used for debridement and loosening of dressings
- Full body immersion (hubbard tank)
 Water temp < 38°C (100°F)
-
Chronic conditions: 37.2 - 40°C (99-104°C)
If patient has PVD, cardiac problems or open wounds, temp < 38°C (100°F)
Indications:
 Decubitus ulcers
 Open wounds/burns
 Post surgical conditions or fracture of hip
 Subacute and chronic musculoskeletal conditions of neck, shoulder, back
 RA
2. Cryotherapy
- Indications:
 Acute and chronic traumatic and inflammatory condition
 Edema
 Muscle spasm
 Musculoskeletal pain
 Thermal burns
- Contraindications:
 Impaired circulation
 Impaired sensation
 PVD
 Neuropraxia
 Raynaud’s phenomenon
 Sensitivity/allergy to cold
A. Cold Pack
- Temp: 0 - 10°F
- Tx time: 10 – 20 min
B. Ice massage
- Tx time: 5-10min
3. Deep Thermotherapy
- Indications
 Joint contractures
 Musculoskeletal pain
 Muscle spasm
 Subacute and chronic traumatic condition
- Contraindications
 acute infections
 impaired circulation, cognitive function or sensation
 malignancy
 thoracic area containing pacemaker
 very young or old patients
A. Ultasound
- Deep aching pain = overheating periosteal tissue => reduce intensity immediately
- Indications
-
-
 Open wounds
 Neuromas
 Periarticular condition
Contraindications
 acute inflammatory joint pathology
 healing fracture
 thrombophlebitis
 radioactive isotopes
Precautions
 Metal implants
 Osteoporosis
 Plastic implants
 Primary repair of tendons or ligaments or scar tissue
B. Phonophoresis
4. Other Physical Agents
A. Mechanical Spinal Traction
- Indications
 Degenerative disc
 Discogenic pain
 HNP (disc protrusion)
 Joint stiffness or disease
 Meniscoid blocking muscle spasm
 Nerve root impingement
 Subacute or chronic joint pain
- Contraindications
 impaired cognitive function
 spinal tumors and infections
 Spondylolisthesis
 RA
 OP
 Very young and very old patients
 Vascular compromise (verterbral artery syndrome)
- Precautions
 Acute inflammation aggravated by traction
 Acute strain and sprains
 Claustrophobia
 Hiatal hernia
 Joint instability
 Pregnancy
 TMJ problems with use of halter, remove dentures
 use mouth piece
B. Cervical traction
- 20 – 30 pounds =distraction of vertebral bodies
C. Lumbar Traction
- 25 – 65 punds = effect change at spinal segments
- Neck position
 0 - 5°  to increase space at C1 – C4
 20 - 30°  for C5 – C7
 0° for disc dysfunction
- Lumbar position
 Spinal stenosis
 Hip/knee (90/90) position
 Posterior HNP
 Prone without pillow preferred
 Intermittent Compression
- Indications
 Chronic Edema
 Lymphedema (postmastectomy)
 Stasis ulcer
 Traumatic edema
 Venous insufficiency
 Amputation
- Contraindications
 Acute or infected treatment area
 Acute DVT or pulmonary edema
 Arterial insufficiency
 Cancer
 Decreased skin sensation
 Kidney, cardiac insufficiency
 HTN
 Cognitive dysfunction
 Obstructed lymph channels
 Very young and frail elderly
5. Electrotherapy
- Indications
 Pain modulation
 Muscle spasm
 Impaired ROM
 Muscle re-ed
 Disuse atrophy (muscle weakness)
 Soft tissue repair (wound healing)
 Edema reduction
 Spasticity (reduce hypertonicity)
 Denervated muscle
- Contraindications
 Healing fractures
-
 Areas of active bleeding
 Malignancies or phlebitis treatment area
 Superficial metal implants
 Pharyngeal or laryngeal muscles
 Demand-type pacemaker
 Myocardial disease
Precautions
 Impaired sensation
 Severe Edema
A. Iontophoresis
- Therapeutic ion must be placed under electrode of similar charge to “push” chemical
past the skin into deeper tissue
- Contraindications
 Impaired skin sensation
 Allergy or sensitivity to therapeutic agent or direct current
 Recent scars, cuts, bruises, broken skin
 Metal in or near treatment area.
