Week 1: Non-systems domain

Modalities:

Modality

Indications

Ultrasound(conver
sion)

Acute & post

acute conditions
(non thermal)
calcium
deposits, chronic
inflammation,
delayed soft
tissue healing,
dermal ulcers,
joint contracture,
muscle spasm,
trigger points,
pain, scar tissue

Phonphoresis

Pain modulation,
decrease
inflammation in
subacute and
chronic ms
conditions.

Contraindicatio
ns
Acute & post
acute conditions
(thermal), areas
of active
bleeding, areas
of decreased
temperature
sensation, areas
of decreased
circulation, DVT,
infection,
malignancy, over
cement or
plastic, over a
pacemaker,
vascular
insufficiency

Acute & post

acute conditions
(thermal), areas
of active
bleeding, areas
of decreased
temperature

Parameters
Generous
amount of
coupling agent.
Transducer sizemost common is
5cm. Intensity: 1
w/cm2 and 3
w/cm2. Lower
intensities for
acute conditions
or thin tissue.
Frequency
(depth) 3MHz
used for 1-2cm
and 1 MHz used
for 5cm. Duty
cycle-100%
=thermal
effects. Duty
cycle =on
time/on time +
off time x 100.
Mode: pulsed
20%, Treatment
intensity: 1-3
w/cm2. Time: 510 minutes.
Medications
used: anti-

Desired
Outcomes
Modulate pain,
increase
connective
tissue
extensibility,
reduce or
eliminate soft
tissue
inflammation,
accelerate rate
of tissue healing,
wound healing,
reduce muscle
spasm

Possible Side
Effects
Hot spot, pain,
dull ache.

Pain modulation,
decrease
inflammation in
subacute and
chronic ms
conditions.

Not likely to burn

Moist Heat

Modulate pain,
increase
connective
tissue
extensibility,
reduce
inflammation,
increase tissue
and wound
healing, reduce
muscle spasm.

Paraffin

Modulate pain,
increase
connective
tissue
extensibility,
reduce
inflammation,
increase tissue
and wound
healing, reduce
muscle spasm.

sensation, areas
of decreased
circulation, DVT,
infection,
malignancy, over
cement or
plastic, over a
pacemaker,
vascular
insufficiency
Impaired
circulation,
Impaired
cognitive
function,
Impaired
sensation,
Malignant
tumors, over
blood clot, over
pacemaker, over
plastic
components.
Impaired
circulation,
Impaired
cognitive
function,
Impaired
sensation,
Malignant
tumors, over
blood clot, over
pacemaker, over
plastic

inflammatory
and analgesics.

Decrease muscle
spasm, decrease
tone, increase
blood flow to
treatment area,
increase
capillary
permeability,
increased
collagen
extensibility,
increased nerve
conduction
velocity
Decrease muscle
spasm, decrease
tone, increase
blood flow to
treatment area,
increase
capillary
permeablity,
increased
collagen
extensibility,
increased nerve

Burns, rashes,
skin irritation

Reaction to
paraffin, spread
of bacteria,
burns,

components.
Fluidotherapy

Modulate pain,
increase
connective
tissue
extensibility,
reduce
inflammation,
increase tissue
and wound
healing, reduce
muscle spasm.

Impaired
circulation,
Impaired
cognitive
function,
Impaired
sensation,
Malignant
tumors, over
blood clot, over
pacemaker, over
plastic
components.

Diathermy

Modulate pain,
increase
connective
tissue
extensibility,
reduce
inflammation,
increase tissue
and wound
healing, reduce
muscle spasm.

Impaired
circulation,
Impaired
cognitive
function,
Impaired
sensation,
Malignant
tumors, over
blood clot, over
pacemaker, over
plastic
components.

Inflammation,
pain control,
abnormal tone,
acute or chronic
pain, bursitis,
muscle spasm,

Cold intolerance,
cold urticaria
(hypersensitivity)
, infection, over
an area of
compromised

Ice Massage

Apply the ice

massage to an
area no larger
than 4x6 inches
in slow
overlapping

conduction
velocity
Decrease muscle
spasm, decrease
tone, increase
blood flow to
treatment area,
increase
capillary
permeability,
increased
collagen
extensibility,
increased nerve
conduction
velocity
Decrease muscle
spasm, decrease
tone, increase
blood flow to
treatment area,
increase
capillary
permeability,
increased
collagen
extensibility,
increased nerve
conduction
velocity
Decrease blood
flow to area,
decrease
spasticity,
decreased
edema,

Spread of
bacteria, burns,

Hot spots, dull

ache, periosteal
pain

Cold, burning,
aching, and
numbness

MS trauma,
trigger points,
tendonitis

circulation, over
regenerating
peripheral
nerves, PVD,
Raynauds, skin
anesthesia

circles. Treat 510 minutes or

until analgesia
occurs.

Inflammation,
pain control,
abnormal tone,
acute or chronic
pain, bursitis,
muscle spasm,
MS trauma,
trigger points,
tendonitis

Cold intolerance,
cold urticaria
(hypersensitivity)
, infection, over
an area of
compromised
circulation, over
regenerating
peripheral
nerves, PVD,
Raynauds, skin
anesthesia

Applied every 12 hrs for 10-20

minutes.
Maintained at 010F.

Ice bath

Commonly use
for the
immersion of the
distal extremities

Cold intolerance,
cold urticaria
(hypersensitivity)
, infection, over
an area of
compromised
circulation, over
regenerating
peripheral
nerves, PVD,
Raynauds, skin
anesthesia

Temperature
ranging from 5564 F. Body part
should be
immersed for 1520 minutes.

Cryocuf

To combine cold
and
compression,

Cold intolerance,
cold urticaria
(hypersensitivity)

Can provide
hours of mild
cooling

Ice
Pack(conduction)

decreased
metabolic rate,
decreased nerve
conduction
velocity,
increase pain
threshold
Decrease blood
flow to area,
decrease
spasticity,
decreased
edema,
decreased
metabolic rate,
decreased nerve
conduction
velocity,
increase pain
threshold
Decrease blood
flow to area,
decrease
spasticity,
decreased
edema,
decreased
metabolic rate,
decreased nerve
conduction
velocity,
increase pain
threshold
Decrease blood
flow to area,
decrease

Red or dark pink.

Abnormal:
Erythema of the
skin with wheal
formation,
associated c
severe itching,
decreased BP,
increased HR

Inappropriate
due to
dependent
position

Red or dark pink.

Abnormal:
Erythema of the

Vapocoolant
Spray(evaporation
)

most often used

on the knee and
post operatively
to decrease pain

, infection, over
an area of
compromised
circulation, over
regenerating
peripheral
nerves, PVD,
Raynauds, skin
anesthesia

Reduce muscle
spasms, trigger
points,
myofascial
referred pain

Cold intolerance,
cold urticaria
(hypersensitivity)
, infection, over
an area of
compromised
circulation, over
regenerating
peripheral
nerves, PVD,
Raynauds, skin
anesthesia
Patient with
demand type
pacemaker,
TENS is not
applied over
neck, eyes,
head, or
following a CVA
or seizures
If the patient has
a pacemaker,
unstable
arrhythmias,
seizure

TENS

Acute or chronic
pain modulation.

NMES

Disuse atrophy,
impaired ROM,
muscle spasm,
muscle
reeducation,

Hold 18-24
inches away
from treatment
area, spray at
30 angle and
sweep spray.
Muscle should be
passively
stretched before
and during. 1015 minutes
treatment time.
See therapy ED
book for all the
different
parameters and
conditions.

Amplitudetitanic muscle
contraction,
Pulse rate- 50-70
PPS, pulse

spasticity,
decreased
edema,
decreased
metabolic rate,
decreased nerve
conduction
velocity,
increase pain
threshold
Increase ROM,
reduce
spasm/pain

skin with wheal

formation,
associated c
severe itching,
decreased BP,
increased HR

Acute or chronic
pain modulation.

Burns from
exposed wires,
Pain with
treatment, to
strong of current,
improper
electrode
placement

Disuse atrophy,
impaired ROM,
muscle spasm,
muscle
reeducation,

Burns from
exposed wires,
Pain with
treatment, to
strong of current,

Frosting of the
skin

spasticity
management
Premod

Modulate pain,
increase muscle
strength,
increase ROM,
decrease edema

Iontophoresis

Analgesia,
calcium
deposits, Dermal
ulcers, edema
reduction, fungal
infections,
hyperhydrosis,
muscle spasm

FES

Disuse atrophy,
impaired ROM,
muscle spasm,
muscle
reeducation,
spasticity
management

IFC

Modulate pain,
increase muscle
strength,
increase ROM,
decrease edema

disorders, over
carotid sinus,
active bleeding,
metal implants,
If the patient has
a pacemaker,
unstable
arrhythmias,
seizure
disorders, over
carotid sinus,
active bleeding,
metal implants,
Impaired skin
sensation,
allergy to agent,
cuts, bruises or
broken skin, over
metal

duration 150200 usec

spasticity
management

improper
electrode
placement

Amplitudestrong but
comfortable,
pulse rate- 1-5
PPS, pulse
duration- 150300 usec, mode
continuous,

Modulate pain,
increase muscle
strength,
increase ROM,
decrease edema

Burns from
exposed wires,
Pain with
treatment, to
strong of current,
improper
electrode
placement

Direct current,
max intensity 45 mA. Negative
electrode should
be twice as large
as positive
electrode.

Skin irritation,
pain, rash,
allergic reaction
to agent, burns,

If the patient has

a pacemaker,
unstable
arrhythmias,
seizure
disorders, over
carotid sinus,
active bleeding,
metal implants,
If the patient has
a pacemaker,
unstable
arrhythmias,
seizure

Tetanic muscle
contraction,
pulse rate 30-85
pps, duration 1530 min,

Decrease In
Analgesia,
calcium
deposits, Dermal
ulcers, edema
reduction, fungal
infections,
hyperhydrosis,
muscle spasm
Disuse atrophy,
impaired ROM,
muscle spasm,
muscle
reeducation,
spasticity
management
Modulate pain,
increase muscle
strength,
increase ROM,
decrease edema

Burns from
exposed wires,
Pain with
treatment, to
strong of current,

Amplitudestrong but
comfortable,
pulse rate- 1-5
PPS, pulse

Burns from
exposed wires,
Pain with
treatment, to
strong of current,
improper
electrode
placement

disorders, over
carotid sinus,
active bleeding,
metal implants,

duration- 150300 usec, mode

continuous,

improper
electrode
placement.

Descriptor

Temperature

Cool

67.0-80.0F (19.0-27.0C)

Cold

55.0-67.0F(13.0-19.0C)

Very Cold

32.0-55.0F(0.0-13.0C)

a. Intermittent Compression Pump

Definition
Pneumatic unit designed to apply external
pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks

Indication

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

Traumatic edema

Infections at the site of treatment may

be spread by introducing bacteria into
the lymphatic or venous drainage

Dependent edema of pregnancy

Any thrombi present may become

mobile

Venous insufficiency

Edema in patients with congestive heart

failure should not be treated, because
the increased peripheral resistance
increases the work of the heart.

Definition
Pneumatic unit designed to apply external
pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks

Indication

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

Amputations

Edema in patients with kidney

dysfunction should not be treated,
because the kidney may not be able to
excrete teh additional fluid

Prevention of thrombophlebitis
postsurgically

Obstructed lymphatic channels do not

allow drainage. Treatment is ineffective,
and the patient may experience
increased pain

Stasis ulcers

Displaced fractures. Treatment may

displace them further

Definition

Indication

Pneumatic unit designed to apply external

pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks
Condition

Ion (Polarity)

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Mode of Action

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

Concentration of
Solution

Dosage

Athletes Foot

Copper (+)

Fungicidal

1% copper sulfate
sodium

10mA for 15 minutes,

2x/week

Slow Healing Wound

Zinc (+)

Bactericidal

1.0 M zinc oxide gel

(8.138 g zinc oxide
powder, 10g glycerol,
10g bentonite, 71.862 g
water)

3-6mA for 20 minutes,

increased to25-30
minutes at end of each
of first 2 weeks; 5 days
a week for 3 weeks.

Definition
Pneumatic unit designed to apply external
pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks
Posttraumatic Edema

Hyaluronidase (+)

Indication

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Breaks down hyaluronic

acid

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

150 units of
hyaluronidase in 250
mL of a buffer solution
that consists of (1)
sodium acetate 3H2O:
11.42 g (2) Glacial
acetic acid: 0.923 mL
(3) distilled H2O,
quantum satis (qs):
1000 mL

20mA for 20 0minutes

3x/week

Definition
Pneumatic unit designed to apply external
pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks

Indication

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

Plantar Warts

Salicylate (-)

Removal and relief of

pain

2% sodium salicylate in
aqueous solution

10mA times min; once

per week for 2-3
treatments

Trigger Points

Procaine or Lidocaine
(+)

Local anesthesia (use

with caution)

1% solution in 60-80%
alcohol with 1:20,000
adrenalin

20-30 mA for 20-30

minutes 1-3 times per
week

Acute RA

Citrate (-)

Prevents local
autoimmune response

1% potassium citrate in
distilled water

7.5-10 mA for 20
minutes; daily 3x/week

Definition
Pneumatic unit designed to apply external
pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks

Indication

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

Peripheral Circulatory
Deficit

Histamine (+)

Vasodilator

1:10,000 histamine
diphosphate

3-12 mA for 5-20 minute

(approximately 60 mA
times minute); 2-3
x/week

Gout

Lithium (+)

Competes with sodium

in formation of urate
lithium urate is soluble

2% lithium chloride

5mA for 20 minutes; one

time per week for 4
weeks

Definition

Indication

Pneumatic unit designed to apply external

pressure to an edematous body part by a
two layered nylon or plastic appliances
shape to fit either the upper or lower
extremity used to help reduce edema.
Treatment should be a minimum of 2 hours
for every 24 hours and should provide
pressure less than 50mmHg for upper
extremities. and 60 mmHg for lower
extremities to be safe and effective. The
pressure is applied for 45-90 seconds and
then released for 15-30 minutes. The
frequency is between 304 weeks
Myositis Ossificans

2.

Contraindications

Postmastectomy lymphedema. Open

the lymphatic channels using manual
lymphatic massage prior to using the
pup

Acetate (-)

Absorption of calcium

Patients with arterial insufficiency have

increased peripheral resistance, and
compression increases it further

3mL of 2% acetic acid

in distilled water

Choosing an Assistive Device

Amount of Weight Bearing

PWB almost full WB

Unilateral LE WB
Restriction
1 Standard Cane

Bilateral LE WB Restriction
2 Standard Canes

4 mA for 20 minutes;
followed by ultrasound
for 8 minutes at 1.5
W/cm2 at 50% duty
cycle

Amount of Weight Bearing

Unilateral LE WB
Restriction

Bilateral LE WB Restriction

Dec PWB

1 Crutch

Lofstrand Crutches

Dec, Dec PWB

2 Canes

2 Crutches or Walker

Dec, Dec, Dec PWB

2 Crutches

2 Crutches or Walker

TT

2 Crutches or walker

Unable to walk

NWB

2 Crutches or walker

Unable to walk

Amount of Strength

Unilateral LE Weakness

Bilateral LE Weakness

Minimal Weakness

1 Standard Cane

2 Standard Canes

Decreased Strength

1 Quad Cane

2 Quad Canes

Dec, Dec Strength

1 Crutch

Lofsrtand Crutches

Significant Weakness

2 Crutches or Walker

2 Crutches or Walker

Balance Impairment

Ambulatory Assistive
Device

Minimally Impaired

1 Cane

Min-Mod Impaired

1 Lofstrand crutch

Balance Impairment

Ambulatory Assistive
Device

Moderately Impaired

2 Crutches or Walker

Significantly Impaired

2 Crutches or walker and

guarding.

Precautions
Standard Precautions

Droplet Precautions

Definition
Universal precautions and
are designed for the care
of all patients in hospitals
regardless of infection or
diagnosis.
Reduce the risk of droplet
transmission of infectious
agents through the mouth,
nose, coughing, sneezing,
talking, or suctioning.
Travel 3 ft or less.

Contact Precautions

Reduce the risk of

transmission of infectious
agents through direct or
indirect contact.

Airborne Precautions

Reduce the risk of airborne

Indications
Procedure: Hand washing,
wear gloves and change
between tasks, wear mask
or gown if risk of
spalashing body fluids.
Private room, may share
room if pt has same
microorganism, maintain
at least 3 ft between pt
and staff. Room door may
remain open, wear a mask
when working within 3
feet. Limit pts transport
outside of room, pt should
wear mask during
transport.
Private room, may share.
Use of gloves when
entering room, change of
gloves, wear a gown if
necessary, limit pts
transport, do not share
equipment
Private room with

Common Situations
Every hospital patient.

Bacterial: meningitis,
pneumonia, sepsis,
pertussis, strep
Viral: adenovirus,
influenza, mumps,
paroviarus, rubells

GI, respiratory, skin or

wound infections, multidrug resistant bacteria, ecoli, diphtheria, herpes,
impetigo, scabies, zoster
Measles, varicella,

transmission of infectious
agents through evaporated
droplets in air or dust
particles

Research Terminology
Sensitivity

Specificity

Independent Variable
Dependent Variable
Control Group

monitored air pressure, 612 air changes within the

room per hour, room door
should remain closed with
pt remaining in room,
respiratory protection worn
when entering the room,
limit pts transport outside
the room, pt should wear
mask during transport.

tuberculosis

Definition
When referring to a medical test, sensitivity refers to
the percentage of people who test positive for a
specific disease among a group of people who have the
disease. A true positive. SnNout: a negative test rules it
out.
When referring to a medical test, specificity refers to
the percentage of people who test negative for a
specific disease among a group of people who do not
have the disease. A true negative. SpPin: a positive test
rules it in.
The variable that is presumed to have caused or
influenced the dependent variable. In research, the IV
is what is controlled or manipulated by the researcher.
The response or outcome assumed to be caused by the
effect of the IV.
A group against which the treatment group is
compared. Should be statistically identical to the
treatment group, except for the variable of interest that

Research Design
Positive Likelihood Ratio
Negative Likelihood Ratio
Randomization

P Value

Blinding

Intrarater reliability
Interrater reliability

Nominal

is being evaluated in the experiment. Used to help

isolate the effect of the IV and eliminate the
unintended influence of extraneous factors that can
confound the results.
The overall strategy that you use to integrate the
different components of the study in a coherent and
logical way
Probability of an individual with the condition having a
positive test.
Probability of an individual with the condition having a
negative test.
A means of assigning subjects to groups in a
experiment so that each subject has an equal chance
of being assigned to each group. The most robust
method of random assignment is accomplished by
computer-generated random numbers or random
number tables.
The probability that a particular statistical result could
have happened by chance. When the p-value is smaller
than the stated value of alpha, or level of significance,
the null hypothesis is rejected. When the p-value is
larger than the stated value of alpha, or level of
significance, the null hypothesis is not rejected.
Conditions that are imposed to keep groups of
individuals from knowing which subjects have or have
not received an intervention. Used to reduce bias and
the placebo effect.
The consistency or equivalent of repeated
measurements made by the same person over time.
The consistency or equivilance of measurements made
by more than one person. Interrater reliability indicates
the agreement of measurements taken by different
examiners.
Classification scale. Qualitative rather than
quantitative. Ex. Blood type, type of breath sound, and
type of arthritis.

Ordinal
Interval
Ratio
Mean
Median
Mode
t-test

Chi-square test

Reliability
Validity
Levels of Evidence

Ranking scale. Intervals between ranks may not be

equal. Ex. MMT grades, levels of assist, pain, and joint
laxity grades.
Intervals between adjacent values are equal, but no
true zero point. Ex. Temperature.
Intervals between adjacent values are equal and there
is a true zero point. Ex. ROM, distance walked, time to
complete activity (seconds), nerve conduction velocity.
The average; sum of all the values divided by the
number of values
Middle value, 50%
The value that occurs most.
An inferential statistical procedure for estimating a
population mean or comparing two means when the
population is normally distributed and the population
variance is not known.
A nonparametric statistical procedure for nominal data.
The test evaluates the difference between observed
and expected frequencies to examine the association
or independence between categorical variables.
Is the reproducibility or repeatability of measurements.
Is the degree to which a useful or meaningful
interpretation can be inferred from a measurement.
Systematic Review, Meta-analysis, Randomized
Controlled Trial, Cohort study, Case control, Crosssectional study, case or report or case series.

Equipment & Devices:

Assistive and Adaptive Devices:
*Pressure relief push-ups are required, typically ever 15-20 minutes.
*Folding frames make wheelchair transport and storage easier. Rigid frames are typically lighter and sturdier.
Standard adult w/c dimensions for environmental access:

360 turning space = 60 inches X 60 inches (5ft x 5ft)

90 turning space= minimum of 36 inches
Minimum for doorways and halls=32 in; ideal is 36 inches
Countertops= no higher than 31 inches
Ramps=recommended ratio of slope to rise is 1:12 (for every inch of vertical rise, 12 inches of ramp is required)
8.3% grade; minimum of 36 inches wide, with nonslip surface; handrail waist high for ambulators (34-38 inches) and
should extend 12 inches beyond the top and bottom of runs; ramp should have level landing at top and bottom.

Wheelchair measurements:
Measurement
Seat height
Seat depth

Seat width
Back height

Armrest height

Device

Instructions
Measure from the users heel to the
popliteal fold and ADD 2 inches to
allow clearance of footrest
Measure from users posterior
buttock, along the lateral thigh to the
popliteal fold and SUBTRACT 2
inches.
Measure the widest aspect of the
users buttocks, hips or thighs and
ADD ~2 inches.
Measure from the seat of the chair to
the floor of axilla with the users
shoulder flexed to 90 and then
SUBTRACT ~4 inches. This will
allow the final back height to be
below the inferior angles of the
scapulae. *Consider seat cushion
Measure from the seat of the chair to
the olecranon process with the users
elbow flexed to 90 and then add ~
1 inch. *Consider seat cushion
Ascending stairs

Average adult size

19.5-20.5 inches
16 inches

18 inches
16-16.5 inches

9 inches above the chair seat

Descending stairs

Walker: Can be used with all levels

of weight bearing. Should allow 2025 of elbow flexion.

The pt should place the walker on the

opposite side of the handrail and turn
the walker sideways. The pt should
then grasp the handrail with one
hand and the top of the walkers
handpiece with the other hand. Using
the handrail and walker for stability,
the pt takes a step up with in
uninvolved extremity. The involved
extremity is then advanced to the
same step and the walker follows.

The walker is positioned in a similar

manner as described previously. The
pt uses the handrail and top of the
walker for stability while lowering the
involved lower extremity. The
uninvolved LE is then lowered and
the walker follows.

Axillary crutches: Can be used with

all levels of weight bearing, however
require higher level of coordination
for use. Crutch height should be
adjusted no greater than 3 finger
widths from the axilla. Handgrip
should be adjusted to the ulnar
styloid process and allow for 20-25
elbow flexion.
Cane: Provides minimal stability and
support for pts during ambulation. A
straight cane should not be utilized
for pts that are partial weight
bearing. Small base & large base
quad canes proved a larger BOS &
can better assist w limiting weight
bearing. Cane is typically used on
opposite side of an involved LE.

The pt should use the handrail and

turn the crutch sideways. This will
result in pt grasping the handrail and
crutch with the same hand. Pt will
advance with uninvolved extremity
followed by involved.

Pt lowers involved LE and the crutch

to the next step followed by the
uninvolved extremity.

The pt should use the handrail and

turn the cane sideways. This will
result in the pt grasping the handrail
and the cane with the same hand.
The pt should use the handrail and
advance the uninvolved LE to the
next step. The pt will then advance
the involved LE.

Pt lowers involved LE to next step

followed by uninvolved LE.

Orthotics:

1. Foot orthosis (FO)-may be attached to the interior of the shoe (inserted pad) or the exterior (Thomas heel).
Soft inserts reduce areas of high loading, restrict forces, and protect painful or sensitive areas.
Ex: Metatarsal pad-located posterior to MT heads; moves pressure from the heads to the shafts; allows more
push-off in weak or inflexible feet.
Ex. Cushion heel-cushions and absorbs forces at heel contact; used to relieve strain on plantar fascia in
plantar fasciitis.
Ex. Heel-spur pad.
Longitudinal arch supports: prevent depression of the subtalar joint and correct for pes planus; flat foot
can be flexible or rigid.
Ex. Scaphoid pad-used to support the longitudinal arch.
Ex. Thomas heel-a heel wedge with an extended anterior medial border used to support the longitudinal arch
and correct for flexible pes valgus (pronated foot)
Posting:
Rearfoot posting-alters the position of the subtalar joint, or rearfoot, from heel strike to footflat. Must be
dynamic, control but not eliminate joint motion.
Ex. Varus post (medial wedge)-limits or controls eversion of the calcaneus and internal rotation of the tibia
after heel strike. Reduces calcaneal eversion during running.
Ex. Valgus post (lateral wedge)- controls the calcaneus and subtalar joint that are excessively inverted and
supinated at heel strike.
Forefoot posting: supports the forefoot
Ex. Medial wedge prescribed for forefoot varus.
Ex. Lateral wedge prescribed for forefoot valgus.
Rocker bar-located proximal to MT heads; improves weight shift onto metatarsals.
Rocker bottom-builds up the sole over the metatarsal heads and improves push-off in weak or inflexible
feet, May also be used with insensitive feet.
2. Ankle-foot orthosis (AFO): consists of a shoe attachment, ankle control, uprights, and a proximal leg band.
Ankle controls:
1. Free motion-provides mediiolateral stability that allows free motion in DF and PF.
2. Solid ankle-allows no movement; indicated with severe pain or instability.
3. Limited motion: allows motion to be restricted in one or both directions
-Bichannel adjustable ankle lock (BiCALL)-an ankle joint with the anterior and posterior channels that can
be fit with pins to reduce motion or springs to assist motion
-Anterior stop (dorsiflexion stop)-determines the limits of ankle DF. If set to allow too much DF knee
buckling could result.

-Posterior stop (plantar flexion stop) determines the limits of ankle PF. If set for too much PF, knee
recurvatum could result.
-Solid AFO-limits all foot and ankle motion.
*Molded AFOs are contraindicated for individuals with changing leg volume.
3. Knee-ankle foot orthosis (KAFO)-consists of a shoe attachment, ankle control, uprights, knee control, and
bands or shells for the calf and thigh.
Craig-Scott knee-ankle-foot Orthosis-designed specifically for persons with paraplegia, This design allows a person to
stand with a posterior lean of the trunk.

4.Hip-knee-ankle-foot orthosis( HKAFO)-indicated for pts with hip, foot, knee, and ankle weakness. It consist of
bilateral knee-ankle-foot orthoses with an extension to the hip joints and a pelvic band, The orthosis can control
rotation at the hip and abd/add. The orthosis is heavy and restricts pts to a swing-to or swing-through gait pattern.
5.Reciprocating gait orthosis (RGO)-is a derivative of the HKAFO and incorporates a cable system to assist with
advancement of the Les during gait. When the pt shifts weight onto a selected LE, the cable system advances the
opposite LE. The orthoses are used primarily for pts with paraplegia.
Lower Limb Prosthetics
Transtibial (below knee) prosthesis:
Foot ankle assembly: Functions to- absorb shock at heel strike, plantarflex in early stance, permits
metatarsophalangeal hyperextension in late stance, cosmetic replacement of foot.
1.Solid ankle cushion heel (SACH) foot-the most commonly prescribed foot; non-articulated; contains an energyabsorbing cushion heel and internal wooden keel that limits sagittal plane motion, primarily plantarflexion. Permits a
very small amount of mediolateral and transverse plane motion. Assists in hyperextension of knee during stance.
2.Solid ankle flexible endoskeleton (SAFE) foot-nonarticulted foot, similar to SACH foot, prescribed for more
active individuals.
3.Flex-foot-a leaf-spring shank (not a foot) used with an endoskeletal prosthesis, the long band of carbon fiber
originates directly from the shank;

Stores energy in early stance for later use during push-off; prescribed for more active individuals.
4.Single axis foot-an articulated foot with the lower shank; motion is controlled by anterior and posterior rubber
bumpers that limited DF and PF; more stable (permits only sagittal plane motion); may be prescribed for individuals
with bilateral transfemoral amputations.
Sockets:
1.PTB (patellar tendon-bearing) socket- a total contact socket that allow for moderate loading area of the
patellar tendon.
Pressure-sensitive areas of the transtibial residual limb include: anterior tibia, anterior tibial crest, fibular head and
neck, fibular nerve.
Pressure-tolerant areas of the transtibial residual limb include: patellar tendon, medial tibial plateau, tibial and
fibular shafts, distal end (rarely, may be sensitive)
Transfemoral (above knee) prosthesis:
1.Single axis-permits knee motions to occur around a fixed axis, knee flexion is needed during late stance and
swing, sitting, and kneeling.
Pressure-sensitive areas of the typical transfemoral residual limb: distolateral end of the femur, pubic symphysis,
perineal area.
Pressure tolerant areas of the typical transfemoral residual limb: ischial tuberosity, gluteals, lateral sides of residual
limb, distal end (rarely, may be sensitive)
Transfemoral gait deviations:
1.Circumduction-prostheis swings out to side in arc. Possible causes: a long prosthesis, locked knee, small or loose
socket, inadequate suspension, foot plantar flexed, abduction contracture, poor knee control
2.Abducted gait-prosthesis is laterally displaced to the side. Possible causes: crotch or medial wall discomfort, long
prosthesis, low lateral wall or malignment, tight hip abductors
3.Vaulting-pt rises up on the sound limb to swing the prosthesis through. Possible causes: prosthesis too long,
inadequate suspension, socket too small, prosthetic foot set in too much plantarflexion, too little knee flexion

4.Lateral trunk bending during stance-trunk bends toward the prosthetic side. Possible causes: low lateral wall, short
prosthesis, high medial wall, weak abductors, abductor contracture, hip pain, short amputation limb
5.Forward flexion during stance-trunk bends forward. Possible causes: unstable knee unit, short ambulatory aids, hip
flexion contracture
6.Lumbar lordosis during stance-exaggeration of the lumbar curve. Possible causes: insufficient support from
anterior or posterior walls, painful ischial weight bearing, hip flexion contracture, weak hip extensors or abdominals.
7.High heel rise-during early swing, the heel rises excessively. Possible causes: inadequate knee friction, too little
tension in the extension aid
8.Terminal swing impact-the prosthesis comes to a sudden stop as the knee extends during lat swing. Possible
causes: insufficient knee friction or too much tension in the extension aid; pt fears that the knee will buckle, forceful
hip flexion.
9.Swing phase whips: at toe-off, the heel moves either medially or laterally. Possible causes; socket it rotated, knee
bolt is rotated, foot is malaligned. *Whip termed by direction of heel.
10.Foot rotation at heel strike-as the heel contacts the ground, the foot rotates laterally, sometimes with vibratory
motion. Possible causes: foot is malaligned, stiff heel cushion, or plantar flexion bumper.
11.Foot slap-excessive PF at heel strike. Possible causes: heel cushion or PF bumper is too soft.
12.Uneven step length-pt favors sound limb and limits weight-bearing time on the prosthetic limb. Possible causes:
socket discomfort or poor alignment; hip flexion contracture or hip instability.
Transtibial amputation:
1. Excessive knee flexion during stance. Possible causes: socket may be aligned too far forward or tilted
anteriorly; plantar flexion bumper is too hard and limits plantar flexion; high heel shoes; knee flexion
contracture or weak quads.
2. Inadequate knee flexion during stance. Possible causes: socket may be aligned too far back or tilited
posteriorly; plantar flexion bumper or heel cushion too soft, how heel shoes; anterodistal discomfort, weak
quads.
3. Lateral thrust at midstance. Possible causes: foot is inset too much
4. Medial thrust at midstance. Possible causes: foot is outset too much.

5. Drop off or premature knee flexion in late stance. Possible causes: socket is set too far forward or excessively
flexed; dorsiflexion bumper is too soft, resulting in excess dorsiflexion of the foot; prosthetic foot keel too
short; knee flexion contracture.
6. Delayed knee flexion during late stance: pt feels as though walking uphill. Possible causes: socket is set too
far back or lacks sufficnet flexion; dorsiflexion bumper is too stiff causing excess plantar flexion; prosthetic
foot keel too long.

Safety and protection

Ergonomics
-

A therapist must consistently use proper body mechanics when treating patients and avoid unnecessary
stress and starin by maintaining proper alignment within the musculo system.
Principles of proper body mechanics
o Use the shortest lever arm possible
o Stay close to the patient when possible
o Use large muscles to perform heavy work
o Maintain a wide base of support
o Avoid any rotary movement when lifting
o Attempt to maintain your center of gravity

Posture Awareness
-

Use plumb line as a tool to determine verticality. Although desirable, rarely will a given patient
demonstrate ideal posture with all the anatomical landmarks.

Medical Equipment
-

Feeding devices
o Nasogastric tube (NG tube)- short term liquid feeding and medication administration.
o Gastric tube (G tube)- Inserted into a small incision in the abdomen, long term feeding.
o Jejunostomy tube (J tube)- inserted into the jejunum, used for long term feeding.
Monitoring devices
o Arterial line- used to measure blood pressure or to obtain blood samples.

Central Venous pressure Catheter- Measuring pressures in RA or superior vena cava

Indwelling right atrial catheter (hickman)- used for long-term administration of substance into the
venous system.
o Intracranial pressure monitor- measures the pressure exerted against the skull. Normal pressure:
90-180 mm H20
o Oximeter- used to determine the oxygen saturation of the blood
o Pulmonary artery catheter (swan-ganz catheter)- used to provide continues pulmonary artery
pressure.
Sterile Techniques
o All items on the sterile field must be and remain sterile
o Sterile gowns are only considered sterile in the front from the waist level upwards, including sleves.
o Only the top surface of the table or sterile drape is considered sterile, outtter 1 inch is not.
o Do not talk sneeze or cough.
o Any item that positions or falls below waist level is considered contaminated.
o Sterile filds should never be left alone
o
o

Emergency Preparedness
-

CPR
o Compression comes first, then focus on airway and breathing.
o No more look, listen, and feeling. Call 911 immediately
o Push chest at least 2 inches down on adults
o 100 compressions/min
o Dont stop pushing, no interruptions
First Aid
o Use gloves when touching all body fluids
o Change gloves between tasks
o Wear mask/eye protection

Abuse Recognition
-

PTs are mandated reporters of neglect and/or abuse of children, elders, and the disabled in all 50 states
o Signs and symptoms of abuse/neglect
Unexplained physical injuries
Withdrawal
Increased agitation

Increased depression
Malnutrition
Substandard care of personal hygiene

Professional Responsibilities
Documentation:
Legal requirements: Must comply with applicable jurisdictional requirements, all handwritten entries should be in ink,
charting errors should be corrected by drawing a single line through the error and initialing and dating the chart,
should include the referral method (direct access, sefl-referral), should include indication of no shows and
cancellations.
Defensible documentation: Limit use of abbreviations, date and sign all entries, document legibly, report progress
towards goals regularly, document at the time of the visit when possible, clearly identify note types (daily, progress),
include all related communications, include missed or cancelled visits, demonstrate skilled care, demonstrate
discharge planning through the episode of care.

Patient Rights:
HIPPA-Pt confidentiality is maintained in all oral, written, and electronic forms, physical identifabilitiy of pts must be
reduced, charts and other documentation must be stored out of public view and secured, faxes must be sent with
cover sheets, cover sheets should be used on clip boards t hat contain pts paperwork. An individual can access all of
their medical records. Providers have 30-60 days to respond.
a.

Ethical Issues:

i. Autonomy- requires the wishes of competent individuals must be honored. Autonomy is often referred to as selfdetermination
ii. Beneficence- A moral obligation of heath care professionals to act for the benefit of others
iii. Confidentiality- the holding of professional secrets or discussions keeping client information within appropriate limits
iv. Duty- the obligation that individuals have to society
v. Fidelity - Related to confidentiality and is defined as the moral duty to keep commitments that have been promised
vi. Justice- The quality of being just of fair; righteousness
vii. Nonmaleficience- the obligation of health care providers to above all else, do no harm.
viii. Paternalism- A term used when someone fails to recognize another individuals rights to autonomy
ix. Rights- The ability to take advantage of a moral entitlement to do something or not to do something
x. Veracity- Obligation of heath care providers to tell the truth.
b. Legal
Term

Definition

Abandonment

unacceptable one-sided termination of services by a health care professional without patient

consent or agreement

Administrative law

administrative agencies at the federal and state level develop rules and regulations to supplement
statutes and executive orders

Common Law

Refers to court decisions in the absence of statutory law often creates legal precedent in areas
where statues have not been enacted.

Constitutional law

Involves law that is derived form the federal constitution. The US Supreme Court is responsible for
ultimately interpreting and enforcing the Constitution

Informed Consent-

The patient is required to sign a document and given permission to the health care professional to
render treatment. This should be obtained from the patient in accordance with the standards of
practice prior to initiation of treatment. The patient has the right to full disclosure of treatment
procedures, risks, expected outcomes, and goals.

Term

Definition

Malpractice

The failure to exercise the skills that would normally be exercised by other members of the
profession with similar skills and training. this can include areas of professional negligence, breach
of contract issues, and intentional conduct by a health care professional

Negligence

The failure to do what a reasonable and prudent person would ordinarily have done under the
same or similar circumstances for a given situation. In order to prove negligence the plaintiff must
prove all of the following:
1. THere was a duty owed to the plaintiff by the defendant
2. There was a breach of that duty under conditions that constituted negligence and
the negligence was the proximate cause of the breach
3. there was damage to the plaintiffs person or property

Risk management

The identification analysis and evaluation of risks and the selection of the most advantageous
method for treating them

Statutory law

Congress and state legislatures are responsible for enacting status. Examples of federal statutes
affecting health care include the Americans with Disabilities Act and the Family and Medical Leave
Act

Tort-

A private or civil wrong or injury, involving omission and/or commission.

Role of PTA:
PTA is a technically educated health care provider who assists the PT in the provision of PT. The PT is directly
responsible for the PTA s actions related to pt/client management. In general, the PT is not required to be on-site for
direction and supervision but must be available at least by telecommunications. The PTA makes modifications to
selected interventions either to progress the pt as directed by the PT or to ensure pt safety and comfort.

Reimbursement Practices:
Private health insurance companies: fee for service basis. Stock, mutual, and non-profit insurance companies.
Government Health Insurance-uses private contractors to manage the payment process of each health plan.
Medicare Part A: provides benefits for care provided in hospitals, outpatient diagnostic services, extended care
facilities, hospice, and short term care at home required by an illness for which the pt is hospitalized. Enrollment is
automatic and funding is through payroll taxes.
Medicare Part B: provides benefits for outpatient care, physician services, and services ordered by physicians such
as diagnostic tests, medical equipment, and supplies. Enrollment is voluntary and funding is through premiums paid
by beneficiaries and general federal tax revenues.
Medicaid provides basic medical services to the economically indigent population who qualify by reason of low
income or who qualify for welfare or public assistance benefits in the state of their residence.
IFC model-International Classification of Functioning, Disability and Health Model=Is a classification of health and
health-related domains.

PT ExaminationCardiopulmonary
Great vessels of the heart:
1. Aorta-the bodys largest artery and the central conduit of blood from the heart to the body. The
aorta begins at the upper part of the left ventricle, and after ascending for a short distance arches
backward and to the left (arch of the aorta). It then descends within the thorax and passes into
the abdominal cavity (abdominal aorta).
2. Superior vena cava-the vein that returns venous blood from the head, neck, and arms to the right
atrium.
3. Inferior vena cava-the vein that returns venous blood from the lower body and viscera to the right
atrium.

4. Pulmonary arteries-the arteries that carry deoxygenated blood from the right ventricle to the left
and right lungs.
5. Pulmonary veins-the veins that carry oxygenated blood from the right and left lungs to the left
atrium.
Heart chambers and valves:
Superior chambers of the heart (right atrium and left atrium). The wall between the atria is the atrial
septum.
The two inferior chambers of the heart are the right ventricle and left ventricle. The wall between the
ventricles is the ventricular septum.
The right chambers collect blood from the body and pump it to the lungs. The left chambers collect blood
from the lungs and pump it to the rest of the body.
The heart has 4 valves that function to maintain unidirectional blood flow. The atrioventricular valves (AV)
are between the atria and ventricles and are named by the number of leaflets or cusps. The right AV valve
or triscupid valve, has 3. It controls blood flow between the RA and RV. The left AV valve, or mitral valve
has 2. It controls blood flow between the LV and aorta; the pulmonary valve is between the RV and
pulmonary artery.
Venous blood from the superior and inferior vena cava enters the RA and is pumped through the
triscuspid valve into the RV. The tricuspid valve closes while the RV contacts to pump blood through the
pulmonary valve into the pulmonary trunk, which divides the right and left pulmonary arteries serving the
right and left lungs, respectively. After picking up oxygen and releasing carbon dioxide in the pulmonary
capillaries, oxygenated blood returns via the pulmonary veins to the LA. Contraction of the LA forces blood
through the mitral valve into the LV. The mitral valve closes when the LV contracts to pump blood through
the aortic valve into the aorta where it is distributed into the coronary circulation and systemic circulation.
Cardiac Cycle:
Atrial systole-the contraction of the right & left atria pushing blood into the ventricles.
Atrial diastole-the period between atrial contactions when the atria are repolarizing.