- Negative
 Salicylate (pain relief)
 Acetic acid (calcium deposits)
 Dexamethasone (anti-inflammatory)
- Positive
 Calcium (muscle spasm)
 Lidocaine (pain relief)
 Magnesium (muscle spasm)
 Zinc (dermal ulcers)
 Copper (fungal infections)
B. TENS (Transcutaneous Electrical Nerve Stimulation)
- Impulses stimulating large A-fiber afferents, can act to blcok the pain impulses (gate
control theory)
- Body’s own endorphins/enkephalins to inhibit pain or pain transmission
- Contraindications
 Demand type pacemakers (anywhere on body)
 Over chest area of patients with cardiac dysfunction
 Over eyes, laryngeal, pharyngeal muscles, head and neck of patient after CVA or
epilepsy.
 Application to mucosal membrane
=Physiological effects of general heat
Increased: CO, metabolic rate, HR, RR, vasodilation
Decreased: BP, muscle activity, blood to internal organs, blood to resting muscle, SV
Physiological effects of local heat
Increased: Blood flow, capillary permeability, elasticity of non-elastic tissues, metabolism, vasodilation,
edema (capillary permeability).
Decreased: Joint stiffness, muscle strength, muscle spasm, pain.
Indications for superficial thermotherapy
Modulate pain, increase CT extensibility, reduce/eliminate ST inflammation/swelling, accelerate rate of
healing, reduce joint restriction/muscle spasm
Precautions for superficial thermotherapy
Cardiac insufficiency, edema, impaired circulation,
impaired thermal regulation, metal in treatment site, open wounds
Contraindications for superficial thermotherapy
Acute/early-subacute trauma/inflammation, decreased circulation/sensation, DVT, impaired cognition,
malignancy, tendancy towards hemorrhage or edema, very young/old
Parameters: Hot packs Immersed in water heated at 165-170 degrees F
Eight layers of toweling between pack and patient
Treatment time: 20-30 mins
Parameters: Paraffin bath
Paraffin wax/oil mix at ~6:1 ration
Melts at 118-130 deg F
Rx temp: ~125 deg F
Self-sterilizing at 175-180 deg F
Treatment time: 15-20 mins
Remove/cover jewlery
Wash part, check for infection and open areas
6-12 layers of paraffin
Wrapped in plastic/wax paper after it solidifies
Covered with several layers of toweling
Place in comfortable or elevated position for 15-20 mins
Alternative part can remain in the bath
Paraffin contraindications
Allergic rash, open wounds, recent scars and sutures, skin infections
Parameters: Hydrotherapy
Temp -
Whirlpool: 103-110
Hubbard tank: 100
PVD: 95-100
Open wounds: 92-96
Treatment time: 20 mins (up to 30 if other procedures also being performed)
Hydro precautions
Use liners for patients with burns/wounds/blood-borne pathogens
Add disinfectant and if open wounds are present
Standard precautions in infected environment (goggles, gown etc. - splashing)
Decreased temp sensation, impaired cognition, incontinence, confusion/disorientation, deconditioned
state, hydrophobia
Hydro indications
Pressure ulcers, open burns/wounds, post-hip #, post-surgical hip conditions, subacute/chronic
conditions of neck/shoulders/ back, RA
Hydro contraindications
Bleeding, wound maceration, cardiac instability, profound epilepsy
Water pick parameters 4-8 psi - can be increased in presence of large amounts of necrotic tissue or
tough eschar
Decrease pressure if bleeding occurs, near a major vessel, or if pt complains of pain
Treatment time usually 5-15 mins
Aquatic therapy parameters
Temp: 92-98 deg F
Treatment time varies with pt. tolerance
Open wounds and skin infections must be covered
Aquatic therapy contraindications
Incontinence, UTIs, severe epilepsy, unprotected open wounds, unstable BP, severe cardiopulmonary
dysfunction
Physiological effects of general cold application
Decreased: Metabolic rate, HR, RR, venous BP
Increased: Blood flow to internal organs, CO, SV, arterial BP, shivering (when core temp drops)
Physiological effects of local cold
Decreased: Blood flow, capillary permeability, elasticity of non-elastic tissues, metabolism, muscle
spasm, muscle strength (after 5-10 mins), spasticity, vasoactive agents
Increased: Joint stiffness, pain threshold, blood viscosity, muscle strength (in first 5 mins)
Vasoconstriction causes skin blanching at center with hyperemia due to histamine reaction around edge
of the contact area.
"Hunting reaction" Cyclic vasodilation/vasoconstriction following prolonged cold exposure (>15 mins).
Occurs mostly in hands, feet and face where atriovenous anastomoses are found.
Cold urticaria
Cold hypersensitivity
Erythema of the skin with wheal formation associated with severe itching due to histamine reaction.