Ventricular systole-contraction of the right and left ventricles pushing blood into the pulmonary arteries
and aorta.
Ventricular diastole-the period between contractions when the ventricles are repolarizing.
Stroke volume-the amount of blood ejected with each myocardial contraction; normal range is 55-100
ml/beat. Its influenced by: Left Ventricular end diastolic volume: the amount of blood left in the ventricle at
the end of diastole, also known as preload. The greater the preload, the greater the quantity of blood
pumped.
Afterload-the force the LV must generate during systole to overcome aortic pressure to open the aortic
valve.
Cardiac Output-the amount of blood discharged from the left or right ventricle per minute. Normal range is
4-5L. Determined by measuring HR x SV.
Ejection fraction-percentage of blood empties from the ventricle during systole; a clinically useful measure
of LV function. Normal averages >55%.
*Diastolic filling time decreases with increased HR and with heart disease.
Heart Sounds:
S1 sound (lub)-normal closure of mitral and triscupid valves; marks beginning of systole. High frequency
sound with lower pitch and longer duration than S2. Decreased in 1st degree heart block.
S2 sound (dub)-normal closure of aortic and pulmonary valves, marks end of systole. High frequency
sound with higher pitch and shorter duration than S1. Decreased in aortic stenosis.
Extra sounds: Murmurs
1. Systolic-falls between S1 and S2. May indicated valvular disease or may be normal.
2. Diastolic-falls between S2 and S1. Usually indicates valvular disease.
3. Thrill-an abnormal tremor accompanying a vascular or cardiac murmur, felt on palpation.
Bruit-adventitous sound or murmur (blowing sound) of arterial or venous origin, common in carotid or
femoral arteries; indicative of atherosclerosis.

Gallop rhythm-an abnormal heart rhythm with three sounds in each cycle; resembles the gallop of a
horse.
1. S3; vibrations of the distended ventricle walls due to passive flow of blood from the atria during the
rapid filling phase of diastole. Normal in healthy young children, abnormal in adults, may be
associated with heart failure. ventricular gallop
2. S4; pathological sound of vibration of the ventricular wall with ventricular filling and atrial
contraction. May be associated with HTN, stenosis, MI. atrial gallop
Auscultation of heart sounds
Procedure:
The bell or diaphragm of the stethoscope is held directly on the pts bare skin with enough pressure to provide a skin
seal while the pt breathes quietly through the nose.
Listen over four designated auscultatory areas:
Aortic area-2nd intercostal space at the right sternal border
Pulmonic area-2nd intercostal spaceat the left sternal border
Mitral valve-5th intercostal space, medial to the left midclaviciular line
Triscupid area-4th intercostal space at the left sternal border
Picture on page 264 of scorebuilders.
Examine heart rhythm:
A 12 lead EKG provides 12 views of the heart. It is used to assess cardiac rhythm, to diagnose the location, extent,
and acuteness of myocardial ischemia and infarction, and to evaluate changes with activity.

Waveforms and Intervals:

1. P wave-atrial depolarization

2. PR interval-time for atrial depolarization and conduction from the SA node to the AV node. Normal duration is
0.12 to .20 seconds.
3. QRS complex-Ventricular depolarization and atrial repolarization. Normal duration is 0.06 to 0.10 seconds.
4. QT interval-Time for both ventricular depolarization and repolarization. Normally ranges from .20 to 0.40
seconds, depending on heart rate.
5. ST segment-isoelectric period following QRS when the ventricles are depolarized.
6. T wave-ventricular repolarization
Sinus Node Rhythms:
1. Normal sinus rhythm-atrial depolarization begins in the SA node and spreads normally throughout the
electrical conduction system with a HR between 60-100 bpm.
2. Sinus bradycardia-sinus rhythm with a HR less than 60 bpm (in adults)
3. Sinus tachycardia-sinus rhythm with a HR more than 100 bpm.
4. Sinus arrhythmia-a sinus rhythm, but with quickening and slowing of impulse formation in the SA node
resulting in a slight beat-to-beat variation of the rate.
5. Sinus arrest-a sinus rhythm, except with intermittent failure of the either the SA node impulse formation or AV
node conduction that results in the occasional complete absence of P or QRS waves.
Atrial dysrhythmias:
Condition:
Premature atrial contractions
(PAC)- occur when an ectopic
focus in the atrium initiates an
impulse before the SA node.

Clinical significance:
PACs are very common and
generally benign, but may
progress to atrial flutter,
tachycardia or fibrillation. May
occur with a normal HR (from
caffeine, stress, smoking, alcohol)
and any type of heart disease

EKG reading
The p wave is premature with
abnormal configuration.

Atrial flutter-An ectopic, very rapid

atrial tachycardia. Atrial rate of
250-350 bpm; ventricular rate
dependent upon AV node
conduction.

Occurs with valvular disease

(especially mitral), ischemic heart
disease, cardiomyopathy,
hypertension, acute myocardial
infarction, chronic obstructive
lung disease, and pulmonary

Saw-tooth shaped P waves (also

known as flutter waves) are
characteristic.

Atrial fibrillation-a common

arrhythmia where the atria are
depolarized between 350 and 600
times a min.

emboli. Signs and symptoms

include palpitations,
lightheadedness, and angina due
to a rapid rate. Stagnation of
blood may predispose to thrombi
in the atria
Occurs in healthy hearts and in
pts with coronary artery disease,
hypertension, and valvular
disease. Symptoms may include
palpitations, fatigue, dyspnea,
lightheadedness, syncope, and
chest pain. Stagnation of blood
may predispose to thrombi in the
atria.

EKG shows characteristically

irregular undulations of EKG
baseline without discrete P waves.

Ventricular arrhythmias:
Condition:
Premature ventricular complex (PVC)premature depolarization arising the
in ventricles due to an ectopic focus.
Unifocal PVCs arise from the same
ectopic focus and have the same
configuration. Multifocal PVCs arise
from different ectopic foci and have
different configurations.
Bigeminy-normal sinus impulse is
followed by a PVC.
Trigeminey-PVC occurs after every
two normal sinus impulses.
Ventricular tachycardia (v-tach)-3 or

Clinical significance:
A common arrhythmia that occurs in
healthy and diseased hearts. Pt may
be asymptomatic or have
palpitations. Common causes include
anxiety, caffeine, stress, smoking,
and all forms of heart disease.

V-tach longer than 30 seconds is a

EKG reading:
On EKG, the P wave is usually absent
and the QRS complex has a wide and
aberrant shape.

P waves are absent and QRS

more consecutive PVCs at a

ventricular rate of >150 bpm.

life threatening arrhythmia and

requires immediate medical
intervention. Pts are not able to
maintain an adequate blood pressure
and eventually become hypotensive.
V-tach may degenerate into
ventricular fibrillation causing cardiac
arrest. Common causes include MI,
cardiomyopathy, and valvular
disease.

complexes are wide and aberrant in

appearance.

Ventricular fibrillation (v-fib)Ventricles do not beat in a

coordinated fashion, but fibrillate or
quiver asynchronously and
ineffectively. No cardiac output; pt
becomes unconscious.

A lethal tachyarrhythmia requires

immediate defibrillation. Additional
measures include medications to
support the circulation and
intravenous antiarrythmic agents.
Common causes include heart
disease of any type, MI, and cocaine
use.

EKG shows characteristic fibrillatory

waves with an irregular pattern that
is either coarse or fine.

Ventricular asystole-Ventricular
standstill with no rhythm.

Requires immediate defibrillation

and/or medications to stimulate
cardiac activity. Common causes
include acute MI, ventricular rupture,
cocaine use, lightning strikes, and
electrical shock.

EKG records a straight-line pattern.

AV Conduction Blocks:
1st degree AV block: PR interval is longer than 0.2 seconds, but relatively constant from beat to beat.
Clinical significance: No symptoms or significant change in cardiac function. PR interval may become prolonged for
many reasons include medications that suppress AV conduction.

2nd degree AV block: AV conduction disturbance in which impulses between the atria and ventricles fail intermittently.
Two major types: Mobitz type 1 block (also called Wenckebach block) and Mobitz type 2 block
Clinical significance: Mobitz I-progressive prolongation of PR interval until one impulse is not conducted (generally
benign)
Mobitz II-consecutive PR intervals are the same and normal followed by nonconduction of one or more impulses (a
more serious condition). If heart rate is slow, cardiac output will decrease with the blocked impulse. Also, 2 nd degree
AV block may progress to 3rd degree AV block
3rd Degree AV block (complete heart block)-All impulses are blocked at the AV node and none are transmitted to the
ventricles. The atria and ventricles are paced independently; atrial rate > ventricular rate.
Clinical significance: Considered a medical emergency requiring a pacemaker. If the ventricular rate is too slow, the
cardiac output drops and the pt may faint. Common causes include degenerative changes of the conduction
systems, digitalis, heart surgery, and acute MI.

Signs and Symptoms

Right Sided Heart
Failure

Nausea
anorexia
weight gain
ascites
right upper quadrant pain.
Increase in RAP, CVP,
Jugular venous distention
Positive heptojugular reflex
right ventricular eave
Murmur of tricuspid insufficiency
Hepatomegaly
Peripheral edema

Signs and Symptoms

Left Sided Heart
Failure

Fatigue
cough
shortness of breath
DOE
Orthopnea
PND
Diaphoresis
Tachycardia
S3 Gallop
Crackles
Increased PAP, PAWP, SVR
Laterally displaced PIM
Left ventricular heave
Pulsus alternans
confussion
decreased urine output
Cheyne Stokes respiration (advanced failure)
Murmur of mitral insufficiency

Tests of peripheral arterial circulation:

Ankle brachial index (ABI)-the ratio of lower extremity pressure divided by upper extremity pressure.
-Performed in UE at brachial artery, LE at posterior tibial and dorsalis pedis arteries.
ABI assists in risk stratification for cardiovascular disease:
<0.90 is associated with 2-4 fold increased risk for cardiovascular events and death.
ABI < 0.50: increased risk of progression to severe or critical limb ischemia in 1 year.

>1.40
1.00-1.40
0.91-0.99
< or equal to 0.90
<or equal to 0.50

Indicates non-compliant arteries

Normal
Borderline
Abnormal
Severe arterial diease, risk for critical limb ischemia, may
have pain at rest

Exercise Stress/Tolerance Testing:

-Serves as a basis for exercise prescription, used as a screening measure for CAD in asymptomatic individuals.
-A pharmacological stress test is used when a patient is unable to perform a regular ETT.
Testing modes: Treadmill and cycle ergometry (leg or arm tests), step test.
Maximal ETT: defined by target endpoint HR. Should only be completed in settings with advanced cardiac life
support.
-Age predicted maximum heart rate: 220-age
-Heart rate range (Karvonenens): 60%-80% (HR max-resting HR) + resting HR=target HR
Submaximal ETT: Symptom limited or terminated at 85% of age predicted HR max; safe in all settings
Continuous ETT: workload is steadily progressed; step test allowing pt reach steady state, ramp test-pt is not
permitted to reach steady state.
Absolute indications for terminating an exercise test:
1.
2.
3.
4.
5.
6.

Drop in SBP>10 mm Hg from baseline despite increase in workload with other evidence of ischemia
Moderately sever angina (three on a scale of four)
Increasing nervous system symptoms (ataxia, dizziness)
Signs of poor perfusion (cynaosis, pallor)
Sustained ventricular tachycardia
1.0 mm ST elevation in leads without diagnostic Q waves

Pulmonary Anatomy:

Muscles of inspiration: diaphragm (primary), external intercostals, and internal intercostals and considered
principal muscles of inspiration.
Accessory muscles of inspiration: sternocleidomastoid, scalenes, pec major & minor, and serratus anterior.
Muscles of exhalation: results from passive recoil of the lungs and rib cage. During forceful breathing the rectus
abdominus, external oblique, internal oblique, and transverse abdominus depress the lower ribs and compress the
abdominal contents, thus pushing up the diaphragm and assisting with active exhalation.
Alveolar-capillary units-The bronchi branch many times before terminating in the acinus or respiratory unit of the
lung. Oxygen diffuses across the alveolar-capillary septum into the red blood cells in the lung capillaries where it
combines with hemoglobin to be transported back to the heart. Carbon dioxide diffuses in the opposite direction.
Pleurae-a membranous serous sac called visceral pleura covers each lung. The pleura covering the surface of the
lungs is called the visceral pleura. The pleural tissue covering the inner surfaces of the chest wall, ribs, vertebrae,
diaphragm, and mediastinum is called parietal pleura. Normally, the two pleurae remain in contact throughout the
respiratory cycle, separated only by serous fluid. Under abnormal circumstances, the pleural space may contain air
(pneumothorax) blood (hemothorax), pus or increased amounts of serous fluid, which compress the lung and cause
respiratory distress.
Pulmonary circulation- the portion of the circulatory system that carries deoxygenated blood from the heart to the
lungs via the pulmonary arterial trunk, right and left pulmonary arteries, lobar arteries, arterioles, and capillaries.
The pulmonary circulation returns oxygenated blood from the lungs to the left atrium via the pulmonary veins.
Bronchial circulation-the portion of the circulatory system that supplies oxygenated blood to the bronchi and
connective tissue of the lungs via the bronchial arteries, which drain directly into the bronchial veins.
Lung Volumes & Capacities:
Anatomic dead space volume (VD)
Expiratory reserve volume (ERV)
Forced expiratory volume (FEV)

The volume of air that occupies the non-respiratory

conducing airways
The maximal volume of air that be exhaled after a
normal tidal exhalation. ERV is approximately 15% of
total lung volume.
The maximal volume of air exhaled in a specified period
of time: usually the 1st, 2nd and 3rd second of a forced vital
capacity maneuver.

Forced vital capacity (FVC)

Functional residual capacity (FRC)
Inspiratory capacity (IC)
Inspiratory reserve volume (IRV)
Minute volume ventilation (VE)
Peak expiratory flow (PEF)
Residual volume (RV)
Tidal volume (TV)
Total lung capacity (TLC)
Vital capacity (VC)

The volume of air expired during a forced maximal

expiration after a forced maximal inspiration. 75%
The volume of air in the lungs after normal exhalation.
FRC=ERV + RV. FRC is approximately 40% of total lung
volume.
The maximal volume of air that can inspired after a
normal tidal exhalation. IC=TV + IRV. IC is approximately
60% of total lung volume.
The maximal volume of air that can be inspired after
normal tidal volume inspiration. IRV is approximately
50% of total lung volume.
The volume of air expired in one minute. VE=TV x
respiratory rate.
The maximum flow of air during the beginning of a forced
expiratory maneuver.
The volume of gas remaining in the lungs at the end of a
maximal expiration. RV is approximately 25% of total
lung volume.
Total volume inspired and expired with each breath
during quiet breathing. TV is approximately 10% of total
lung volume. (500ml)
The volume of air in the lungs after a maximal
inspiration; the sum of all lung volumes. TLC=RV + VC or
TLC= FRC + IC
The volume change that occurs between maximal
inspiration and maximal expiration. VC= TV + IRV + ERV.
VC is ~75% of total lung volume.

Normal breath sounds:

Tracheal & bronchial sounds-Loud, tubular sounds normally heard over the trachea. Inspiratory phase is shorter than
the expiratory phase and there is a slight pause between them.
Vesicular breath sounds-High pitched, breezy sounds normally heard over the distal airways in healthy lung tissue.
Inspiratory phase is longer than expiratory phase and there is no pause between them.

Adventitous breath sounds:

Crackles (also termed rales, crepitations): a crackling sound heard usually during inspiration that indicates pathology
)atelectasis, fibrosis, pulmonary edema)
Wheezes: a musically pitched sound, usually heard during expiration, caused by airway obstruction (asthma, COPD,
foreign body aspiration)

Lung Lobe Location & Postural Drainage Position

Lobe

Position

Right or Left Anterior Upper

Lobe/Segment

Supine in a reclined seated position with knees supported

Right or Left Posterior Apical Segment

Seated and slumped over a pillow with lower extremities supported

in a comfortable position

Right and Left Anterior Segments

Supine with knees supported with a pillow

Right Posterior Segment

Prone slightly on the left side

Left Posterior segment

Prone with left side of torso propped up on pillows. Torso is at a 45

degree angle.

Right Middle Lobe

Supine with right side propped up on pillows and lower extremities

elevated 12 inches

Lobe

Position

Left Ingular

Supine with left side propped up on pillows and lower extremities

elevated 12 inches

Anterior Segments (Lower Lobes)

Supine with knees supported with pillows and lower extremities

elevated 18 inches

Right Lateral Segment

Left sidelying with lower extremities elevated 18 inches

Left Lateral Segments

Right sidelying with lower extremities elevated 18 inches

Posterior segments

Prone in comfortable position/neutral spine with pillows under

abdomen and comfortable feet position with pillows under lower
legs with lower extremities elevated 18 inches

Superior Segments

Prone in comfortable position/neutral spine with pillows under

abdomen and comfortable feet position with pillows under lower
legs.

Arterial blood gases:

pH
PaCO2 (amount of carbon dioxide within arterial blood)
PaO2
HCO3- (amount of bicarbonate ions within arterial blood)
SaO2
*By convention, ABG results are written or spoken in the
following order: pHPaCO2PaO2HCO3- (e.g.

7.4 (7.35-7.45)
40 mm Hg at sea level breathing ambient air (35-45mm
Hg)
97 mm Hg at sea level breathing ambient air (80-100
mm Hg)
24 mEq/L (22-26)
95-98%

7.4/40/97/24)
Acidemia
Alkalemia
Eucapnia
Hypercapnia
Hyopcapnia
Hypoxemia
Mild hypoxemia
Moderate hypoxemia
Severe hypoxemia
Hypoxia

Elevated acidity of blood (pH < 7.35)

Decreased acidity of blood (pH > 7.45)
Normal level of CO2 in arterial blood (35-45 mm Hg)
Elevated level of CO2 in arterial blood( > 45 mm Hg)
Low level of CO2 in arterial blood (<35 mm Hg)
Low level of O2 in arterial blood (PaO2 < 80 mm Hg)
PaO2 60-79 mmHg
PaO2 40-59 mmHg
PaO2 < 40 mmHg
Low level of O2 in the tissue despite adequate perfusion
of the tissue
*An increase in the PaCO2 decreases the bodys pH. A decrease in the PaCO 2 raises the bodys pH.
*Supplemental oxygen is usually prescribed when the PaO 2 falls below 55 mmHg.

Other values:
White Blood Cells (WBCs)
Red Blood Cells (RBCs)
Erethrosedimentation Rate (ESR)
Hematocrit
Platelet
Sodium
Calcium
Potassium
Magnesium
Total cholesterol
LDL
HDL
Triglyceride

4300-10,800
Male: 4.6-6.2 Female: 4.2-5.9
Male: <15 mm/hr Female: <20
Male: 45%-52% Female: 37%-48%
150,000-450,000
135-146
8.4-10.4
3.5-5.5
1.8-2.4
<200
<100
<40
<150

Acid-Base balance
Type

pH

PaCO2

HCO3-

Causes

Respiratory
alkalosis

WML

Alveolar
hyperventilation

Respiratory
acidosis

WNL

Alveolar
hypoventilation

Metabolic
alkalosis

WNL

Metabolic
acidosis

WNL

Bicarbonate
ingestion,
vomiting,
diuretics,
steroids, adrenal
disease
Diabetic, lactic,
or uremic
acidosis,
prolonged
diarrhea

Signs &
Symptoms
Dizziness,
syncope, tingling,
numbness, early
tetany
Early: anxiety,
restlessness,
dyspnea,
headache
Late: confusion,
somnolence,
coma
Vague symptoms:
weakness,
mental dullness,
possibly early
tetany
Secondary
hyperventilation
(Kussmaul
breathing),
nausea, lethargy,
coma

Common Disorders/Pathology of the Cardiopulmonary System:

Pathology
Aneurysm

What is it
A localized abnormal

Etiology
Congenital defect;

Signs & Symptoms

Variable based on the

Treatment
Antihypertensive

Angina pectoris

dilation of a blood
vessel, usually an
artery. Common sites
include the thoracic
& abdominal aorta
and vessels within
the brain.

weakness in the wall

of vessel often due to
chronic HTN,
connective tissue
disease (Marfan
Syndrome), trauma,
infection

A transient precordial
sensation of pressure
or discomfit resulting
from myocardial
ischemia. Common
types of angina
pectoris are : Stable
(occurs at predictable
level of exertion,
responds to rest or
nitroglycerin)
Unstable (usually is
more intense, lasts
longer, is precipitated
by less exertion,
occurs spontaneously
at rest, is
progressive)

Inadequate blood
flow & oxygenation of
the heart muscle
mostly due to
coronary artery
disease.

site. Aortic
aneurysms are
usually
asymptomatic, but
may include
generalized
abdominal or LBP.
Abdominal aortic
aneurysms may
cause pulsations near
the navel. A cerebral
aneurysm can cause
a sudden and severe
headache, nausea &
vomiting, stiff neck,
seizure, loss of
consciousness, &
double vision.
Usually described as
pressure, heaviness,
fullness, squeezing,
burning or aching
behind the sternum,
but may also be felt
in the neck and back,
jaw, shoulders, and
arms. The sensation
may be associated
with difficulty
breathing, nausea or
vomiting, sweating,
anxiety, or fear. It is
typically triggered by
exertion or strong
emotion and
subsides with rest.

medications may be
recommended for
HTN. Surgery is
recommended to
repair large aortic
aneurysms and
consists of replacing
the aneurysm with a
synthetic fabric graft.
Two surgical options
for ruptured brain
aneurysms are
surgical clipping &
endovascular coiling.