Other adverse effects of cold due to hypersensitivity
Facial flush, eyelid puffiness, respiratory
problems, anaphylaxis (decreased BP, increased HR), with syncope
Related to histamine release
Indications for cryotherapy: Modulate pain, reduce/eliminate inflammation/swelling, reduce muscle
spasm, and reduce spasticity.
Cryotherapy precautions: HTN, impaired temperature sensation, open sound, over a superficial nerve,
very old/young
Cryotherapy contraindications: Cold hypersensitivity, cold intolerance, cryoglobulinemia, PVD, impaired
temp sensation, Raynaud's
Cold/ice pack parameters
Wrap pack in damp towel
Packs maintained at 0-10 deg F
Treatment time: 10-20 mins
If using ice towel replace towel every 45-60 secs
Ice massage parameters
Apply to area no larger than 4x6"
Apply slowly (2" sec), overlapping circles or long strokes
Do not massage over bony prominences or superficial nerves
Treatment time: 5-10 mins or until anagesia occurs
Vapocoolant spray parameters Indications:
Reduce spasm, desensitize trigger points
Invert container, hold ~18-24" from treatment area
Spray at 30 deg angle and sweep at 4" per sec
Allow liquid to completely dry before next sweep
Muscle should be passively stretched before and during application
Treatment time: 10-15 mins
Contrast bath parameters Indications:
Pain modulation, PVD, sprains, strains, trauma (after acute phase ends) effectiveness at raising deep
temperature is questioned
Begin in 80-110 deg F water - 4 mins
Cold water (55-65) for 1 min
Continue in sequence of 1:4
End in warm water - ending in cold water may be more beneficial if goal is to reduce edema
Treatment time: 20-30 mins
Contrast bath contraindications
Advanced atherosclerosis, arterial insufficiency, loss of sensation to heat and cold.
Ultrasound:
Transducer head size, Range from 1-10 cm
5cm most common
Should be relative to treatment area size: wrist- 1cm, shoulder/leg - 5cm
Ultrasound: Spatial average intensity
Total power (watts) divided by area (cm2) of transducer head
Typically the measurement used in documenting US treatments (0.25 w/cm2 - 2.0 w/cm2) (measure of
intensity)
Ultrasound: Beam non-uniformity ratio Ratio of spatial peak intensity to average intensity
Lower BNR = more uniform energy distribution and less risk of tissue damage
Should be between 2:1 and 6:1
Ideal 1:1 is not technically feasible
Ultrasound: Duty cycle the fraction of time the US is on over one pulse period
Time on/time on+time off
Duty cycle of 50% or less is considered pulsed
Ultrasound: Structures with high attenuation
High protein and collagen content - muscles, tendons, ligaments, capsules
Ultrasound: Depth of penetration
3-5 cm
At 3 MHz - greater attenuation in superficial tissues (e.g. TMJ)
At 1MHz - increased heat production in deep layers due to less superficial scatter
Ultrasound: Thermal effects Produced by continuous US at 0.5-3 W/cm2 (intensity will vary
depending on tissue type and pathology)
Increased: Tissue temp, pain threshold, collagen extensibility, enzyme activity, tissue perfusion, temp at
tissue interfaces.
Alteration of nerve conduction velocity.
Excessively high temps may produce sudden, strong ache due to overheating periosteal tissue - reduce
intensity or increase surface area.
Ultrasound: Non-thermal effects
Generated by very low intensity or pulsed US. Typically duty cycles of 20-50%
Cavitation: Alternating compression and expansion of small gas bubbles caused by mechanical pressure
waves.
Stable cavitation: Bubbles resonate but no tissue damage. May be responsible for diffusional changes in
cell membranes.
Unstable cavitation: Secure collapse of gas bubbles - can result in local tissue destruction due to high
temps.
Acoustic streaming: Movement of fluids along the boundaries of cell membranes resulting from
mechanical pressure wave. May produce:
Alterations in cell membrane activity increase: cell wall permeability, intracellular calcium, macrophage
response, protein synthesis. May be of some value in tissue healing.
Ultrasound: Goals/indications Modulate pain - increase CT extensibility, reduce inflammation,
accelerate healing rate, reduce joint restriction/muscle spasm.
Ultrasound: Precautions Acute inflammation, breast implants, open epiphyses, healing fractures.
Ultrasound: Contraindications Impaired circulation/cognition/sensation
Thrombophlebitis, joint cement, plastic components, over vital areas (ear, brain, heart, eye, cervical
ganglia, carotid sinuses, reproductive organs, SC, pacemakers, pregnant uterus)
Ultrasound: Procedures - Direct content
Apply generous amount of coupling medium
Move head slowly in overlapping circles or long strokes
Do not cover an area greater than 2-3x size of the ERA per five minutes of treatment
While head is moving turn up intensity to desired level - lower intensities for acute conditions or thin
tissue; higher intensities for chronic conditions or thick tissue.
Treatment time: 3-10 mins depending area, intensity, condition and frequency
Ultrasound: Procedures - indirect contact (water immersion)
Use with irregular bod parts
Plastic container preferred to decrease reflection
Place part in water
Place sound head in water, 0.5-1" from skin surface at right angle to body part
Move head slowly - if using stationary technique decrease intensity or use pulsed US
Turn up intensity to desired level
Periodically wipe off any air bubbles that form on sound head or body part during treatment
Ultrasound: Procedures - indirect contact (fluid-filled bag)
Thin-walled bag over irregular bony surface
Not widely used
Place sound head inside bag, apply coupling agent to skin and place bag over treatment area
Move head slowly within the bag, do not slide bag on skin
Increase intensity to desired level
Ultrasound: Phonophoresis
Use of US to drive medications through the skin into deeper tissues
Local analgesics (lidocaine)
Anti-inflammatory (dexamethasone, salicylates)
Method is similar to direct contact except medicine is used as part of coupling agent
Intensity: 1-3 W/cm2
Treatment time: 5-10mins
Low intensities and longer time is more effective to introduce drug to skin
Traction: Goals/indications
Decrease: Joint stiffness, meniscoid blocking, muscle spasm, DJD, disc protrusion
Modulate disc pain, sub-acute/chronic pain, reduced nerve root impingement
Traction: Precautions Acute inflammation aggravated by traction, acute strains/sprains,
claustrophobia, hiatus hernia, joint instability, osteoporosis, pregnancy, TMJ problems with halter use.
Traction: Contraindications
Impaired cognition, RA, spinal tumors, spinal infections,
spondylolysthesis, vascular compromise, very old/young.
Traction: Cervical halter
Pull of ~7% of body weight
Seated or supine
Head halter under occiput and mandible, attached to cord or spreader bar
Slack is removed
0-5 deg flxn to increase IV space at C1-C5
25-30 deg flxn to increase IV space at C5-C7
0 for disc dysfunction
Facet joint separation may require 15 degrees of neck extension
Traction applied to occiput, not chin
If pt. experiences discomfort at TMJ, stop and adjust halter
Traction: Cervical sliding device Head placed on padded headrest which positions the neck in 20-30 deg
flxn
Adjustable neck yoke tightened to firmly grip below mastoid
Head strap across forehead
Device attached to spreader bar
Acute phase: Disc protrusion, elongation of soft tissue, muscle spasm: 10-15 lbs or 7-10% of BW
Joint distraction ~20-30 lbs
5-10 mins for acute conditions and 15-30 mins for other conditions.
Duty cycle 1:1 - except joint distraction best at 3:1
Traction: Lumbar
Split table (minimize friction)
Supine, pillow under knee or small bench under lower leg
Prone may be preferable in case of posterior herniated disc
45-60 deg hip flxn for L5-S1
75-90 deg hip flxn for L3-4
Apply pelvic harness with top edge above iliac crest
Attach thoracic harness with inferior margin slightly below ribs
Thoracic harness counteracts pull of pelvic harness
Acute: 25-40 lbs
Disc protrusion, spasm, elongation of soft tissues: 25% BW
Joint distraction: 50 lbs or 50% of BW
5-10 mins for herniated disc; 10-30 mins for other conditions
Intermittent Mechanical Compression Pneumatic
Applies pressure to limb via inflatable sleeve
Single compartment=uniform circumferential pressure
Multiple compartments =Applies pressure sequentially (greater pressure in distal compartments)
Cold can be applied simultaneously - coolant pumped through sleeve
Intermittent Mechanical Compression: Physiological effects
Increased interstitial fluid pressure - fluids forced into lymphatic and venous return systems = reduced
fluid volume in limb
Intermittent Mechanical Compression: Goals/indications
Amputation, arterial insufficiency, decrease chronic edema,
Post mastectomy lymphedema, stasis ulcer, venous insufficiency.