Tx for acute angina

include supplemental
oxygen, nitroglycerin,
and rest. Chronic or
recurring angina
pectoris is treated
with long-acting
nitrates, beta
blockers, and calcium
channel blockers.
Angioplasty with
stenting of the
coronary arteries or
coronary artery
bypass surgery
(CABG) may be
performed when
medications are not

Atherosclerosis

Chronic venous
insufficiency (CVI)

Prinzmetal or
variant angina
(occurs due to
coronary artery
spasm most often
associated with
coronary artery
disease)
A slow progressive
accumulation of fatty
plaques on the inner
walls of arteries.
Over time the plaque
can restrict blood
flow, causing a blood
clot.

A condition in which
the veins and valves
in the LE are
damaged and cannot
keep blood flowing
toward the heart.
This causes veins to
remain filled with

effective.

Although the exact

cause is unknown,
the process may
begin with damage or
injury to the inner
wall of the artery
from HTN, high
cholesterorl, smoking
or diabetes. Over
time, fatty plaques
made of cholesterorl
and other cellular
waste products build
up at the site of the
injury & harden,
narrowing the artery
and impacting blood
flow.
Weak or damaged
valves inside the
veins. Risk factors
include age, female
gender, obesity,
pregnancy, and
prolonged sitting or
standing.

Varies based on the

severity of disease &
the artery affected.
When the coronary
arteries are affected,
angina pectoris may
result. When cerebral
arteries are affected,
numbness or
weakness of the arms
or legs, difficulty
speaking or slurred
speech, or drooping
face muscles may
result. When
peripheral arteries
are affected,
intermittent
claudication may
result.
Leg swelling, varicose
veins, aching,
heaviness or
cramping, itching,
redness or skin ulcers
of the legs and
ankles.

Lifestyle changes,
medications, &
surgery. Changes
include cessation of
smoking, regular
exercise, healthy
diet, stress
management.
Medications may
include
antihypertensive,
antiplatelet, and
antilipidemic agents.
Surgical procedures
may include
angioplasty,
endarterectomy, and
bypass surgery.
Compression
stockings and
elevation of the legs
help decrease chronic
swelling. Varicose
vein stripping may be
performed for cases
with persistent leg

blood.
Atrial septal defect
(ASD)

Cor Pulmonale

Coronary Artery
Disease (CAD)

A hole in the wall of

heart separating the
right & left atria. In
fetal circulation,
there is normally an
opening between the
two atria to allow
blood to bypass the
lungs. This opening is
termed foramen
ovale and usually
closes at birth. If the
ASD persists, blood
continues to flow
from left to the right
atria and is called a
shunt. In severe
cases, blood may
flow from the right to
the left atria.
Also known as
pulmonary heart
disease, refers to
hypertrophy of the
right ventricle cased
by altered structure
or function of the
lungs.

Congenital heart
defects arise from
errors early in the
hearts development.
Genetics &
environmental
factors may play a
role.

Small to moderate
sized defects may
produce no
symptoms or
symptoms that
appear after 30 years
of age. Large or long
standing atrial septal
defects may cause:
heart murmur, SOB,
fatigue, swelling of
the legs, heart
palpitations, frequent
lung infections,
stroke, cyanosis of
the skin.

Pulmonary
hypertension from
chronically increased
resistance in the
pulmonary circulation

Is the narrowing or
blockage of the

CAD is thought to
begin with damage or

The cardinal
symptom is
progressive shortness
of breath, especially
with exertion. Other
signs & symptoms
are fatigue,
palpitations, atypical
chest pain, swelling
of the Les, dizziness,
& syncope.
The degree of
stenosis required to

pain or skin ulcers

due to poor
circulation.
Surgical closure is
recommended if the
defect is large, the
heart is swollen or
symptoms occur. A
non-surgical
procedure involves
placing a device into
the heart and across
the ASD using a
catheter.

Supplemental oxygen
sufficient to maintain
SaO2 >90% and or
PaO2 >60 mm Hg.
General measures
include diuretics &
anticoagulation.

Aggressive
modification of

Deep Vein thrombosis

(DVT)

coronary arteries due

to atheromatous
plaques resulting in
diminished blood
flow.

injury to the inner

layer of a coronary
artery. Cholesterol
then tends to
accumulate at the
site. If a plaque
ruptures, platelets
will clump at the site
to try to repair the
artery. This clump
can block the artery,
leading to a heart
attack.

produce signs &

symptoms varies
with the oxygen
demand. The
diminished blood flow
may cause angina,
shortness of breath
or other symptoms,
which may not be felt
until >70% of the
lumen is occluded. A
complete blockage
can cause a heart
attack.

A condition in which
a blood clot forms in
one or more of the
deep veins, usually in
the lower extremities.
DVT is a serious
condition because
the clot can break
loose and travel to
the lungs, resulting in
a pulmonary
embolism.

Any condition that

impairs normal
circulation or normal
blood clotting. Many
factors increase the
risk of a DVT
including prolonged
sitting or bed rest,
inherited blood
clotting disorders,
injury or surgery of
the veins, pregnancy,
cancer, birth control
or hormone

About 50% of DVT

cases are
asymptomatic. When
signs & symptoms
occur they can
include swelling,
pain, redness, and
warmth in the
affected leg.

atherosclerosis risk
factors to slow
progression and
induce regression of
existing plaques and
restore or improve
coronary blood flow.
This includes
smoking cessation;
weight loss; a heart
healthy diet low in
saturated fat,
cholesterol and
sodium; regular
exercise. Drug
therapy includes
antiplatelet agents
(aspirin, Clopidogel),
ACE inhibitors,
angiotensin II
receptor blockers and
statins.
The goal of tx is to
prevent the blood
clot from getting
bigger and to prevent
it form breaking loose
and causing a
pulmonary embolism.
Medications include
anticoagulant and
thrombolytic agents.
Filters may be
surgically inserted
into the vena cave to
prevent clots from

replacement therapy,
being overweight,
obesity, and
smoking.
Endocarditis

Is inflammation of
the endothelium that
lines the heart and
cardiac valves. If left
untreated,
endocarditis can
damage and destroy
heart valves and
become life
threatening.

Heart Failure
congestive heart
failure

Is a progressive
condition in which
the heart cannot
maintain a normal
cardiac output to
meet the bodys
demands for blood
and oxygen. Heart
failure often develops
after other conditions
have damanged or
weakened the heart.
The ventricles
weaken and dilate to
the point that the
heart cant pump

Caused by bacteria
that may enter the
blood from catheters
or needles, dental
procedures, gum
disease, sexually
transmitted disease
or inflammatory
bowel disease.
Individuals with a
damaged heart
valve, and artificial
heart valve or other
heart defects are at
the greatest risk.
CAD, HTN, DM, MI,
abnormal heart
valves, and
cardiomyopathy.

May develop slowly,

depending on the
cause of the infection
and if the heart is
affected, but can
include fever, chills,
heart murmur,
fatigue, shortness of
breath, weight loss,
blood in urine, and
skin petechiae.

SOB, fatigue and

weakness, swelling in
the legs, feet and
abdomen, rapid or
irregular heartbeat
with S3 or S4 heart
sound, persistent
cough or wheezing
and weight gain from
fluid retention.

reaching the lungs.

Compression
stockings may be
recommended to
reduce blood pooling.
Antibiotics are the
first line of treatment.
Surgery may be
needed to treat
persistent infections
or replace a damaged
heart valve.

Sometimes treating
the underlying cause
can correct heart
failure (repairing a
damaged heart valve
or controlling an
abnormal heart
rhythm). In most
cases, tx is a balance
of medications,
devices, and lifestyle
changes to help the
heart contract
normally. Medications
include
anticoagulants,

Heart murmur

Hypertension

efficiently. It can
affect the right side,
left side, or both
sides of the heart,
but typically begins
with the left
ventricle. The term
congestive heart
failure comes from
blood backing up into
the liver, abdomen,
Les, and lungs. The
condition can be
acute or chronic.
An abnormal
swishing or
whooshing sound
heard by auscultation
sometime during the
cardiac cycle.

Arterial hypertension
in adults is a

antihypertensives,
and digitalis to
increase the strength
of contraction. In
severe cases, surgery
and medical devices
may be needed to
correct the
underlying cause of
the heart failure.

Innocent heart
murmurs occur when
blood flows rapidly
through the heart
due to activity,
pregnancy, fever,
and anemia.
Abnormal heart
murmurs may be
caused by turbulent
blood flow through a
damaged or
narrowed heart valve
or a hole in one of
the hearts walls.
Other causes include
rheumatic fever,
endocarditis, calcified
valves, and mitral
valve prolapsed.
Primary or essential
hypertension has no

Innocent murmurs
are not usually
associated with other
signs or symptoms.
Abnormal murmurs
may be associated
with cyanosis, limb
edema, shortness of
breath, enlarged
neck veins, weight
gain, chest pain,
dizziness, and
fainting.

HTN is often
asymptomatic until

Innocent murmurs
usually do not require
treatment. Treatment
for abnormal heart
murmurs depends on
the underlying cause
and can include
medications or
surgery. Common
medications are:
digoxin,
anticoagulants,
diuretics, and other
antihyperstensive
agents. Surgical
procedures include
valve replacement or
patching atrial or
ventricular septal
defects.
Recommendations
include lifestyle

Lymphedema

sustained elevation
of systolic pressure
>140 mm Hg or
diastolic pressure
>90 mm Hg.

known cause. HTN

with an identified
cause (usually renal
disease) is called
secondary HTN.

complications
develop in the
organs. An S4 heart
sound is an early
sign. Severe HTN
(diastolic >120) can
cause significant CNS
symptoms
(confusion, cortical
blindness,
hemiapresis,
seizures)
cardiovascular
symptoms (chest
pain, dyspena) and
renal involvement.

Edema, or swelling,
due to an
accumulation of
lymph in the
extremities

Primary lymphedema
is a rare, inherited
condition caused by
problems with the
development of
lymph vessels.
Causes of secondary
lymphedema include
any condition or
procedure that
damages or obstructs
lymph nodes or
vessels

Swelling with the

restricted motion of
the upper or lower
extremity, arching
and heaviness or a
felling of fullness,
brawny, fibrous, non
pitting edema in one
or more limbs.

modifications (30
min/day exercise,
weight loss to a BMI
of 18.5-24, smoking
cessation, reduced
intake of sodium and
alcohol, increased
consumption of fruits,
vegetables, low fat
dairy and
medications. Classes
of medications for
HTN include diuretics,
beta blockers,
calcium channel
blockers, ACE
inhibitors.
There is no cure, but
treatments focused
on reducing swelling
and controlling pain
may lessen
symptoms and slow
or halt progression.
Treatments include:
gentle active
exercise, pressure
gradient bandages,
massage, pneumatic
compression, and
compression
garments. Surgery to
remove excess tissue
in the affected
extremity may be
considered.

Myocardial Infarction

AKA heart attack, a

MI occurs when the
blood flow through
one or more of the
coronary arteries is
severely reduced or
cut off completely.
This causes
irreversible necrosis
to the portion of
myocardium supplied
by the blocked artery.

Most occur when a

ruptured
atherosclerotic
plaque or blood clot
blocks the flow of
blood through a
coronary artery. An
uncommon cause is a
spasm of a coronary
artery

Chest discomfort with

pressure, squeezing
or pain, shortness of
breath, discomfort in
the upper body
including the arms,
shoulder, neck or
back, nausea,
vomiting, dizziness,
sweating, and
palpitations.

Peripheral arterial
disease

Stenotic, occlusive,
and aneurismal
diseases of the aorta
and peripheral
arteries.

Caused primarily by
atherosclerosis and
thromboemboic
processes that alter
the structure and
function of the aorta
and its branches

Fatigue, aching,
numbness, or pain
primarily in the
buttock, thigh, calf,
or foot at rest or
when walking, poorly
healing wounds of
the legs or feet,
distal hair loss,
trophic skin changes,
and hypertrophic
nails.

Treatment of MI
varies from
medication to surgery
or both, depending
on the severity and
the amount of heart
damage. Medications
used to treat the
acute MI include
anticoagulants and
thrombolytic agents,
pain relievers,
antihypertensives
and cholesterol
lowering medications.
Surgical procedures
may include coronary
angioplasty with
stenting or bypass
surgery.
Recommended
lifestyle changes.
For pts with
asymptomatic
disease, tx consist of
smoking cessation,
lipid lowering
medications, and
control of diabetes
and HTN (with beta
blockers). For pts
with disabling
intermittent
claudication,
treatment consists of
revascularization

procedures (stent,
lasers) and surgery
(bypass) may be
recommended.
Supervised exercise
training should be
performed for a
minimum of 30-45
minutes, at least 3x a
week, for a minimum
of 12 weeks.
Rheumatic Fever

Acute respiratory
distress syndrome
(ARDS)

An inflammatory
disease that can
develop as a
complication of
untreated or poorly
treated strep throat
from group A
streptococcus
bacteria. Rheumatic
fever can damage
the heart valves and
cause heart failure.
Is a sudden
respiratory failure
due to fluid
accumulation in the
alveoli. ARDS usually
occurs in people who
are already critically
ill or who have
significant injuries.
Severe shortness of
breath develops
within a few hours to

Streptococus
pyogenes or group A
strep that cause
strep throat or scarlet
fever.

Result from the

inflammation of the
heart, joints, skin or
central nervous
system that may
include red, swollen,
fever, and painful
joints, heart
palpitations, chest
pain, shortness of
breath, and skin rash.

The goals of
treatment are to
destroy group A strep
bacteria, relieve
symptoms, and
control inflammation.
Medications include
antibiotics and antiinflammatory agents.

Mechanical cause is
from fluid leaking
from the smallest
blood vessels in the
lungs into the alveoli.
Injuries include:
severe viral or
bacterial pneumonia,
heart failure, serious
head or chest injury,
fxs, smoke inhalation,
near drowning,

Varies based on the

cause. Usually
include SOB, labored
and unusually rapid
breathing,
hypotension,
confusion, extreme
fatigue, cough, and
fever.

It is important to
identify the cause of
ARDS bc it can
determine treatment
and predict the
chances for survival.
The first goal of
treatment is to get
oxygen to the lungs
and organs. Most
people will be treated
with supplemental

a few days after the

original disease or
trauma. ARDS is fatal
in 25-40% of the
people who develop
it.

prolonged use of
large volumes of
supplemental
oxygen, drug
overdose, shock.

Atelectasis

A condition in which
one or more areas of
the lungs collapse or
do not inflate
properly

Conditions and
factors that prevent
deep breathing and
coughing can cause
it. These include post
operataive pain,
pleural effusion,
tumor, ARDS,
asthma, COPD, and
cystic fibrosis.

If a small area of the

lung is affected,
there may be no
signs or symptoms. If
a large area is
affected, there may
be cyanosis,
shortness of breath,
increased breathing
rate, and increased
HR.

Lung cancer
(bronchial carcinoma)

Refers to any
epithelias carcinoma
occurring in the
bronchopulmonary
tree. Cancers are
broadly divided into
two main groups:
small cell lung
carcinomas and non-

Smoking is the
primary cause of the
majority of lung
cancers, but it can
occur in people who
have never smoked
or had prolonged
exposure to
secondhand smoke.

A new cough or
changes in a chronic
cough, coughing up
blood, shortness of
breath, wheezing,
weight loss, and bone
pain. Typically, signs
& symptoms are not
present until the

oxygen and
mechanical
ventilation. Treating
the underlying
condition then
becomes equally
important.
Medications are given
to prevent and treat
infection, relieve
pain, provide
sedation, and prevent
blood clot formation.
Deep breathing,
changing positions,
and airway clearance
techniques assist to
fully expand the
lungs. Supplemental
oxygen, nebulized
bronchodilators, and
mucolytic agents.
Bronchoscopy may
be used to remove
foreign objects or
mucous plugs
blocking the airways.
Surgery (wedge
resection, segmental
resection, lobectomy,
pneumonectomy,
chemotherapy, and
radiation therapy.

Bronchiectasis

Chronic Obstructive
Pulmonary Disease

small cell lung

carcinomas, including
squamous cell
carcinoma,
adenocarcinoma, and
large cell carcinoma
A progressive
obstructive lung
disease that
produces abnormal
dilation of a
bronchus. This is an
irreversible condition
usually associated
with chronic
infections, aspiration,
cystic fibrosis or
immune system
impairment. The
bronchial walls
weaken over time
due to infection and
allow for permanent
dilation of bronchi
and bronchioles.
Refers to a group of
lung diseases that
block airflow due to
narrowing of the
bronchial tree.
Emphysema and
chronic bronchitis are
the two main
conditions that make
up COPD. Pts have an
increased total lung

In these cases, the

exact etiology may
be unknown.

disease is advanced.

Injury to the airways

or lung infection
(pneumonia,
whooping cough,
measles,
tuberculosis, fungal
infections).

Consistent productive
cough, hemoptysis,
weight loss, anemia,
crackles, wheezes,
and loud breath
sounds.

Medications include
antibiotics,
bronchodilators,
expectorants, and
mucolytics.

Caused by long term

smoking

Excessive mucus
production, chronic
productive cough,
wheezing, shortness
of breath, fatigue,
and reduced exercise
capacity.

Medications, surgery,
maintaining good
nutrition, and airway
clearnance, breathing
exercises.

Cystic fibrosis

Emphysema

capacity with a
significant increase in
residual volume.
Is an autosomal
recessive genetic
disease of the
exocrine glands that
primarily affects the
lungs, pancrease,
liver, intestines,
sinusues, and sex
organs. People who
have CF inherit two
faulty CF genes, one
from each parent.

The alveolar walls are

gradually destroyed
and the alveoli are
turned into large,
irregular pockets with
gaping holes in the
walls. In addition, the
elastic fibers that
hold open the
bronchioles are
destroyed, so that
they collapse during
exhalation, not
letting air escape

The causative factor

is a mutation of the
cystic fibrosis
transmembrane
conductance
regulator or
chromosome 7. A
defective gene and
its protein product
cause the body to
produce unusually
think, sticky mucus
that leads to life
threatening lung
infections, obstructs
the pancreas, and
inhibits normal
digestion and
absorption of food.
Smoking is the
leading cause.

Vary with progression

and may include
salty tasting skin,
persistent and
productive coughing,
frequent lung
infections, wheezing,
shortness of breath,
poor growth/weight
gain in spite of a
good appetite, and
frequent greasy,
bulky stools.

Shortness of breath,
wheezing, chronic
coughing, orthopnea,
barrel chest, increase
use of accessory
muscles, increased
respiration rate,
fatigue, and reduced
exercise capacity.

Antibiotics,
nutritional
supplements,
pancreatic enzyme
replacements,
mucolytics, and
bronchodilators. PT
includes airway
clearance, breathing
techniques, assisted
cough, and
ventilatory muscle
training. General
exercise is indicated
to improve overall
strength and
endurance, except
with severe lung
disease.
Medications,
supplemental
oxygen, antibiotics (if
bacterial infection is
present). Surgery,
maintaining good
nutrition. Etc.

Pleural effusion

Pneumonia

Pulmonary edema

from the lungs. The

alveoli are
permanently
overinflated and
dead space increase
within the lungs.
Is a buildup of fluid in
the pleural space
between the lungs
and chest cavity. The
excess fluid can push
the pleura against
the lung making it
hard to breath, and in
some cases, causing
atelectasis. If the
fluid gets infected
and turns into an
abscess, the
condition is called
empyema.
Refers to
inflammation of the
lungs

Occurs when fluid

collects in the alveoli
within the lungs,
making it difficult to
breathe. *Acute
pulmonary edema is
a medical emergency.

Pleuritis, or
inflammation of the
visceral and parietal
pleura. Pleuritis can
be caused by a viral
infection, pneumonia,
and RA.

Shortness of breath.
If the fluid becomes
infected, dry cough,
fever, and chills may
appear.

Usually caused by
bacterial, viral,
fungal, or parasitic
infection

Fever, cough, SOB,

sweating, shaking
chills, chest pain that
fluctuates with
breathing, headache,
muscle pain, and
fatigue.
Extreme shortness of
breath, a feeling of
suffocating or
drowning, gasping for
breath, anxiety,
restlessness, a sense
of apprehension,
coughing, frothy

Occurs when the left

ventricle is unable to
pump blood
adequately (left sided
heart failure).
Pressure increases
inside the left atrium
and then in the

If the pleuritis is
caused by a bacterial
pneumonia, an
antibiotic will be
used. Most viral
infections run their
course without
requiring treatment.
NSAIDS may help
relieve some of the
signs and symptoms.
If the fluid buildup is
large, a chest tube
may be inserted to
drain the fluid.
Antibiotics, antiviral
agents, antifungal
agents. Lifestyle
remedies include rest
and drinking plenty of
fluids.
Supplemental oxygen
and medications. Call
911 for acute
pulmonary edema.

Pulmonary embolism

PE is a condition
where one or more
arteries in the lungs
become blocked. PE
can be life
threatening but
prompt treatment
with anti-clotting
medications can
greatly reduce the
risk of death.