Intermittent Mechanical Compression: Precautions
Impaired sensation, malignancy, uncontrolled HTN,
Obstructed lymph/venous return
Intermittent Mechanical Compression: Contraindications
Acute inflammation, DVT, acute pulmonary edema, diminished sensation, cancer, edema with cardiac or
renal impairment, impaired cognition, infection in treatment area.
Obstructed lymph channels, very old/young patients
Intermittent Mechanical Compression: Procedures
Check BP
Comfortable position with limb at ~45deg elevation, abd 20-70
Apply stocking, no wrinkles
Apply appliance
Edema reduction: Inflation/deflation ratio ~3:1 (45:15)
Shape stump: 4:1 often used
Power on, slowly increase pressure to desired level
Usually an elastic bandage/compression stocking used to retain reduction before dependant position
allowed
Intermittent Mechanical Compression: Pressure Pt.’s BP determines setting
Some manufacturers recommend the pressure never exceed diastolic
Others advise pressure should fall between diastolic and systolic.
Numbness, tingling, pain, pulse should not be felt by pt. during treatment
Intermittent Mechanical Compression: Treatment time depends on tolerance
Minimum daily treatment:
Lymphedema - 2 hrs to two 3 hr sessions
Traumatic edema - 2 hrs
Venous ulcers - 2.5 hrs/3x/week to two 1 hr periods
Stump reduction - 1 hr to 3 hr sessions totalling 4 hrs
Intermittent Mechanical Compression: Indications
Chronic edema, lymphedema, stasis ulcer,
traumatic edema, venous insufficiency, amputation.
CPM: Physiological effects
Accelerate rate of intra-articular cartilage regeneration, tendon and ligament healing
Decrease edema and joint effusion
Minimize contractures, decrease post-op pain, increase synovial fluid lubrication of joint,
Improve circulation, prevent adhesions, improve nutrition to articular cartilage and periarticular tissues,
and increase ROM
CPM: Indications
Post-immobilization #, tendon/ligament repair, total knee/hip replacement
CPM: Precaution
Intracompartmental hematoma from anticoagulants
CPM: Contraindications Increases in pain, edema of inflammation following treatment
CPM: Procedure (post-op knee) Applied immediately
Set at 1-4 minute cycles
At knee ROM may be 20-40 deg flxn initially, increased 5-10 as tolerated
Usually goal of 110-120 flxn
Treatment time: 1 hr 3x daily to 24 hr continuous
Duration: 1-3 weeks or until goals achieved
Tilt Table: Physiological effects
Stimulate postural reflexes to counteract orthostatic hypotension
Facilitate postural drainage
Gradual loading of one or both LLs
Begin active head/trunk control
Provide positioning for stech of hip flexors, knee flexors PFs
Tilt Table: Indications
Prolonged bed rest, immobilization, SCI, TBI, orthostatic hypotension, spasticity
Tilt Table: Procedure
Supine
Abdominal binder, long elastic stockings or tensor bandaging to counteract orthostatic hypotension may
be used
Secured by straps - Proximal to patella, pelvis, chest under axilla
Table gradually raised
Can be maintained as long as 30-60 mins - initially no longer than 45 mins 1-2x daily
Monitor vitals
Massage: Physiological effects
Increased venous and lymph flow, stretching and loosening of adhesions, edema reduction, sedation,
muscle relaxation, modulate pain.
Massage: Contraindications
Acute inflammation in area, acute febrile condition, severe atherosclerosis, severe varicose veins,
phlebitis, areas of recent surgery, thrombophlebitis, arrhythmia, malignancy, hypersensitivity, severe
RA, hemorrhage to area, edema due to kidney dysfunction, heart failure and venous insufficiency.
Electrical Stimulation:
Characteristics of nerve/muscles cells
Duration of 1 ms is enough to depolarize a nerve cell, too short to stimulate a muscle cell
<0.05 ms with low intensities can depolarize sensory nerves
<1 ms required for motor nerves
>10 ms with high intensities needed for denervated muscle
Rate of rise must be rapid enough to prevent accommodation (square wave = instantaneous rise)
Electrical Stimulation: Rheobase Intensity of the current (have a long duration) required to produce a
minimum muscle contraction
Electrical Stimulation: Chronaxie
Pulse duration of stimulus at twice rheobase intensity.
Chronaxie of a denervated muscle is greater than 1 ms
Electrical Stimulation:
Motor point: Area of greatest excitability on skin
Small current generates a muscle response
In innervated muscle - located at/near where motor nerve enters muscle, usually over belly
denervated muscle - located over muscle distally towards insertion
Electrical Stimulation:
Types of muscle contraction
Low freq pulse (1-10/sec) produces brief twitch with each stim
Increasing number of stim progressively fuses twitches to tetanic contraction
Asynchronous/worm-like (vermicular) muscle response is noted in denervated muscle
Electrical Stimulation: Amperage Rate of flow of electrons
Electrical Stimulation: Voltage Force driving electrons
Electrical Stimulation: Ohm's law Current is directly proportional to voltage and inversely proportional to
resistance.
Electrical Stimulation: Monophasic waveform, Direct/galvanic
Unidirectional flow
Has either positive or negative charge
Electrical Stimulation: Biphasic waveform Alternating current
Bidirectional flow
Half cycle above baseline, half below
Two phases = one cycle
Zero net charge if symmetrical
Electrical Stimulation: Polyphasic waveform Russian current or interferential current
Biphasic current modified to produce three or more phases in a single pulse
Electrical Stimulation: Surge mode Gradual increase in decrease in intensity over finite period of time
Electrical Stimulation: Ramped mode Gradual rise in intensity with maintenance of intensity at a
selected lever for a given period of time, then gradual or abrupt decline.
Electrical Stimulation: Indications
Pain modulation (gate control or descending inhibition), Decrease muscle spasm, Impaired ROM, Edema,
Muscle re-education (assistive, feedback, coordiation), disuse atrophy, wound-healing, decrease
spasticity, stimulate denervate muscle
Electrical Stimulation: Methods to Decrease muscle spasm
Muscle fatigue - tetanic contraction
Muscle pump - interrupted/surge modulation, increase circulation
Muscle pump and heat - Combination of electric stim and US to increase tissue temp and produce
muscle pump at same time
Electrical Stimulation: Methods to increase ROM
mechanical stretching - used when muscle strength in deficient of dysfunction (e.g. spasticity) prevents
adequate joint movement
Electrical Stimulation: Wound healing - Pulsed currents Interrupted modulations
Improved circulation (muscle pump) - improved tissue nutrition and waste metabolism
Electrical Stimulation: Wound healing - Monophasic Low volt continuous, high volt pulsed
Low amp for 30-60 mins
-Restores electrical charges at wound
-Disruption of bacterial DNA, RNA synthesis, cell transport
-Increased ATP concentration, amino acid uptake, protein and DNA synthesis
-Attraction of cells:
Inflammation - Macrophages (+ve), mast cells (-ve), neutrophils (+ve/-ve)
Proliferation - Fibroblasts (+ve)
Wound contraction - Alternating (+ve/-ve)
Epithelialization - Epithelial cells (+ve)
Electrical Stimulation: Edema reduction Muscle pump - increase lymph and venous flow
Electrical field phenomenon - Effect of electrical charge in interstitial proteins increase lymph and
venous flow.
Electrical Stimulation: Spasticity Fatigue of agonist
Reciprocal inhibition - stimulate antagonist, inhibit agonist
Electrical Stimulation: Stimulate denervated muscle
Goal is to decrease effects of disuse and shorten recovery time
May be deleterious to denervated muscle by:
Interfering with regeneration of NMJ and subsequent reinnervation
Traumatizing hypersensitive denervated muscle
Financial cost and prolonged treatment time required until reinnervation are additional factors to
consider.
Electrical Stimulation: Contraindications
Healing fractures, areas of active bleeding, malignancies or phlebitis in area,
superficial metal implants, pharyngeal/laryngeal muscles, demand-type pacemaker, myocardial disease
Electrical Stimulation: Precautions
Areas of impaired sensation and severe edema
Electrical Stimulation: Electrodes
Two required - one active (stimulating), one dispersive
Active placed on motor point
Dispersive placed on treatment site or at a remote site
Current density is relative to electrode size (small size, high density, strong stim)
Electrode size should be relative to size of treatment site
Electrical Stimulation: Electrode placement
Unipolar/monopolar:
Single or bifurcated active electrodes placed over treatment area. Usually larger size dispersive
electrode placed ipsilaterally away from treatment area.
Bipolar:
Equal sized active and dispersive electrodes in same treatment area.
Space between A and D electrodes should be at least the diameter of the active electrode and as far as
practically possible. Greater space = less current density in intervening tissue - less risk of burns and skin
irritation.