Pulmonary Fibrosis

A condition in which
microscopic damage
to the alveoli causes
irreversible scarring
of the interstitial
tissue. Normally, the
tissue is highly
elastic, expanding
and contracting with
each breath. Scarring

pulmonary veins and

capillaries, causing
fluid to be pushed
through the capillary
walls into the alveoli.
Non cardiac
pulmonary edema,
fluid leaks from the
capillaries within the
alveoli since the
capillaries
themselves become
more permeable.
Caused by blood
clots from LEs.

blood tinged sputum,

chest pain, irregular
pulse.

Cause is unknown.
Chronic exposure to
silica dust,
asbestosis, grain
dust, sugar cane, and
bird and animal
droppings can cause
pulmonary fibrosis.
Radiation for lung or
breast cancer, chemo

SOB, especially
during or after
physical activit, and a
dry cough which
usually does not
appear until the
disease is advanced
and irreversible lung
damage has already
occurred. Fatigue,

Sudden onset of SOB,

chest pain that
becomes worse with
deep breathing,
coughing sputum.
Extremity swelling,
fainting.

Prompt treatment of
anticoagulants and
thrombolytic agents
greatly reduces the
risk of death. Surgery
may be done to
remove the clot.
Prevention includes
compression
stockings, pneumatic
compression,
physical activity, and
drinking fluids.
Lung scarring is
irreversible and no
current treatment has
proven effective in
stopping the
progression of the
disease, some tx may
improve symptoms
temporarily &
improve quality of

Restrictive Lung
Dysfunction (RLD)

makes the interstitial

tissue stiff and thick
and the alveoli less
flexible, making
breath more difficult.

drugs, certain
antiarrhythmic
medications, and
some antibiotics and
can also cause
fibrosis.

unexplained weight
loss, and aching
muscles and joints.

RLD is an abnormal
reduction in lung
expansion and
pulmonary
ventilation

Caused by abnormal
lung parenchyma
(atelectasis,
pneumonia,
pulmonary fibrosis,
pulmonary edema,
ARDS, abnormal
pleura (pleural
effusion, fibrosis,
pneumothorax,
hemothroax, and
disorders affecting
ventilatory pump
function.

Dyspnea on exertion,
a persistent non
productive cough,
increased respiratory
rate, hypoxemia,
decreased vital
capacity, abnormal
breath sounds.

life. Corticosteriods
and
immunosuppressive
agents are often
prescribed initially.
Lung transplantation
may be used in cases
of advanced disease.
Supplemental oxygen
and pulmonary
rehab.
Antibiotics for
pneumonia,
treatment of edema,
reversal of CNS
depression.
Mechanical
ventilation,
supplemental
oxygen, nutrition
support, muscle
training.

Common Diagnostic Procedures:

1. Holter monitoring-EKG electrodes record 24-48 hours or longer to evaluate cardiac rhythm.
2. Angiography-inject a contract medium into the blood vessels. Can show the location of plaques in the arteries
and the extent of occlusion.
3. Bronchoscopy-Direct visualization of the bronchial tree via fiberoptic instrument that transmits image to
screen.
4. Cardiac catheterization-thin, inserted into an artery in the leg or arm where a contract dye is injected.

5. Carotid ultrasound-uses sound waves to examine and visualize the structure and function of the carotid
arteries.
6. Chest radiograph-used to visualize the location, size, and shape of the heart, lungs, blood vessels, ribs, and
bones of the spine. Can also reveal fluid in the lungs or pleural space, pneumonia, emphysema, cancer or
other conditions.
7. Computed tomography (CT)-uses an x-ray machine that rotates around a pt lying on a table. The pictures are
slices of the body called tomograms and each picture is called a computed tomograph.
8. Echocardiography-uses high frequency sound waves non invasively to evaluate the functioning of the heart
via real time images. Can provide information on the size and function of the ventricles, thickness of the
septums, and function of the walls, valves, and chambers.
9. Fluroscopy-A continuous x-ray procedure that shows the heart and lungs. Involves a high dose of radiation, it
has largely been replaced by echocardiography.
10.Magnetic Resonance Imaging (MRI)-uses a magnetic field and radio waves to create 3D images of the heart
and blocked vessels to assess the size and function, thickness, and damage or heart disease. Limited for
imaging the lungs.
11.Positron Emission Tomography (PET)-imaging test in which a small amount of radioactive material is injected,
inhaled, or swallowed,. Radioactive material tends to accumulate in areas with high levels of chemical activity
corresponding to areas of disease. PET is useful in evaluating heart disease and cancer.
12.Cardiovascular/pulmonary Systems:
13.
Innervation of the Heart:
14.The sympathetic influence is achieved by release of epinephrine & norepinephrine. Sympathetic nerves
stimulate the chambers to beat faster (chronotrophic effect) and with greater force of contraction (inotroophic
effect). Sympathetic activation leads to cardiac contractility, HR, venoconstriction, and arterial
vasoconstriction, ultimately leading to BP.
15.The parasympathetic influence is achieved via acetylcholine release from the vagus nerve. Parasympathetic
nerves slow the heart rate (chronotrophic effect) primarily through their influence on the SA node.
Parasympathetic leads to a HR and a small decrease in contractility, resulting in a in BP.
16.Valsalva Maneuver: Forced expiration against a closed glottis produces intrathoracic pressure, central
venous pressure and venous return. The resultant decrease in cardiac output and BP is sensed by
baroreceptors, which reflexively increase HR and myocardial contractility.
17.
Pathology
Cerebrovascular

Diagnosis
Occurs when there

Laboratory/Imagi
ng
CT can confirm an

Management/Pro
gnosis
Medical

Accident (CVA)

is an interruption of
cerebral circulation
that results in
cerebral
insufficiency,
destruction of
surrounding brain
tissue, and
subsequent
neurological deficit.

area of infarct in
the brain and its
vascular origin,
however it can
present as
negative for up to
a few days after
the event. MRI
allows for the
diagnosis of
ischemia within the
brain almost
immediately after
onset. PET can
provide info
regarding cerebral
perfusion and cell
function.
Ultrasonography
identifies areas of
diminished blood
flow in vessels and
angiography may
identify a clot and
determine if
surgical
intervention is
necessary.

management will
initially include
medically
stabilizing the pt
through medication
and surgical
intervention. PT in
acute phase
focuses on
positioning,
pressure relief,
sensory awareness
re-education,
balance, ROM,
weight-bearing,
facilitation, postural
control. Rehab can
include Bobaths
NDT, Brunnstroms
Movement therapy,
Rood, Kabat, Knott,
PNF. The outcome
depends on pts
overall health, level
of cognition, motor
recovery, and
family support. The
first 3 months of
recovery typically
reveals the most
measureable
neurologic recovery
and is usually a
good indicator of
the long-term
outcome. Research

Congestive Heart
Failure (CHF)
Left sided heart
failure: generally
associated with
signs of pulmonary
venous congestion.
Right sided heart
failure: associated
with signs of
systemic venous
congestion.

Occurs when the

heart can no longer
meet the metabolic
demands of the
body. The hearts
inability to pump a
sufficient amount
of blood occurs
when there in
insufficient or
defective cardiac
filling and/or
impaired
contraction &
emptying of the
heart. The
impairment in
cardiac output
causes the body to
compensate for
this deficit and this
results in an
increase in blood
volume, cardiac
filling pressure, HR,
and cardiac muscle
mass. A pt with
CHF will initially
show signs of
tachycardia. Other
signs include

Urinalysis and a
CBC count that
includes
electrolyte, thyroid
stimulating
hormone, blood
urea nitrogen
(BUN), and serum
creatinine levels
should be
performed. A chest
x-ray,
electrocardiogram,
and
echocardiogram
are also
recommended. A
Doppler
echocardiogram
can determine
systolic & diastolic
performance, the
cardiac output
(ejection fraction),
and pulmonary
artery and
ventricular filling
pressures.

shows a pt can
continue to
improve for an
average of 2-3
years post CVA.
CHF is a common
disorder. A pt can
live with CHF and
should benefit from
PT in order to
improve endurance
and strength after a
decline in function
from hospitalization
or bed rest. After
diagnosis there is
mean of 3.2 years
of survival for men
and 5.4 years for
females.

Cystic Fibrosis
(CF)

venous congestion,
high catecholamine
levels, & impaired
cardiac output,
sudden weight
gain, SOB, S3
gallop.
Is an inherited
disease that affects
the ion transport of
the exocrine glands
resulting in
impairment of the
hepatic, digestive,
respiratory, and
reproductive
systems. The
disease causes the
exocrine glands to
overproduce thick
mucus,
overproduce
normal secretions
or overproduce
sodium & chloride.
Mostly affects
children, African
American followed
by Caucasians.

Neonates
meconium can be
tested as a
screening tool for
increased albumin.
The quantitative
pilocarpine
iontophoresis
sweat test is the
sole diagnostic tool
in determining the
presence of CF.
Sodium & chloride
amounts greater
than 60 mEq/l
(standard value is
40 mEq/l) is a
positive diagnosis
for CF. The sweat
test should be
performed twice to
ensure accuracy.

Chest PT should be
performed several
times a day and
includes bronchial
drainage,
percussion,
vibration, breathing
and assistive cough
techniques &
ventilatory muscle
training. A pt with
CF will require
intermittent PT
thought their life.
The goals are to
maximize secretion
clearance from the
lungs, optimize
pulmonary
function, and
maximize the pts
quality of life. CF is
a terminal disease,
however, the
median age of
death as increased
to 35 years of age
due to early
detection and

Emphysema

Refers to a
pathologic
accumulation of air
in the lungs found
with COPD. COPD
is the second
leading cause of
disability in
individuals under
65 years of age
worldwide.
Emphysema results
from a nonreversible injury
and destruction of
elastic protein
within the alveolar
walls.

X-ray is utilized to
visually evaluate
the shape and
spacing of the
lungs. Other
imaging studies
include a
planogram to
detect bullae and a
bronchogram to
evaluate mucus
ducts and detect
possible
enlargement of the
bronchi. Arterial
blood gases may
indicated a PaO2.
Impaired FEV1,vital
capacity and forced
vital capacity. Total
lung capacity,
residual volume,
and functional
residual volume
will be .

comprehensive
management. The
most common
cause of death is
respiratory failure.
Males generally
have a better
prognosis than
females.
Pharmacological
intervention,
oxygen therapy, PT.
PT intervention
consist of
generalized
exercise,
endurance training,
pursed-lip
breathing,
ventilatory muscle
strengthening,
chest wall
exercises, and pt
education on
posture, airway
secretion
clearance.
Emphysema is a
chronic progressive
disease process.
Pts require ongoing
medical care and
intermittent
physical therapy
intervention. Life
expectancy

Lymphedema
Post-Mastectomy

Lymphedema
following a
mastectomy is
termed secondary
lymphedema and is
the result of
damage to the
lymphatic nodes
and vessels during
surgery. Excessive
accumulation of
lymph fluid within
the soft tissues is
caused by an
excess load of
lymph fluid or
inadequate
transport capacity
within the
lymphatic system
secondary to the
loss of
homeostasis.

Lymphedema
classified into 3
stages. Stage I:
pitting edema that
reduces with
elevation overnight
and does not
exhibit any fibrotic
changes. Stage II:
identified by some
fibrotic changes
that being to occur
& increase in nonpitting edema that
does not reduce
with elevation.
Stage III: is
characterized by
skin changes,
frequent infections,
and severe edema
that is non-pitting
and fibrotic.
Diagnosis is
confirmed through
history,
observation, and
several diagnostic
tools to rule out
other disorders. A

decreases to less
than 5 years with
severe expiratory
slowing measured
at a rate of <1 L of
air during FEV1.
Pharmacological
intervention or
natural substances
that increase
proteolysis and
macrophage
activity. No cure.
Surgery is used in
the treatment of
severe cases.PT
follows a treatment
approach termed
combined
decongestive
physiotherapy
(CDP).
Lymphedema is
progressive if left
untreated, but can
be managed
through
intervention and
education. Pts must
comply with a
home program and
must remain aware
of all activities that
place the pt at an
increased risk for
lymphedema.

Myocardial
Infarction (MI)

Occurs when there

is poor coronary
artery perfusion,
ischemia, and
subsequent
necrosis of the
cardiac tissue
usually due to
thrombus, arterial
blockage or
atherosclerosis.
The location and
severity of the
infarct will
determine
symptoms and
overall clinical
picture.

Doppler is used to
rule out DVT. CT or
MRI to rule out
malignancy. A
lymphoscintigram
is a nuclear
medicine procudre
that tests the
function of the
lymphatic system.
Primary tool to
detect MI is a 12
lead EKG. An
inverted T wave
indicates
myocardial
ischemia, elevated
ST segment
indicates acute
infarction, and a
depressed ST
segment indicates
a pending
subendocardial or
transmural
infarction. A blood
serum analysis can
be utilized to
determine the level
of selected cardiac
enzymes. CPK,
AST, and lactic
dehydrogenase can
be dramatically
altered during and
after a MI.

Stabilize the pt and

initiate
pharmacological
intervention to
hinder the
evolution of the MI.
Cardiac rehab is
recommended
status post MI. The
pt should start in
the coronary care
unit (CCU) and
progress through
each of the phases
of cardiac rehab. P
that that has
experienced an MI
may be able to
return to all
previous activities
after successful
completion of a
cardiac rehab
program. A pt must
continue to reduce
the modifiable risk

Restrictive Lung
Disease (RLD)

Is a classification of
disorders caused
by a pulmonary or
extrapulmonary
restriction that
produces
impairment in lung
expansion and an
abnormal reduction
in pulmonary
ventilation. There
are multiple
conditions that can
cause restrictive
lung disease.
Pulmonary
restriction can be
caused by tumor,
interstitial
pulmonary fibrosis,
scarring within the
lungs, and
pneumonia.
Extrapulmonary
restrictions include
pleural effusion,
chest wall stiffness,
structural
abnormality,
postural deformity,
muscle weakness,

A chest
radiography is
utilized to evaluate
lung structure and
evidence of
fibrosis, infiltrates,
tumor, and
deformity. Arterial
blood gas analysis
may indicated a
decrease in PaO2.
VC, FVC, and TLC
will be impaired.
Normal residual
volume, and
expiration flow
rates. ERV and FRC
are often
decreased.

factors and
maintain an
appropriate level of
exercise in order
limit another MI.
PT includes body
mechanics, posture
training, diaphragm
and ventilatory
muscle
strengthening,
relaxation and
energy
conservation.
Outcome is based
on the etiology of
the restrictive lung
disease and pt
response to PT
intervention. Some
disorders require
surgical
intervention that
alleviates the
condition while
other are
progressive and
irreversible. Some
pts with end-stage
disease may be
candidates for lung
transplantation,
however most
eventually progress
to ventilatory
failure.

and central
nervous system
injury. RLD includes
a in lung & chest
wall compliance,
in lung volumes
and an in the
work of breathing.
A pt with restrictive
lung disease is
characterized by a
reduction of lung
volumes, chest
mobility, breath
sounds, SOB,
hypoxemia, rapid
and shallow
respiratory pattern,
ineffective cough.
18.
19.

Description of Blood Gases:

Arterial Blood Gas

(ABG)

Are collected to evaluate acid-base status (pH), ventilation

(PaCO2), and oxygenation of arterial blood (PaO2). The partial
pressure of oxygen in arterial blood PaO2 and the percent
oxygen saturation of hemoglobin (SaO2) provide information
about how well the lungs are functioning to oxygenate the
blood. The partial pressure of carbon dioxide in arterial
blood (PaCO2) provides info on how well the lungs are able to
remove carbon dioxide. Changes in PaCO2 directly affect the
balance of pH in the body. Blood pH is tightly regulated, as
an imbalance in either direction can affect the nervous
system and can cause convulsions or coma. Bicarbonate
(HCO3-) is an important component of the chemical buffering
system that keeps the blood from becoming too acidic or
basic and is often part of an ABG test.

Cardiac Biomarkers

Cholesterol Test

Complete Blood
Count (CBC)

Hematocrit (Hct)

Certain enzymes leak out of the heart cells and into the
blood after a myocardial infarction. Cardiac enzyme studies
measure the levels of creatine phosphokinase (CK) and the
protein troponin in the blood. CK-MB is a relatively specific
test for myocardial infarction. It appears in blood
approximately 4 hours after infarction, peaks at 12-24 hours,
and declines over 48-72 hours. Cardiac troponin-I is also a
specific marker for infarction, and unlike CK-MB levels, it
remains elevated for 5-7 days.
Also called a lipid panel or lipid profile, a cholesterol test
measures the amount of cholesterol and triglycerides in the
blood in order to determine the risk of atherosclerosis.
Cholesterol is carried in the circulation in association with
lipoproteins. A complete lipid profile includes the
measurement of 4 types of lipids in the blood: total
cholesterol, high-density lipoprotein (HDL) cholesterol, lowdensity lipoprotein (LDL) cholesterol, and triglycerdies. HDL
cholesterol is referred to as the good cholesterol because
it helps carry away LDL cholesterol and is protective against
atherogenesis. LDL is referred to as the bad cholesterol
since it is associated with the buildup of fatty plaques within
the arteries which reduce blood flow. The body converts any
calories it does not need to use right away into triglycerides,
which are stored in adipose tissue. High levels of
triglycerides are seen in overweight people, in those
consuming too many sweets or too much alcohol, and in
people with diabetes who have elevated blood sugar levels.
Measures red blood cell count, white blood cell count, white
blood cell differential, platelets, hemoglobin, and
hematocrit. A CBC is performed to assess health, to
diagnose and monitor a medical condition, and to monitor
the effects of medical treatment.
Is the percentage of red blood cells in total blood volume. A
low hematocirt may indicate anemia, blood loss, and vitamin
or mineral deficiencies. A high hematocrit may indicate
dehydration or polycythemia vera, a condition that causes

Partial
Thromboplastin Time
(PTT) and
Prothrombin Time
(PT)

20.

an overproduction of red blood cells.

PTT and PT tests measure how quickly the blood clots. The
tests are commonly used to monitor oral anticoagulant
therapy or to screen for selected bleeding disorders. The
tests examine all of the clotting factors of the intrinsic
pathway with the exception of platelets. Partial
thromboplastin time is more sensitive than prothrombin time
in detecting minor deficiencies.

Arterial blood gases:

pH
PaCO2 (amount of carbon dioxide
within arterial blood)
PaO2
HCO3- (amount of bicarbonate ions
within arterial blood)
SaO2
*By convention, ABG results are
written or spoken in the following
order: pHPaCO2PaO2HCO3- (e.g.
7.4/40/97/24)
Partial Thromboplastin Time (PTT)
Acidemia
Alkalemia
Eucapnia
Hypercapnia
Hyopcapnia
Hypoxemia
Mild hypoxemia

7.4 (7.35-7.45)
40 mm Hg at sea level breathing ambient air
(35-45mm Hg)
97 mm Hg at sea level breathing ambient air
(80-100 mm Hg)
24 mEq/L (22-26)
95-98%

26-39 seconds
Elevated acidity of blood (pH < 7.35)
Decreased acidity of blood (pH > 7.45)
Normal level of CO2 in arterial blood (35-45
mm Hg)
Elevated level of CO2 in arterial blood( > 45
mm Hg)
Low level of CO2 in arterial blood (<35 mm
Hg)
Low level of O2 in arterial blood (PaO2 < 80
mm Hg)
PaO2 60-79 mmHg

Moderate hypoxemia
Severe hypoxemia
Hypoxia

PaO2 40-59 mmHg

PaO2 < 40 mmHg
Low level of O2 in the tissue despite
adequate perfusion of the tissue
21.*An increase in the PaCO2 decreases the bodys pH. A decrease in the PaCO 2 raises the bodys pH.
22.*Supplemental oxygen is usually prescribed when the PaO 2 falls below 55 mmHg.
23.
24.
Other values:

White Blood Cells (WBCs)

(Leukocytes)
Red Blood Cells (RBCs)
(Erythrocytes)
Erethrosedimentation Rate
(ESR)
Hematocrit
Platelet
Sodium
Calcium
Potassium
Magnesium
Total cholesterol
LDL
HDL
Triglyceride
25.
Drug
Alpha
Adrenergic
Antagonist
Agents

4300-10,800
Male: 4.6-6.2 Female: 4.2-5.9
Male: <15 mm/hr Female: <20
Male: 45%-52% Female: 37%-48%
150,000-450,000
135-146
8.4-10.4
3.5-5.5
1.8-2.4
<200
<100
<40
<150

Pharmacological Management of Heart and Vascular Diseases:

Action

Indications

Side
Effects

Reduce
peripheral
vascular
tone by
blocking

Hypertension
, benign
prostatic
hyperplasia

Dizziness,
palpitations
, orthostatic
hypotensio
n,

Implicati
ons for
PT
Use
caution
when
rising
from a

Examples
Cardura
(doxazosin,
Minipress
(prazosin),
Hytrin

alpha-1
adrenergic
receptors.
This action
causes
dilation of
arterioles &
veins and
BP.

drowsiness

AngiotensinConverting
Enzyme
(ACE)
inhibitor
Agents

Decrease
blood
pressure
and
afterload by
suppressing
the enzyme
that
converts
angiotensin I
to
angiotensin
II.

HTN,
congestive
heart failgure

Hypotensio
n, dizziness,
dry cough,
hyperkalem
ia,
hyponatrem
ia

Angiotensin II

Block

HTN,

Dizziness,

sitting or
lying
position
due to the
risk of
dizziness
and/or
orthostati
c
hypotensi
on.
Closely
monitor
pt during
exercise.
Avoid
sudden
changes
in posture
due to the
risk of
dizziness
& fainting
from
hypotensi
on. Pts w
heart
failure
should
avoid
rapid
increases
in
physical
activity.
Minimal

(terazosin)

Capoten
(captorpril),
Vasotec
(enalapril),
Prinivil
(lisinopril),
Altace
(ramipril)

Cozaar

receptor
antagonist
angents

Antiarrhythm
ic Agents

angiotensin
II receptors
which limit
vasoconstric
tion &
stimulation
of vascular
tissue
Divided into
4 classes.
Class I
(sodium
channel
blockers)contorl
cardiac
excitation &
conduction.
Class II (beta
blockers)inhibit
sympathetic
activity by
blocking Badrenergic
receptors.
Class IIIprolong
repolarizatio
n by
inhibiting
both
potassium &
sodium
channels &
are often

congestive
heart failure

back and
leg pain,
angina
pectoris

implicatio
ns for PT

(losartan),
Atacand
(candesart
an), Diovan
(valsartan)

Cardiac
arrhythmias

Unique to
the specific
antiarrhyth
mic agent;
exacerbatio
n of cardiac
arrhythmias
, dizziness,
hypotensio
n

Encourag
e pts to
adhere to
the
prescribe
d dosing
schedule
and
immediat
ely report
any
adverse
reactions
to a
healthcar
e
professio
nal.

Sodium
channel
blockers:
quinidine
(generic),
Xylocaine
(lidocaine)
Beta
blockers:
Tenormin
(atenolol)
Prolonged
repolariza
tion:
Cordarone
(amiodaron
e
Calcium
channel
blockers:
Cardizem
(diltiazem)

Anticoagulan
t Agents

considered
the most
effective
antiarrhytmi
c agent.
Class IV(calcium
channel
blockers)depress
depolarizatio
n & slow
conduction
through the
AV node.
Inhibit
platelet
aggregation
& thrombus
formation

Post
percutaneous
transluminal
coronary
angioplasty &
coronary
artery bypass
graft surgery,
prevention of
venous
thromboemb
olim &
cardioemboli
c events in
pts with atrial
fibrillation &
prosthetic
heart valves

Hemorrhag
e, risk of
bleeding,
gastrointest
inal distress
with oral
medication

A
therapist
must be
careful to
avoid
injury
secondar
y to the
risk of
excessive
bleeding
or
bruising.
Pt
education
regarding
common
side
effects is
also
indicated

Heparin,
Coumadin
(warfarin),
Lovenox
(enoxapari
n)

Antihyperlipi
demia
Agents

Antithrombot
ic
(antiplatelet)

There are 5
categories
of lipidmodifying
agents. The
most
commonly
used drugs,
the statins,
inhibit
enzyme
action in
cholesterol
synthesis,
break down
LDL,
triglyceride
levels, and
HDL
levels. The
other
categories
are bile acid
sequestrants
, nicotinic
acid,
cholesterol
absorption
inhibitors, &
fibric acid
derivatieves
Antithrombo
tic agents
inhibit

Hyperlipidemi
a,
atheroscleros
is, prevent
coronary
events in pts
with existing
coronary
disease,
diabetes or
PVD

Headache,
GI distress,
myalgia,
rash

Postmyocardial
infarction, a-

Hemorrhag
e,
thrombocyt

to protect
the pts.
Aerobic
exercise
can
increase
high
density
lipoprotei
ns and
maximize
the
effects of
drug
therapy

Must be
careful to
avoid

Lipitor
(atorvastati
n), Zocor
(simvastati
n), Tricor
(fenobibrat
e)

Bayer
(aspirin),
Plavix

agents

platelet
aggregation
and clot
formation

fib, prevent
arterial
thrombus
formation

Beta Blocker
Agents (BetaAdrenergic
Blocking
Agents)

Decrease
the
myocardial
oxygen
demand by
decreasing
heart rate
and
contractility
by blocking
B-adrenergic
receptors

HTN, agina,
arrhythmias,
heart failure,
migraines,
essential
tremor

Calcium
Channel
Blocker
Agents

Decrease
the entry of
calcium into
vascular

HTN, angina
pectoris,
arrhythmias,
congestive

openia,
potential
liver toxicity
with the
use of
aspirin, GI
distress
Bradycardia
, cardiac
arrhythmias
, fatigue,
depression,
dizziness,
weakness,
blurred
vision

Dizziness,
headache,
hypotensio
n,

injury
secondar
y to the
risk of
bleeding.

(clopidogrel
),
Persantine
(dipyridam
ole)

HR & BP
response
to
exercise
will be
diminishe
d. Rate of
perceived
exertion
may be
used to
monitor
exercise
intensity.
Closely
monitor
pts during
positional
changes
due to an
risk for
orthostati
c
hypotensi
on.
HR & BP
response
to
exercise

Tenormin
(atenolol),
Lopressor
(metoprolol
), Inderal
(propanolol
)

Norvasc
(amlodidine
), Procardia
(nifedipine)

Diuretic
Agents

smooth
muscle cells
resulting in
diminished
myocardial
contraction,
vasodilation,
and
oxygen
demand of
the heart

heart failure

peripheral
edema

the
excretion of
sodium &
urine. This

HTN, edema
associated
with heart
failure,

Dehydratio
n,
hypotensio
n,

will be
diminishe
d. Monitor
pt closely
when
moving to
an
upright
position
secondar
y to
dizziness
and/or
orthostati
c
hypotensi
on.
Observe
the Pt for
signs &
symptom
s of
congestiv
e heart
failure
such as
worsening
peripheral
edema,
dyspnea
or weight
gain.
Positionin
g changes
can
increase

, Calan
(verapamil)
Cardizem
(dilitazem)

Thiazide:
Diuril
(chlorothiaz
ide)

Nitrate
Agents

causes a
reduction in
plasma
volume
which
blood
pressure.
Classificatio
ns include
thiazide,
loop, and
potassium
sparing
agents.

pulmonary
edema,
glaucoma

electrolyte
imbalance,
polyuria,
LDL,
arrhythmias

ischemia
through
smooth
muscle
relaxation
and dilation
of peripheral
vessels

Angina
pectoris

Headache,
dizziness,
orthostatic
hypotensio
n, reflex
tachycardia
, nausea,
vomiting.

the risk of
dizziness
and falls
due to
BP.
Monitor
pts
closely for
signs &
symptom
s of
electrolyt
e
imbalanc
e and
muscle
weakness
or
cramping.
Pts must
be
educated
to come
to a
standing
position
slowly.
Sublingua
l
administr
ation of
nitroglyce
rin is the
preferred
method
to treat

Loop:
Lasix
(furosemid
e)
Potassium
sparing:
Dyrenium
(triamteren
e)

Nitrostat
(nitroglycer
in), Isordil
(isosorbide
dinitrate),
Amyl nitrite
solution for
inhalation.

Positive
Inotrophic
Agents

the force
and velocity
of
myocardial
contraction,
slow the HR,
conduction
velocity
through the
AV node, &
the
degree of
activation of
the
sympathetic
nervous
system.

Heart failure,
atrial
fibrillation

Cardiac
arrthytmias,
GI distress,
dizziness,
blurred
vision

Thrombolytic
Agents

Facilitate
clot
dissolution
through
conversion
of
plasminogen
to plasmin.
Plasmin
breaks down
clots &
allows

Acute
myocardial
infarction,
pulmonary
embolism,
ischemic
stroke,
arterial or
venous
thrombosis

Hemorrhag
e
(specifically
intracranial
in certain
populations
), allergic
reaction,
cardiac
arrhythmia

an acute
angina
attack.
Therapist
s should
monitor
HR during
activity,
teach the
pt and
fam to
take the
pts pulse,
and seek
health
care
providers
advice for
rates less
than 60
bpm or
more
than 100
bpm.
Therapist
must be
careful to
avoid
situations
that may
cause
trauma
due to
altered
clotting
activity.

Lanoxin
(digoxin)

Linlytic
(urokinase),
Activase
(alteplase)

occluded
vessels to
reopen to
maintain
blood flow.

Pharmacological Management of Airway and Lung Diseases:

Drug

Action

Indications

Antihistamin
e Agents

Block the
effects of
histamine
resulting in a
in nasal
congestion,
mucosal
irritation, &
symptoms of
the common
cold, sinusitis,
conjunctivitis,
& allergies

Respiratory
seasonal
allergies,
rhinitis &
sneezing
from the
common
cold, allergic
conjunctiviti
s, motion
sickness,
and
Parkinsons
disease

AntiInflammator
y Agents

Inhaled
corticosteroid
s, leukotriene
modifiers, &

Bronchospa
sm, asthma

Side
Effects

Implicati
ons for
PT
Arrhythm Increase
ias,
guarding
postural
when
hypotens rising
ion, GI
from a
distress,
sitting or
dizziness, lying
drowsine position
ss,
due to
headach
the risk of
e, blurred orthostati
vision,
c
fatigue,
hypotensi
nausea,
on.
thickenin Closely
g of
monitor
bronchial pt during
secretion exercise.
s
Corticost Instuct
eroid:
the pt in
systemic the use of
side
correct

Examples
Benadryl
(diphenhydram
ine), Allegra,
Zyrtec, Claritin

Corticosteroid:
Qvar,
Pulmicort,
AeroBid

mastcell
stabilizers
help prevent
inflammatory
mediated
bronchoconstr
citon by
inhibiting
production of
inflammatory
cells,
suppressing
release of
inflammatory
mediators
(cytokines,
prostaglandin
s,
leukotrienes),
and reversing
capillary
permeability,
in turn
reducing
airway
edema.

affects
are
decrease
d with
the
inhaled
form, but
may
include
damage
of
supportin
g tissues,
skin
breakdo
wn,
osteopor
osis,
bone
density,
glaucom
a, and
delayed
growth.
Local
effects
include
nasal
irritation
and
dryness,
sneezing
and
bloody
mucus;
Leukotrie

use the
inhaler
and to
rinse
their
mouth
with
water
after use
to avoid
irritation
of local
mucosa.
Advise
the pts
that
these
agents
are not
bronchodi
lators and
should
not be
used to
treat
acute
episodes
of
asthma.

Leukotriene
modifier: Zyflo
Mast cell
stabilizer:
Nasalcrom

Bronchodilat
or Agents

Relieve
bronchospas
m by
stimulating
the receptors
that cause
bronchial
smooth
muscle
relexation or
by blocking
the receptors
that trigger
bronchoconstr
iction.
Primary
classifications
include
anticholinergi
c,

Bronchospa
sm,
wheezing,
and SOB in
asthma &
COPD

ne
modifier:
liver
dysfuncti
on; Mast
cell
stabilizer
:
bronchos
pasm,
throat
and
nasal
irritation,
cough, GI
distress
Paradoxic
al
bronchos
pasm,
dry
mouth,
GI
distress,
chest
pain,
palpitatio
ns,
tremor,
nervousn
ess. Long
acting
sympath
omimetic
s,
including

Should
advice
pts to
take their
bronchodi
lator
medicatio
n as
prescribe
d before
therapy
and to
bring
their
short
acting
meds
with
them.
Cardiac

Anticholinergic
: Atrovent,
sprivia.
Sympathomim
etics: Ventolin,
Primatene
mist, Serevent.
Xanthine
derivative:
Theo-Dur,
Aminophylline

sympathomim
etics, &
xanthine
derivatives.

Expectorant
Agent

Increase
respiratory
secretions
which help to
loosen
mucus.
Reducing the
viscosity of
secretions
and
increasing
sputum
volume
improves the
efficiency of
the cough
reflex and of
ciliary action
in removing
accumulated
secretions.

salmeter
ol,
increase
the risk
of
asthma
related
death.

Cough
associated
with
respiratory
tract
infections
and related
conditions
such as
sinusitis,
pharyngitis,
bronchitis,
and asthma,
when
complicated
by
tenacious
mucus or
mucus plugs
and
congestion

GI
distress,
drowsine
ss

or vision
abnormali
ties may
indicate
toxicity,
and
physician
should be
notified
immediatl
ey.
Therapist
s can
exploit
the
effects of
expectora
tnt
agents by
performin
g airway
clearance
interventi
ons
within
one hour
after drug
administr
ation.
Encourag
e pts to
take
meds
with a
glass of
water.

Mucinex
(guaifenesin),
terpin hydrate

Mucolytic
Agents

the
viscosity of
mucus
secretions by
altering their
composition
and
consistency,
making them
easier to
expectorate.
They are
administered
by a
nebulizer.

Vicous
mucus
secretions
due to
pneumonia,
emphysema
, chronic
bronchitis,
and cystic
fibrosis

Pharyngit
is, oral
mucosa
inflamma
tion,
rhinitis,
chest
pain

Exploit
the
effects by
performin
g airway
clearance
interventi
ons

Pulmozyme,
Mucosil or
Mycomyst

Cardiovascular/pulmonary/lymphatic Interventions:
Aerobic Exercise Prescription:
Aerobic exercise, or cardiorespiratory endurance exercise, refers to submaximal, rhythmic repetitive exercise of large
muscle groups during which adenosine triphosphate is synthesized primarily by the long-term energy system and
the utilization of inspired oxygen.
Type (modality): walking, cycling, jogging are recommended to improve exercise tolerance, can be maintained at a
constant velocity, very low interindividual variability.
Dynamic arm exercise (arm ergometry): uses a smaller muscle mass, results in lower VO2 max (60%-70%lower)
than leg ergometry; at a given workload, HR will be higher, stroke volume lower; systolic and diastolic BPs will be
higher.
Early rehab: activity is discontinuous (interval training), with frequent rest periods; progressing to continuous
training. Interval training can also be incorporated in vigorous training to allow patient to work at higher percentage
of V02 max.
Warm and up and cool down: gradually decrease the intensity of exercise, 5-10 minutes.

Resistive exercises: to improve strength and endurance in clinically stable pts. Usually prescribed in later rehab,
after a period of aerobic training. Moderate intensities are typically used (60%-80% of 1 repetition or 10 repetition
maximal voluntary contraction. Precautions: monitor BP, avoid breath holding (Valsalvas response: may
dramatically BP and work of heart). Contraindicated for patients with: uncontrolled hypertension or arrhythmias
Intensity: prescribed as % of functional capacity revealed on ETT, within a range of 40%-85% depending upon
initial level of fitness; typical training intensity is 60%-80% of functional capacity; lower training intensities may
necessitate an increase in training duration; most clinicians use a combination of HR, RPE, and METs to prescribe
exercise intensity (eliminates problems that may be associated with individual measures)
Heart rate:
1. Percentage of maximum HR achieved on ETT; without ETT 208-0.7 x age. 70%-85% HR max closely
corresponds to 60%-80% of functional capacity or VO2 max.
2. Estimated HR max is used in cases where submax ETT has been given.
3. Heart rate range or reserve (Karvonens formula) Can more closely approximate the relationship between HR
and VO2 max, but increased variability in pts on medications. Problems associated with use of HR alone to
prescribe exercise intensity. 60%-80% (HR max-resting HR) + resting HR = target HR.
4. Beta blocking: affects ability of HR to rise in response to an exercise stress.
5. Pacemaker: can affect the ability of HR to rise in response to an exercise stress if it is fixed.
6. Environmental extremes, heavy arm work, isometric exercise and valsalva may affect HR and BP responses.
Rating of perceived exertion, the original Borg RPE scale (6-20).
1. Useful along with other measures of pts effort if beta blockers or other HR suppressors are used.
2. Problems with use of RPE alone to prescribe exercise intensity:
Individuals with psychological problems (depression)
Unfamiliarity with RPE scale; may affect selection of ratings
RPE scale 6-20 is linearly associated with HR.
Ex. Multiple by 10. 6x10=60 bpm.
If pt is 42 years old and reports 16 on the scale: 220-42=178 (predicted Max HR) 16x10=160bpm (borg scale)
160/178=89% so answer would be the one that correlates most with 89%.
METs, or estimated energy expenditure (V02)

1. 40%-85% of functional capacity (maximal METs) achieved on ETT. Without a maximal ETT, this is an estimation
of workload.
2. Problems associated with use of METs alone to prescribe exercise intensity:
-With high intensity activities (jogging) need to adopt a discontinuous work pattern: walk 5 minutes, jog
3 minutes to achieve the desired intensity.
-Varying skill level or stress of competition may affect the known metabolic cost of an activity.
-Environmental stresses (heat, cold, high humidity, altitude, wind, changes in terrain such as hills) may
affect the known metabolic cost of an activity.
Duration: Conditioning phase may vary from 10-60 minutes, depending upon intensity; the higher the intensity, the
shorter the duration.
-Average conditioning time is 20-30 minutes for moderate intensity exercise.
-Severely compromised individuals may benefit from multiple, short exercise sessions spaced throughout the day (310 min sessions)
-Warm-up and cool-down periods are kept constant 5-10 min each.
Frequency:
-Frequency of activity is dependent upon intensity and duration; the lower the intensity, the shorter the duration, the
greater the frequency.
-Average: 3-5 sessions/week for exercise at moderate intensities and duration (>5 METs)
-Daily or multiple daily sessions for low intensity exercise (<5 METs)
Progression:
-Modify exercise prescription if:
-HR is lower than target HR for a given exercise intensity
-RPE is lower (exercise is perceived as easier) for a given exercise
-Symptoms of ischemia (angina) do not appear at a given exercise intensity
-Rate of progression depends on age, health status, functional capacity, personal goals, and preferences.
-As training progresses, duration is increased first, then intensity.
Normal Cardiorespiratory

Response to Acute
Aerobic exercise:
- oxygen consumption due
to cardiac output, blood
flow, and oxygen utilization in
the exercising skeletal
muscles
-Linear increase in SBP with
increasing workload (8 to 12
mm Hg per MET)
-No change or moderate
decrease in DBP
-respiratory rate and tidal
volume
Consider reduction in
exercise/activity with:
-Acute illness: fever, flu
-Acute injury, orthopedic
complications
-Progression of cardiac
disease: edema, weight gain,
unstable angina
-Overindulgence: food,
caffeine, alcohol
-Environmental stressors:
extremes of heat, cold,
humidity, air pollution
Consider terminating
exercise: Absolute
Indications:
-Drop in systolic BP >10 mm
Hg with increased workload

-Moderate to severe angina

- nervous system symptoms
(ataxia, dizziness, near
syncope)
-Signs of poor perfusion
-Technical difficulties in
monitoring EKG or BP
-Subjects desire to stop
-Sustained VT
-ST elevation > or equal to
1.0 mm
Relative Indications to
terminate exercise:
-ST or QRS changes
(excessive ST depression) or
marked axial shift
-Arrhythmias other than
sustained VT (multifocal
PVCs, triplets, SVT, heart
block, bradyarrhythmaias)
-Fatigue, SOB, wheezing, leg
cramps or claudication
-Development of bundle
branch block that cant be
distinguished from VT
-Increasing chest pain
-Hypertensive response (SBP
>250 mmHg or DBP >115
mmHg)
Exercise prescription for post-PTCA (percutaneous transluminal coronary angioplasty):
1. Wait to exercise vigorously approximately 2 weeks post-PTCA to allow inflammatory process to subside.
Walking program can be initiated immediately.