Electrical Stimulation: Muscle strength/spasm/edema (muscle pump)
Slowly increase intensity until muscle response observed
10-25 contractions may be sufficient depending on goal
Muscle re-education sessions may last 10-30 mins
Interrupted/ramped allows muscles to recover
Ratio of 1:3 or more minimizes fatigue
Use continuous to induce fatigue for spasm
Electrical Stimulation: Iontophoresis
Transport medications through skin
Continuous, direct, monophasic
Like charges repel like
+ve ions move towards cathode where secondary alkaline reaction occurs (NaOH)
-ve ions move towards annode where acid is produce (HCl)
The number of ions transferred is directly related to the treatment duration, current density and ion
concentration
Electrical Stimulation: Iontophoresis ions
Analgesia: Lidocaine, xylocaine (+ve) ; Salicylate (-ve)
Calcium deposits: Acetate (-ve)
Dermal ulcers: Zinc (+ve)
Edema reduction: Hyaluronidase (+ve)
Fungal infections: Copper (+ve)
Hyperhidrosis: Water (+ve-ve)
Muscle spasm: Calcium, magnesium (+ve)
Musculo inflam: Hydrocortisone (+ve) ; Dexamethasone (-ve)
Electrical stimulation: Iontophoresis Procedure To reduce alkaline effect the -ve electrode should be 2x
size of +ve, regardless of which is the active electrode
Dispersive electrode placed at either proximal or distal distant site, ~4-6" away
Dosage = time x intensity
Anode safe limit = 1.0mA/cm2; Cathode safe limit = 0.5mA/cm2
Duration is 10-40 mins
Turn intensity up slowly
Observe treatment area every 3-5 minutes
Electrical stimulation: Iontophoresis contraindications
As per general for elec stim
Impaired skin sensation
Allergy/sensitivity to therapeutic agent or direct current
Denuded area or recent scars
Cuts, bruises, broken skin
Metal in or near treatment area
Electrical stimulation: TENS: Physiological effects
Pain inhibition through gate-control therory:
Large A-beta fibers activate inhibitory interneurons in dorsal horn, inhibiting smaller A-delta and C
fibers. Also enkephalin release which combines with opiate receptors to depress release of substance P.
Pain modulation through descending pathways
Noxious stim generates endorphin production.
Efferents from PAG and other areas travel through dorsal SC and synapse with enkephalinergic
interneurons in SC to presynaptically inhibit release of substance P from A-delta and C fibers.
Electrical stimulation: TENS: Wave form Typically assymetrical biphasic
Zero net direct current
Pulsed monophasic sometimes used
Electrical stimulation: TENS: ModulationContinuous or burst
Electrical stimulation: TENS: Conventional (high-rate)
Most common mode
For acute or chronic pain
Pain modulated via gate mechanism
Onset of relief is fast with short duration of relief.
Amplitude: Comfortable tingling, no muscle response
Pulse rate: 50-80 pps
Pulse duration: 50-100 microsec
Duration: 20-60min
Electrical stimulation: TENS: Acupuncture-like (strong low-rate)
Chronic pain
Endogenous opiate mechanism
Onset of relief may take 20-40 mins
Duration is long-lasting, 1+ hrs
Amplitude: Strong, comfortable rhythmic twitches
Pulse rate: 1-5 pps
Pulse duration: 150-300 microsec
Duration: 30-40 min
Electrical stimulation: TENS: Brief, intense
Used to provide rapid onset, short-term pain relief during painful procedures (debridement, deep
frictions, mobs etc)
Relief lasts ~30min-1 hour
Amplitude: To tolerance
Pulse rate: 80-150 pps
Pulse duration: 50-250 microsec
Duration: 15 min
Electrical stimulation: TENS: Burst mode
Combines characteristics of high and low rate TENS
Stimulation of endogenous opiates but current is more tolerable than low-rate TENS
Long-lasting pain relief (hours)
Amplitude: Comfortable, intermittent paresthesia
Pulse rate: 50-100 pps delivered in burst of 1-4 pps
Pulse duration: 50-200 microsec
Duration: 20-30 min
Electrical stimulation: TENS: Hyper stimulation Point stimulation
Use small probe to locate and stimulate acupuncture or trigger points. Multiple sites may be stimulated
per treatment. Onset of pain relief is similar to acupuncture-like TENS.
Long-lasting relief
Amplitude: Strong, to pt's tolerance
Pulse rate: 1-5 pps
Pulse duration: 150-300 microsec
Duration: 15-30 sec increments
Electrical stimulation: TENS: Modulation mode
Modulate other TENS modes to prevent neural/perceptual adaptation. Can change frequencies,
intensities or pulse durations by 10+ % 1-2 times per second
Electrical stimulation: TENS: Electrode placement several options:
Acupuncture site, dermatome distribution of involved nerve, over painful site, proximal or distal to pain
site, segmentally related myotomes, trigger points.