2. Use post-PTCA ETT to prescribe exercise.

Exercise prescription post-CABG (coronary artery bypass graft):
1. Limit upper extremity exercise while sternal incision is healing
2. Avoid lifting, pushing, pulling for 4-6 weeks postsurgery
_____________________________________________________________________________________
Phase 1: Inpatient Cardiac Rehabilitation (Acute)
Length of hospital stay is commonly 3-5 days for uncomplicated MI (no persistent angina, malignant arrhythmias, or
heart failure)
1. Exercise/activity goals out outcomes
-Initiate early return to independence in ADLs, typically after 24 hours or until the patient is stable for
24 hours; monitor activity tolerance
-Counteract deleterious effects of bed rest: reduce risk of thrombi, maintain muscle tone, reduce
orthostatic hypotension, and maintain joint mobility
-Help allay anxiety and depression
-Provide medical surveillance
-Provide pt & fam education
-Promote risk factor modification
2. Exercise/activity guidelines:
-Program components: ADLs, selected arm and leg exercises, early supervised ambulation
-Initial activities: low intensity (2-3 METs) progressing to > or equal to 5 METs by discharge.
-Post-MI: limited to 70% max HR and/or 5 METs until 6 weeks post-MI.
-Short exercise sessions, 2-3 times a day; gradually duration is lengthened and frequency is decreased.
Post surgical pts:
-Typically are progressed more rapidly than post MI, unless there was a peri-operative MI.
-Lifting activities are restricted, generally for 6 weeks.
Patient and family education goals:
-Improve understanding of cardiac disease, support risk factor modification

-Teach self-monitoring procedures, warning signs of exertional intolerance; (persistent dyspnea, angina
pain, dizziness)
-Teach concepts of energy costs, fatigue monitoring, general activity guidelines, activity pacing, energy
conservation techniques; home exercise program
-Provide emotional support and assist with referral to social work as needed
Home Exercise Program (HEP):
-Low risk pts may be safe candidates for unsupervised exercise at home
-Gradual increase in ambulation time: goal of 20-30 minutes, 1-2 times per day at 4-6 weeks post MI.
-Upper and lower extremity mobility exercises.
-Elderly homebound pts with multiple medical problems may benefit from a home cardiac rehab program.
-Pts should be skilled in self-monitoring procedures.
-Recommended family training in CPR, and AED as indicated; emergency lifeline for some pts.
Phase 2: Outpatient Cardiac Rehabilitation (Subacute):
1. Eligible patients
-MI/acute coronary syndrome
-CABG
-PCI
-Stable angina
-Heart valve surgical repair or replacements
-Heart or heart/lung transplantation
-Heart failure and PAD: not covered by insurance but these populations benefit from supervised exercise
program

2. Exercise/activity goals and outcomes:

-Improve functional capacity
-Progress towards full resumption of activities of daily living, habitual and occupational activities.
-Promote risk-factor modification, counseling as to lifestyle changes.
-Encourage activity pacing, energy conservation; stress importance of taking proper rest periods
3. Exercise/activity guidelines:

Outpatient Program :
-Pts at risk for arrhythmias with exercise, angina, other medical problems benefit from outpatient programs with
availability of EKG monitoring, trained personnel and emergency support.
-Group camaraderie and support of program participants may assist in risk-factor modification and lifestyle changes
-Frequency: 2-3 sessions/week
-Duration: 30-60 minutes with 5-10 minutes of warm-up and cool down
-Programs may offer a single mode of training (walking) or multiple modes using a circuit training approach
(treadmill, cycle ergometer, arm ergometer); strength training.
-Pts are gradually weaned from continuous monitoring to spot checks and self-monitoring.
-Suggested exit point: 9 MET functional capacity (5 MET capacity is needed for safe resumption of most daily
activities)
Strength training in Phase 2 programs:
-Guidelines: after 3 weeks cardiac rehab; 5 weeks post MI or 8 weeks post CABG.
-Begin with use of elastic bands and light hand weights (1-3 lbs)
-Progress to moderate loads, 12-15 comfortable repetitions.
Phase 3: Community Exercise Programs (Post-acute, Postdischarge from Phase 2)
1. Exercise/activity goals and outcomes:
-Improve and/or maintain functional capacity
-Promote self-regulation of exercise programs
-Promote life-long commitment to risk-factor modification
2. Exercise/Activity guideliens:
-Location: community centers, YMCA, or clinical facilities
-Entry level criteria: functional capacity of 5 METs, clinically stable angina, medically controlled arrhythmias during
exercise
-Progression is from supervised to self-regulation of exercise
-Progression to 50%-85% of functional capacity, 3-4 times/week, 45 minutes or more/session.
-Regular medical check-ups and periodic ETT generally required
-Utilize motivational techniques to maintain compliance with exercise programs, life-style modifications
-Discharge typically in 6-12 months.
Clinical indications for

inpatient & outpatient

cardiac rehab:
-Medically stable post MI
-Stable angina pectoris
-PTCA
-CABG
-Compensated heart
failure
-Cardiomyopathy
-Heart transplant
-Other cardiac surgery
(valve repair, pacemaker)
-Peripheral arterial
disease
-High risk for coronary
artery disease with
diagnosis of DM,
dyslipidemia, HTN, or
obesity
-End-stage renal disease
Clinical
Contraindications for
inpatient & outpatient
cardiac rehab:
-Unstable angina
-Resting SBP >200 mm Hg
or resting DBP >110 mm
Hg
-Orthostatic blood
pressure drop of >20 mm
Hg with symptoms
-Critical aortic stenosis
-Acute systemic illness or
fever

-Uncontrolled
atrial/ventricular
arrhythmias
-Third-degree atrial
ventricular block without
pacemaker
-Active pericarditis or
myocarditis
-Recent embolism
-Thrombophlebitis
-Resting ST segment
depression or elevation
>2 mm
-Uncompensated
congestive heart failure
-Orthopedic or metabolic
conditions that would
prohibit exercise

Resistance Exercise Training:

Goals: Improve muscle strength and endurance; enhance functional independence; decrease cardiac demands
during daily activities
Patient criteria for resistance training:
-Post MI: resistance training permitted if remain under 70% max HR or 5 METs for 6 weeks post MI, be cautious of
Valsalva with resistance training
-Cardiac surgery: LE resistance training can be initiated immediately, in the absence of peri-operative MI. UE
resistance training should be avoided until soft tissue and bony healing has occurred: 6-8 weeks.
-Post-transcatheter procedure (PTCA, other): minimum of 3 weeks following procedure and 2 weeks of consistent
participation in a supervised CR endurance training program.
-No evidence of the following conditions: congestive heart failure, uncontrolled dysrhythmias, severe valvular
disease, uncontrolled hypertension and unstable symptoms.

Exercise Prescription:
-Start with low resistance (one set of 10-15 reps) and progress slowly
-Resistance can include:
-Weights, 50% or more of maximum weight used to complete one repetitition (1RM)
-Elastic bands
-Light (1-5 lb) cuff and hand weights
-Wall pulleys
-Perceived exertion (RPE-Borg scale) should range from 11 to 13 (light to somewhat hard), but this needs to
be correlated to hemodynamic response to activity.
-Rate pressure product should not exceed that prescribed during endurance exercise
Rehab Guidelines for Arterial Disease:
1. Risk factor modification
2. Limb protection
a. Avoid excessive strain, protection of extremities from injury and extremes of temperature
b. Bed rest may be required if gangrene, ulceration, acute arterial disease are present
3. Exercise Training for pts with PAD:
a. May result in improved functional capacity, improved peripheral blood flow via collateral circulation and
muscle oxidative capacity.
b. Consider interval training with frequent rests
c. Walking program: intensity such that pt reports 1 on claudication scale within 3-5 minutes, stopping if
they reach a 2 (until pain subsides), total of 30-60 minutes (intervals as necessary), 3-5 days per week.
d. Record time of pain onset and duration
e. Non-weight bearing exercise (cycle ergometry, arm ergometry) may be necessary in some pts; less
effective in producing a peripheral conditioning effect.
f. Well-fitting shoes essential; with insensitive feet, teach techniques of proper foot inspection and care.
g. Beta blockers for treatment of HTN or cardiac disorders may decrease time to claudication or worsen
symptoms.
h. Pentoxifylline, dipyridamole, aspirin and warfarin may improve time to claudication.
i. High risk for CAD.
4. Lower extremity exercise:
a. Modified Buerger-Allen exercises: postural exercises plus active plantar and dorsiflexion of the ankle;
active exercises improve blood flow during and after exercise; effects less pronounced in pts with PAD.
b. Resistive calf exercises: most effective method of increasing blood flow.
5. Medical treatment:

a. Medications to decrease blood viscosity, prevent thrombus formation (heparin)

b. Vasodilators: controversial
c. Calcium channel blockers in vasospastic disease
6. Surgical management:
a. Atherectomy, thromboembolectomy, laser therapy
b. Revascularization: angioplasty or bypass grafting
c. Sympathectomy: results in permanent vasodilation, improvement in blood flow to skin
d. Amputation when gangrene is present
_____________________________________________________________________________________
Rehab Guidelines for Venous Disease:
1. Deep vein thrombophlebitis (DVT):
a. Early stages may be asymptomatic; symptomatic pts demonstrate dull ache, pain, tenderness in calf;
may also see slight edema or fever.
b. Acute: activity limited until a dose of low molecular weight heparin, then ambulation permitted.
Compression stockings (>30-40 mm Hg) can assist with pain control
c. Anticoagulation medications
2. Chronic venous insufficiency (CVI)
a. Management of edema:
i. Positioning: extremity elevation, minimum of 18 cm above heart. Encourage pts to elevate leg as
much as possible and avoid the dependent position
b. Compression therapy
i. Bandages (elastic, tubular); applied within 20 minutes of rising
ii. Paste bandages (Unna boot). Gauze impregnated with zinc oxide, gelatin and glycerine; applied
for 4-7 days (less with some wounds)
iii. Graduated compression stockings (Jobst), at least 30 mm Hg
iv. Compression pump therapy, used for a 1-2 hour session twice daily
v. Red flag: consider consequences of compression therapy to a limb with an ankle-brachial index
(ABI) <0.8 or with evidence of active cellulitis or infection
3. Exercise
a. Active ankle exercises: emphasis on muscle pump exercises (dorsiflexion/planatarflexion, foot circles)
b. Cycle ergometry in sitting or attached to foot of bed
c. Early ambulation as soon as pt is able to get out of bed, 3-4 times a day.

Patient education: meticulous skin care

Severe conditions with dermal ulceration may require surgery (ligation and vein stripping, vein grafts,
valvuloplasty.
_____________________________________________________________________________________
Rehab Guidelines for lymphatic Disease:
1. Phase 1 Management: edema secondary to lymphatic dysfunction
a. Short stretch compression bandages, worn 24 hours/day
b. Manual lymph drainage (MLD) with complete decongestive therapy
i. Massage and passive ROM to assist lymphatic flow (Vodder techniques, modifications by Askonk.
Leduc, Fodi)
ii. Emphasis is on decongesting proximal segments first (trunk quadrant), then extremities,
directing flow distal to proximal
iii. Compression using multilayered padding and short-stretch bandages
1. Bandages have low resting pressure and high working pressure
2. Bandages maintain limb after techniques applied to reduce limb
3. Decongestive exercises with padding in place. Activate muscles in extremity. Work trunk
and limb girdle first, then limb muscles from proximal to distal. Performed with
compression bandages on.
4. Certified specialists (certified lymphedema therapist)
c. Functional activities:
i. Walking program, cycling
ii. Water-based programs: swimming
iii. Tai chi and balance activities
iv. ADL training
v. RED FLAG: strenuous activities, jogging and ballistic movements are contraindicated, as they
are likely to exacerbate lymphedema.
vi. Signs of lymph overload: discomfort, aching or pain in proximal lymph areas (axilla or inguinal
areas), change in skin color. If any of these are present, discontinue activity.
d. Meticulous skin care: hygiene, nail care.
e. Contraindicated modalities:
i. Ice, heat, hydrotherapy, saunas, contract baths, paraffin; all cause vasodilation and increase
lymphatic load of water

ii. No electrotherapeutic modalities greater than 30 Hz.

f. Compression garments at end of Phase 1.
g. Red flag: excessively high pressures will occlude superficial lymph capillaries and restrict fluid
absorption
2. Phase II Management (self-management)
a. Skin care
b. Compression garments
c. Exercise
d. Lymphedema bandaging at night
e. MLD as needed
f. Compression pumps: use with caution; limited benefits
g. RED FLAG: pressures higher than 45 mm Hg are contraindicated, as they can cause lymphatic
collapse; contraindicated with soft tissue injury
3. Education
a. Skin and nail care
b. Self-bandaging, garment care
c. Infection management
d. Maintain exercise while preventing lymph overload
_____________________________________________________________________________________

Basic Life Support and CardioPulmonary Resuscitation (CPR)

1.
2.
3.
4.
5.
6.

Compressions come first, and then focus on airway and breathing. Only exception is newborn babies.
No more looking, listening, and feeling. Call 911 immediately.
Push a little harder for adult CPR: at least 2 inches deep on chest.
Push a little faster: about 100 compressions/min.
Hands only CPR for untrained lay rescuers.
Dont stop pushing, no interruptions.

First Aid:
1. External bleeding
a. Minor bleeding:
i. Usually clots within 10 minutes

ii. If pt/client is taking aspirin or nonsteroidal anti-inflammatory drugs, clotting may take longer
b. Severe bleeding characteristics:
i. Blood spurting from a wound
ii. Blood fails to clot even after measures to control bleeding have been taken
iii. Arterial bleed: high pressure, spurting, red
iv. Venous bleed: low pressure, stead flow, dark red or maroon blood
v. Capillary bleed: low pressure, oozing, dark red blood
c. Controlling external bleeding:
i. Use standard precautions such as wearing gloves
ii. Apply gauze pads using firm pressure. If no gauze available, use a clean cloth, towel, a gloved
hand or pts own hand. If blood soaks through, do not remove any gauze, add additional layers.
iii. Elevate the part if possible unless it is deformed or it causes significant pain when elevated.
iv. Apply a pressure bandage, such as roller gauze, over the gauze pads.
v. If necessary, apply pressure with the heel of your hand over pressure points. The femoral artery
in the groin and the brachial artery in the medial aspect of the upper arm are two such points.
vi. Monitor A, B, Cs and overall status of the pt. Administer supplemental oxygen if nearby. Seek
more advanced care as necessary
2. Internal bleeding:
a. The possible result of a fall, blunt force trauma or a fx rupturing a blood vessel or organ.
b. Severe internal bleeding may be life-threatening
c. Severe internal bleeding characteristics:
i. Ecchymosis (black and blue) in the injured area
ii. Body part, especially the abdomen, may be swollen, tender, and firm
iii. Skin may appear blue, gray or pale and may be cool or moist
iv. Respiratory rate in increased
v. Pulse rate is increased and weak
vi. Blood pressure is decreased
vii. Pt may be nauseated or vomit
viii. Pt may exhibit restlessness or anxiety
ix. Level of consciousness may decline
d. Management of internal bleeding
i. If minor, follow RICE procedure
ii. Major internal bleeding
1. Summon advanced medical personnel
2. Monitor A, B, Cs and vital signs
3. Keep the pt comfortable and quiet. Keep them from getting chilled or overheated.

4. Reassure pt or victim
5. Administer supplemental oxygen if available and nearby
3. Shock (hypo-perfusion)
a. Failure of the circulatory system to perfuse vital organs
b. At first, blood is shunted from the periphery to compensate
i. The victim may lose consciousness as the brain is affected
ii. The heart rate increases, resulting in increased oxygen demand
iii. Organs ultimately fail when deprived of oxygen
iv. Heart rhythm is affected, ultimately leading to cardiac arrest and death
c. Types and causes of shock:
i. Hemorrhagic: severe internal or external bleeding.
ii. Psychogenic: emotional stress causes blood to pool in body away from the brain
iii. Metabolic: loss of body fluids from heat or severe vomiting or diarrhea
iv. Anaphylactic: allergic reaction from drugs, food or insect stings
v. Cardiogenic: MI or cardiac arrest results in pump failure
vi. Respiratory: respiratory illness or arrest results in insufficient oxygenation of the blood
vii. Septic: severe infections cause blood vessels to dilate
viii. Neurogenic: traumatic brain injury, spinal cord injury or other neural trauma causes disruption of
blood vessel dilation/constriction
d. Signs and symptoms:
i. Pale, gray or blue, cool skin
ii. Increased, weak pulse
iii. Increased respiratory rate
iv. Decreased blood pressure
v. Irritability or restlessness
vi. Diminishing level of consciousness
vii. Nausea or vomiting
e. Care for shock:
i. Obtain a history if possible
ii. Examine the victim for airway, breathing, and circulation and bleeding
iii. Assess level of consciousness
iv. Determine skin characteristics and perform capillary refill test of finger tips
1. Capillary refill test: squeeze fingernail for 2 seconds
2. In healthy individuals, the nail will blanch and turn pink when pressure is released
3. If nail bed does not refill and turn pink within 2 seconds, the cause could be that blood is
being shunted away from the periphery to vital organs or to maintain core temperature.

4. Treat any specific condition if possible: control bleeding, splint a fx, Epipen for anaphylaxis
and so on.
5. Keep the victim form getting chilled or over heated
6. Elevate the legs 12 inches unless there is suspected spinal injury or painful deformities of
the lower extremities
7. Reassure the victim and continue to monitor A, B, Cs
8. Administer supplemental oxygen if nearby
9. Do not give any food or drink

Bronchial Drainage
Upper lobes Apical segments
Bed or drainage table flat
Pt leans back on pillow at 30-degree angle against therapist.
Therapist claps with markedly cupped hand over area between the clavicle and top of
the scapula on each side.
Upper lobes posterior segments
Bed or drainage table flat
Pt leans over folded pillow at 30 degrees angle
Therapist stands behind and claps over upper back on both sides
Upper lobes anterior segments
Bed or drainage table flat
Pt lies on back with pillows under knees
Therapist claps between clavicle and nipple on each side
Left Upper lobe Lingular Segments
Foot of table or bed elevated 16 inches
Pt lies head down on right side and rotates turn backward. Pillow may be placed from
behind shoulder to hip. Knees should be flexed
Therapist claps with cupped hands over left nipple area
Right Middle Lobe
Foot of table or bed elevated 16 inches
Pt lies head down on left side and rotates turn backward. Pillow may be placed
behind from shoulder to hip. Knees should be flexed

Therapist claps over right nipple area

Lower Lobe anterior basal segment
Foot of table or bed elevated 20 inches
Pt lies on side head down, pillow under knees
Therapist claps with cupped hands over lower ribs.
Draining left lie on right, Draining right Lie on left
Lower lobes Posterior Basal segments
Foot of table or bed elevated 20 inches
Pt lies on abdomen, head down with pillow under hips.
Therapist claps over lower ribs close to spine on each side
Lower Lobes Superior Segments
Babe or table flat
Pt lies on abdomen with two pillows under hips
Therapist claps over middle of back at tip of scapula on either side of spine
Lower Lobes Lateral basal segments
Foot of table or bed elevated 20 inches
Pt lies on abdomen, head down and rotates turn upward. Upper leg is flexed over
pillow for support.
Therapist claps over uppermost portion of lower ribs
Drainage of left lie on right, Drainage of right lie on left.
Airway clearance techniques
Cough: Pt should be asked to cough in the upright position, if possible, after each area of lung
has been treated.
Huffing: more effective in Pt with collapsible airways. Prevents the high intrathoracic pressure
that causes premature airway closure.
Ask pt to inhale deeply
Immediately, the pt forcibly expels the air, saying ha, ha
Assisted cough: the therapist hands or fist become the force behind the pt exhaled air. Used
when the pts abdominal muscles cannot generate an effective cough.
Position the Pt against a solid surface; supine with head of bed or table flat or in a
Trendelenburg position, or sitting with wheelchair against the wall.
The therapists hand is placed below the pts subcostal angle
Pt inhales deeply

As the pt attempts to cough, the therapist hand pushes inward and upward, assisting
the rapid exhalation of air.
Any secretions raised should be removed by a suction catheter if expectoration is
problematic
Tracheal stimulation: used with pts who are unable to cough on command.
The therapist finger or thumb is placed just above the substernal notch, and a quick
inward and downward pressure on the trachea elicits the cough reflex.
Endotrachel suctioning: used only when the above airway clearance techniques fail to
adequately remove secretions. (10-15 seconds)

Airway Clearance Techniques:

Airway clearance techniques are intended to manage or prevent the consequences of impaired mucociliary transport
or the inability to protect the airway (impaired cough). The techniques may include breathing strategies, manual and
mechanical techniques, and postural drainage.
Indications for Airway Clearance:
-Restrained secretions in the central airways
-Prophylaxis against postoperative pulmonary complications
-Obtain sputum for diagnostic analysis
-Difficulty clearing secretions
-Atelectasics caused by or suspected of being caused of mucus plugging
Technique:
Active Cycle of
Breathing (ACB)

What is it:

Procedure:

ACB was developed

under the name
forced expiratory
technique to assist
secretion clearance in
pts with asthma. The
name of the technique
was changed to
active cycle of

Breathing control:
Gentle, relaxed
breathing (may be
diaphragmatic
breathing at pts tidal
volume and resting
respiratory rate for 510 seconds, or as long
as the pt needs in

Precautions/Contra
indications:
-Splinting postoperative incisions to
achieve adequate
expiratory force
-Bronchospasm or
hyper-reactive
airways

breathing to
emphasize that ACB
always couples
breathing exercise with
the huff cough. It
includes 3 phases:
breathing control,
thoracic expansion
exercises, and forced
expiratory technique.

Autogenic
Drainage (AD)

AD uses controlled
breathing to mobilize
secretions by varying
expiratory airflow
without using postural
drainage positions or
coughing. The theory
is to improve airflow in
small airways to
facilitate the
movement of mucus.
AD requires patience

order to prepare for

the next phase.
Thoracic
expansion exercise:
3-4 deep, slow,
relaxed inhalations to
inspiratory reserve
with passive
exhalation Chest
percussion, vibration
or shaking may be
combined with
exhalation
Forced expiratory
technique:
1 or 2 huffs at mid to
low lung volumes with
the glottis open into
the expiratory reserve
volume; a brisk
adduction of the
upper arms may be
added to selfcompress the thorax
The pt is sitting
upright in a chair with
back support.
Controlled breathing
at three lung
volumes:
-Unsticking
phase: slowly
breathe in through
nose at low-lung
volumes followed by a
2-3 second breath-

Requires motivation
and concentration to
learn

to learn, so this may

not be suitable for
young children and pts
who are not motivated
or easily distracted.
Because AD does not
require the assistance
of another person or
equipment, it can be
performed anywhere
and during activities of
daily living.