Electrical stimulation: TENS: Contraindications Demand-type pacemaker
Over chest of pt. with cardiac disease
Over eyes, larynx, pharynx
Head/neck of pt. following CVA or with epilepsy
Mucosal membranes
Electrical stimulation: High Voltage Pulsed Galvanic Stimulation
Passage of HVPC decreases skin resistance due to current flowing toward skin capacitors rather than
resistors. Thermal effects are negligible (little resistance to the current).
Electrical stimulation: High Voltage Pulsed Galvanic Stimulation – Parameters Paired monophasic
waveform
Instantaneous rise and exponential fall of current
Continuous, surged or pulsed
Typically twin-peaked pulses of short duration
Electrical stimulation: High Voltage Pulsed Galvanic Stimulation - Wound healing concept intact skin
surface -ve with respect to deeper epidermal layers
Injury to skin develops +ve potentials initially and -ve potentials during healing
Absent or insufficient +ve potentials retard tissue regeneration
Addition of +ve potentials initially through anode may promote or accelerate healing
Electrical stimulation: High Voltage Pulsed Galvanic
Stimulation - Wound healing parameters Amplitude: Comfortable tingling, paresthesia, no muscle
response
Pulse rate: 50-200 pps
Pulse duration: 20-100 microsec
Duration: 20-60 min\Both high volt pulse and low volt continuous can be used
Clean and debride wound first and pack with sterile saline-soaked gauze.
Place active electrode over gauze
For bactericidal effect active electrode should be -ve
For culture-free wound, AE should be +ve
Electrical stimulation: High Voltage Pulsed Galvanic
Stimulation - Indications
Inflammation phase: Free from necrosis and exudates, promote granulation
Proliferation phase: Reduce wound size (depth, diameter, tunneling)
Epithelialization phase: Stimulate epidermal proliferation and capillary growth
Electrical stimulation: Functional electrical stimulation (FES)
Also called neuromuscular stimulation (NMES)
Used as an alternative or supplement to orthotic devices
Electrical stimulation: Functional electrical stimulation (FES) - parameters for shoulder subluxation
Asymmetrical biphasic square
Interrupted modulation
Bipolar electrodes on supraspinatus and deltoid
Amplitude: Tetanic contraction to tolerance
Pulse rate: 12-25 pps
Duration of treatment: 15-30 mins. 3x daily up to 6-7 hours.
Duty cycle (on:off): 1:3 (2sec:6sec) progressing to 12:1 (24sec:2sec)
Electrical stimulation: Functional electrical stimulation (FES) - parameters for DF assists
Asymmetric biphasic square
Pulse duration: 20-250 microsec
Modulation: Interrupted by foot switch
Amplitude: Tetanic contraction sufficient to decrease PF
Pulse Rate: 30-300 pps
Bipolar electrodes on peroneal nerve near head of fibula or on tibialis anterior
Heel-switch contains pressure-sensitive contact which stops stimulation during stance phase and
activates stimulation during swing phase. Hand switch also allows therapist to control stim during gait.
Electrical stimulation: (EMG) Instrument used to measure motor unit action potentials (MUAP) generated by active muscles
(measured in microvolts)
Reinforces voluntary control
Electrical stimulation: Electromyographic feedback (EMG) - electrodes
Small electrodes for
specific muscles, large for large muscles or muscle groups
Two active and a single reference electrode (may be placed adjacent to active electrodes to minimize
cross-talk)
Active electrodes placed near motor point ~1-5cm apart, parallel to muscle fibers
Active electrodes placed close together minimizes cross-talk, yields smaller, more precise signals.
Active electrodes placed further apart detects from more than one muscle.
Electrical stimulation: Electromyography feedback (EMG) - Procedure
Quiet setting
For weak muscles begin with electrodes widely spaced and instrument sensitivity high
As pt's motor ability improves make it harder
Use facilitation techniques
Progress from simple to complex, functional movements
Treatment time depends on pt tolerance
For spastic muscle begin with electrodes close together and instrument sensitivity low to minimize
cross-talk
Progress to high sensitivity as pt gains ability to relax and perform functional activities
Use relaxation techniques, imagery etc
Electrical stimulation: (EMG)
Criteria for pt selection Good vision, hearing, communication
Good comprehension of simple commands
Good concentration
Good motor planning skills
No profound sensory or proprioceptive loss