Directed cough
and huffing

A directed cough tries

to compensate for the
pts physical limitations
to elicit a maximum
forced exhalation.
Huffing is a forced
expiratory maneuver
performed with the
glottis open. The
maneuver is similar to

hold to allow
collateral ventilation
to get air behind the
secretions, then
exhale down into the
expiratory reserve
volume.
-Collecting
phase:breath at
tidal volume,
interspersed by 2-3
second breath holds
-Evacuating
phase: deeper
inspirations from lowto-mid inspiratory
reserve volume, with
breath holding
followed by a huff
Exhalation through
pursed-lips may be
used to control
expiratory flow rate
-An average
treatment is 30-45
min
Cough: Inhale
maximally , close the
glottis and hold
breath for 2-3
seconds; contract the
expiratory muscles to
produce increased
intrathoracic pressure
against the closed
glottis; cough sharply

-Inability to control
possible transmission
of infection from pts
suspected or known
to have pathogens
transmittable by
droplets
-Elevated intracranial
pressure or known
intracranial

fogging a pair of
glasses with your
breath. Although a huff
does not produce the
same airflow velocity
as a cough, the
potential for airway
collapse is less.
Huffing may be
reinforced by a quick
adduction of the arms
to self-compress the
chest wall.

2-3 times through a

slightly open mouth;
post-surgical pts may
need to splint the
chest or abdomen by
applying pressure
over the incision with
a pillow or blanket
roll.
Huff: Inhale deeply
through an open
mouth; contract the
abdominal muscles
during a rapid
exhalation with the
glottis open, saying,
Ha, ha, ha.

High-frequency
airway oscillation

The Acapella & Flutter

are handheld devices
that combine positive
expiratory pressure
and high frequency
airway vibrations to
mobilize mucus
secretions in the
airways

Postural

Postural drainage

-Place the device in

the mouth the lips
firmly sealed around
the mouthpiece
-Inhale slowly to 75%
of a full breath
-Hold the breath for 23 seconds
-Exhale through the
device for 3-4
seconds
-Repeat 10-20 breaths
-Remove the device
and perform 2-3
coughs or huffs to
raise secretions
Postural drainage:

aneurysm
-Reduced coronary
artery perfusion
(acute MI)
-Acute unstable
head, neck or spine
injury
-Potential for
regurgitation/aspirati
on
-Acute abdominal
pathology, abdominal
aortic aneurysm,
hiatal hernia or
pregnancy
-Untreated
pneumothroax
-Osteoporosis
-Flail chest
-Pt tolerance of
increased work of
breathing (acute
asthma, COPD)
-Intracranial pressure
>20 mm Hg
-Recent facial, oral,
or skull surgery or
trauma
-hemodynamic
instability
-Acute sinusitis
-Nosebleed
-Esophageal surgery
-Active hemoptysis
-Nausea
All positions are

drainage,
percussion, and
vibration

consists of positioning
the pt so that gravity
will help drain
bronchial secretions
from specific lung
segments toward the
central airways where
they can be removed
by cough or
mechanical aspiration.
Percussion, also known
as cupping & clapping,
is the rhythmic
clapping or striking of
the thorax with a
cupped hand or
mechanical percussor
directly over the lung
segment being
drained. This rhythmic
sequence should last
for several minutes
and should not be
painful.
Vibration is the
application of a fine,
tremulous action on
the chest wall over the
lung segment being
drained in the direction
the ribs move during
exhalation. It may be
performed manually or
with a mechanical
vibrator. Vibration
should be performed

The pt assumes the

appropriate position
for the affected lung
segment. Standard
positions may be
modified as the pts
conditions and
tolerance warrant.
Maintain each
position for 2-3
minutes.
Percussion &
vibration: -Place the
pt in the appropriate
postural drainage
position; cover the
skin overlying the
affected segment with
a thin material (towel,
t-shirt, hospital
gown); therapist
rhythmically strikes
the chest with a
cupped hand for 2-3
minutes per lung
segment; therapist
places one hand on
top of the other over
affected area or one
hand on each side of
the rib cage; vibrate
the chest wall as the
pt exhales by tensing
the muscles of the
hands and arms while
applying moderate

contraindicated
for:
-ICP >20 mm Hg
-Head and neck
injury until stabilized
-Active hemorrhage
with hemodynamic
instability
-Recent spinal
surgery or acute
spinal injury
-Active hemoptysis
-Empyema
-Bronchopleural
fistula
-Pulmonary edema
associated with CHF
-Large pleural
effusion
-Confused or anxious
pts who do not
tolerate position
changes
-Rib fx, with or
without fail chest
-Surgical wound or
healing tissue
Trendelenburg
position is
contraindicated for:
-Uncontrolled HTN
-Distended abdomen
-esophageal surgery
-Recent gross
hemoptysis related
to lung carcinoma

during exhalation.

pressure downward;
the maneuver is
performed in the
direction in which the
ribs move on
expiration; encourage
the pt to cough or
huff after 2-3
vibrations

-Uncontrolled airway
at risk for aspiration )
tube feeding or
recent meal)
-Subcutaneous
emphysema
-Recent epidural
spinal infusion or
spinal anesthesia
-Recent skingrafts, or
flaps on the thorax
-Burns, open wounds,
and skin infections
-Recently placed
transvenous or
subcutaneous
pacemaker
-Suspected
pulmonary
tuberculosis
-Lung contusion
-Bronchospasm
-Osteomyelitis of the
ribs
-Osteoporosis
-Complaint of chest
wall pain

Breathing Exercises:
Exercise
Diaphragmatic

Indications
-Post surgical

Precautions/C
ontra
-Moderate to

Procedure
-Semi-fowlers

Expected
Outcomes
-Decreased

Breathing
(DB): involves
breathing
predominately
with the
diaphragm
while
minimizing the
action of
accessory
muscles and
motion of the
upper rib cage
during
inspiration

pt with pain in
the chest wall
or abdomen,
or restricted
mobility
-Pt learning
active cycle of
breathing or
autogenic
drainage
airway
clearance
techniques
-Dysnpea at
rest or with
minimal
activity
-Inability to
perform ADLs
due to
dyspnea or
inefficient
breathing
pattern

severe COPD &

marked
hyperinflation
of the lungs
with
diaphragmatic
movement
-Pts with
paradoxical
breathing
patterns or who
demonstrate
increased
inspiratory
muscle effort,
and increased
dyspnea during
DB

positions is a
good starting
position
-Sniffing can
be used to
facilitate
contraction of
the diaphragm
-Have the pt
place one
hand on the
upper chest
and the other
just below the
rib cage
-Instruct the pt
to:
Breathe in
slowly through
your nose so
that your
stomach
moves out
against your
hand. The
hand on your
chest should
remain as still
as possible.
Feel your
abdomen
gently rise into
your hand.
Exhale through
pursed lips, let
the hand on

respiratory
rate
-Decrease use
of accessory
muscles of
inspiration
-increase tidal
volume
-Decrease
respiratory
flow rate
-Subjective
improvement
of dyspnea
-Improve
tolerance for
activity

Inspiratory
Muscle
training (IMT):
attempts to
strengthen the
diaphragm and
intercostals
muscles. Two
different IMT
devices
provide
different
modes of
training: flow
resistive
breathing and
threshold
breathing.
During flow
resistive
breathing, the
pt inspires
through a
mouthpiece
and adapter
with an
adjustable
diameter.
Decreasing the
diameter

Impaired
inspiratory
muscle
strength
and/or a
ventilatory
limitation to
exercise
performance

-Clincal signs of
inspiratory
muscle fatigue
-Tachypnea
-Reduced tidal
volume
-Increased
PaCO2
-Bradypnea and
decreased
minute
ventilation

your abdomen
descend, while
the hand on
your upper
chest remains
still.
Measure the
pts maximum
inspiratory
pressure (MIP)
with a
manometer.
Use the
measured MIP
to calculate
the training
load. Using the
threshold
inspiratory
muscle trainer:
Place
mouthpiece in
mouth and
inhale with
enough force
to open the
valve, the
higher the
setting the
greater the
effort needed,
begin training
with the
setting that
elicits 30% to
40% of the pts

-Increased
inspiratory
muscle
strength and
endurance;
decrease
dysnpea at
rest and
during
exercise;
increase
functional
exercise
capacity

increases the
resistance to
breathing,
provided that
breathing rate,
tidal volume,
and inspiratory
time are kept
constant.
Threshold
loading
requires a
buildup of
negative
pressure
before flow
occurs through
a valve that
opens at a
critical
pressure.
Threshold
breathing
provides
consistent and
specific
pressure for
IMT, regardless
of how quickly
or slowly pts
breathe.
Paced
breathing and
exhale with
effort: Paced
breathing is a

MIP. Pt
breathes at
tidal volume
for 5-15 min.
Using the
PFLEX
Inspiratory
muscle trainer:
Place PFLEX in
mouth and
breath at tidal
volume,
setting 1
provides the
least
resistance,
begin training
that elicits 3040% level MIP
for 10-15 min
daily.

-Pts with
dysnpea at
rest or with
minimal
activity

Avoid valsalva
maneuver
during activity

Perform
activity at a
tempo that
does not
exceed the pts

Complete
activity
without
dyspnea;
decrease pts

strategy to
decrease the
work of
breathing and
prevent
dyspnea
during activity.
It allows
anyone who
experiences
shortness of
breath to
become less
fearful of
activity and
exercise.
Exhale with
effort is a
breathing
strategy
employed
during activity
to prevent a pt
from holding
their breath.
The technique
breaks any
activity into
one or more
breaths with
inhalation
during the
resting or less
active phase
of the activity
and exhalation

-Inability to
perform
activity due to
pulmonary
limitation
-Inefficient
breathing
pattern during
activity

breathing
limitations;
find a
comfortable
inspiration to
expiration time
to synchronize
with the
exertion phase
of activity;
synchronize
breathing with
components of
the activity:
inhale before
or during the
easier
component of
the activity,
exhale during
the more
vigorous
component of
the activity, do
not hold
breath or rush
through the
activity.
Walking:
Inhale through
the nose while
walking 2
steps and then
pause; exhale
through
pursed lips

fear of
becoming
short of breath
during activity

during the
movement or
more active
phase of the
activity.

Pursed-lip

Tachypnea,

Forcing

while walking
4 steps.
Climbing
stairs: inhale
through the
nose while
standing,
exhale through
pursed lips
while stepping
up (or down) 1
or 2 stairs,
remain on the
step until
breathing
control is
restored
Lifting: inhale
through the
nose while
standing or
sitting; exhale
through
pursed lips
while bending
to reach the
object; pause;
inhale through
the nose while
grabbing the
object; exhale
through
pursed lips
while standing
up
Semi-fowlers is

-Decrease

breathing
(PLB) is a
simple
technique to
reduce
respiratory
rate, reduce
dyspnea, and
maintain a
small positive
pressure in the
bronchioles,
which may
help prevent
airway
collapse in pts
with
emphysema.
Any pt who is
SOB may use
this technique.

dysnpea

exhalation

Segmental
breathing: also
known as
localized
breathing or
thoracic
expansion
exercises, is
intended to
improve

-Decreased
intrathoracic
lung volume,
decreased
chest wall lung
compliance,
increased flow
resistance
from
decreased

None

a good
position to
initiate the
breathing
technique.
Instruct the pt
to: breathe in
slowly through
your nose with
the mouth
closed for two
counts.
Pucker, or
purse your lips
as if you were
going to
whistle, then
gently breathe
out through
pursed lips, as
if trying to
make a candle
flame flicker,
for a 4 count.
Do not blow
with force.
Position the pt:
-sitting
position for
basal
atelectasis
-sidelying with
affected lung
uppermost
-Postural
drainage

respiratory
rate, relieve
dyspnea,
reduce arterial
partial
pressure of
carbon
dioxide,
improve tidal
volume,
improve
oxygen
saturation,
prevent airway
collapse in pts
with
emphysema,
increase
activity
tolerance

-Increase chest
wall mobility
-Expand
collapsed
alveoli via
airflow through
collateral
ventilation
channels
-assist with

regional
ventilation and
prevent and
treat
pulmonary
complications
after surgery.
It is based on
the
presumption
that
asymmetrical
chest wall
motion may
coincide with
underlying
pathology
(pneumonia,
pleuritic chest
wall pain,
retained
secretions)
and that
inspired air
can be
directed to a
particular area
by facilitation
or inhibition of
chest wall
movement
through proper
hand
placements,
verbal cues or
coordination of

lung volume,
ventilation:
perfusion
mismatch

positions with
affected lung
uppermost to
assist with
secretion
removal
-Therapist
applies firm
pressure at the
end of
exhalation to
the pts chest
wall overlying
the area to be
expanded
-pt inhales
deeply and
slowly
expanding the
rib cage under
the therapist
hands
-Therapist
reduces hand
pressure
during the pts
inhalation

secretion
removal

breathing.
Sustained
maximal
inhalation with
incentive
spirometer:
(SMI), a
maximal
inspiratory
effort is held
for 3 or more
seconds at the
point of
maximum
inspiration
before
exhalation.
Many airway
clearance
techniques
include SMI to
compensate
for
asynchronous
ventilation, to
promote air
passage past
mucus
obstructions in
airways, and
to maximize
alveolar
expansion. SMI
is also called
incentive
spirometry

-Decreased
intrathoracic
lung volume
-Decreased
chest wall lung
compliance
-Increased flow
resistance
from
decreased
lung volume
-ventilation:
perfusion (V:Q)
mismatch
-Atelectasis or
risk of
atelectasis due
to thoracic and
upper
abdominal
surgery
-Restrictive
lung defect
associated
with
quadriplegia
and/or
dysfunctional
diaphragm

-Pt is not
cooperative or
is unable to
understand or
demonstrate
proper use of
the incentive
spirometer
-Pt is unable to
deep breathe
effectively (with
vital capacity
less than 10
mL/Kg or
inspiratory
capacity less
than 1/3 of
predicted)
-Pts with
moderate to
severe COPD
with increased
respiratory rate
and
hyperinflation

-Hold the
incentive
spirometer in a
vertical
position
-Have the pt
exhale
completely,
then seal his
lips around the
mouthpiece
-breath in
slowly and
deeply through
the mouth,
raising the ball
or piston of
the spirometer
-Encourage
the pt move
the diaphragm
and expand
the lower
chest, not the
upper chest
-Hold the
breath for at
least 3
seconds and
note the
highest level
the piston
reaches
-Perform SMI
independently

-Absence of or
improve
improvement
in signs of
atelectaiss
-Decreased
respiratory
rate
-Resolution of
fever
-Normal pulse
rate
-Normal chest
x-ray
-Improved
paO2
-Increased
forced vital
capacity and
peak
expiratory
flows

when using a
5-10 breaths
device that
per hour when
provides visual
awake
or other
feedback to
encourage the
pt to take long,
slow, deep
inhalations.
o Abdominal Breathing
Used when abdominal muscles are too weak to provide an effective cough. Abdominal
splinting: used when the abdominal muscles cannot provide the necessary support needed for
passive exhalation.
Glossopharyngeal breathing (air gulping) can also be taught to assist coughing.
Positions to relieve Dyspnea:
A number of positions may be used to provide relief from dyspnea. The choice of position will depend on the
circumstances at the time. The forward leaning position often provides relief of dyspnea to pts with lung disease.
Forward leaning with arm support optimizes the length-tension relationship of the diaphragm and allows the
pectorals minor and pectoralis major muscles to assist in elevating the rib cage during inspiration. The positions may
be combined with other breathing techniques.
Reverse Trendelenburg position:
The opposite of the Trendelenburg position, the reverse Trendelenburg position places a person in supine with their
head above their trunk and lower extremities, decreasing the weight of the abdominal contents on the diaphragm
and reducing the resistance to movement during breathing.
Semi-Fowlers position:
The semi-fowlers position places a pt in supine with the head of the bed elevated to 45 and pillows under the
knees for support and maintenance of a proper lumbar curve. This position is used often for pts with congestive
heart failure or other cardiac conditions.

Musculoskeletal SystemPhysical Therapy Examination

1. Anatomy and Physiology of the MS System

Muscle
Deltoid--Clavicular part
Acromial part
Spinal part

Origin
Lateral clavicle
Acromion
Scapular spine

Insertion
Humerus
(deltoid
tuberosity)

Supraspinatu
s
Infraspinatus

Supraspinous
fossa
Infraspinous
fossa
Lateral border

Greater
tuberosity
Greater
tuberosity
Greater
tuberosity
Lesser
tuberosity
Humerus (crest
of greater
tuberosity)

Teres Minor
Subscapulari
s
Pectoralis
Major-Clavicular part
Sternocostal
part
Abdominal part

Subscapular
fossa
Clavicle
Sternum and
costal
cartilages 1-6
Rectus sheath

Coracobrachi
alis
Pectoralis
Minor

Coracoid
process
3rd to 5th ribs

Humerus
Coracoid
process

Action
Flexion, IR,
ADD
Abduction
Extension, ER,
ABD
Abduction
ER
ER, weak
adduction
IR
Entire muscle:
adduction, IR
Clavicular &
sternocostal
parts:flexion;
assist in
respiration
when shoulder
is fixed
Flexion, ADD,
IR
Draws scapula
downward,
causing
inferior angle
to move
posteromediall
y; rotates
glenoid
inferiorly

Innervation
Axillary n. C5,
C6

Suprascapular
n. C4-C6
Suprascapular
n. C4-C6
Axillary n.
C5,C6
Subscapular n.
C5, C6
Medial &
lateral pectoral
nn. C5-T1

Musculocutane
ous C6, C7
Medial &
lateral pectoral
nn. C6-T1

Serratus
Anterior
Superior part
Intermediate
part
Inferior part

1st to 9th ribs

Scapula
(medial
border)

Trapezius
1.Descending
part
2.Transverse
part
3.Ascending
part

1.Spinous
process C1-C7
2.Spinous
process T1-T4
3.spinous
process T5-T12

1.Clavicle
2.Acromion
3.Scapular
spine

Muscle
Levator
Scapulae

Origin
Transverse
process C1-C4

Insertion
Scapula,
superior angle

Lowers the
raised arm,
draws scapula
laterally
forward;
elevates ribs
when shoulder
is fixed,
rotates scapula
laterally
1.Upward
rotation,
rotates gleniod
superiorly, tilts
head to SAME
side and
rotates to
OPPOSITE
2.Draws
scapula
medially
3.Draws
scapula
medially
downward
Entire
muscle:steadie
s scapula on
thorax

Long thoracic n
C5-C7

Action
Upward
rotation,
inclines neck
to SAME side

Innervation
Dorsal
scapular n. C4C5

Accessory n
(CN XI),
cervical plexus
C3, C4

Rhomboid
minor

Spinous
process C6,C7

Medial border
above scapular
spine

Rhomboid
major

Spinous
process T1-T4
vertebrae

Medial border
below scapular
spine

Latissimus
Dorsi
Veretbral part
Scapular part
Costal part
Iliac part

Spinous
process T7-T12
vertebrae
Scapula:inferio
r angle
9th to 12th ribs
Iliac crest
Scapula
(inferior angle)

Crest of lesser
tuberosity of
the humerus

Teres major
Biceps
brachii
Long head
Short head

Supraglenoid
tubercle of
scapula
Coracoid
process of
scapula

Brachialis

Humerus
(distal half of
anterior
surface)
Scapula
(infraglenoid
tubercle)
Posterior
humerus
(medial

Triceps
brachii
Long head
Medial head
Lateral head

Crest of lesser
tuberosity of
the humerus
Radial
tuberosity

Ulnar
tuberosity
Olecranon of
ulna

Steadies
scapula,
upward
rotation
Steadies
scapula,
upward
rotation
IR, ADD,
extension,
cough
muscle

Dorsal
scapular n. C4C5

IR, ADD,
extension

Lower
subscapular n.
C5-C7
Musculocutane
ous n. C5, C6

Elbow: flexion,
supination
(when elbow
flexed powerful
supinator)
Shoulder:flex,
abd, and IR of
humerus
Flexion of
elbow
Elbow:
extension
Shoulder-long
head:extension
and ADD

Dorsal
scapular n. C4C5
Thoracodorsal
n. C6-C8

Musculo. C5,C6
& radial C7
Radial n. C6-C8

Anconeus

septum)
Posterior
humerus
(lateral
septum)
Lateral
epicondyle of
humerus

Olecranon of
ulna

Extends the
elbow and
tightens joint

Radial n. C6-C8

Insertion
Lateral radius
(distal to
supinator
insertion)

Action
Elbow: weak
flexor
Forearm:
pronation

Innervation
Median n. C6,
C7

Flexor carpi
radialis

Origin
Humeral
head:medial
epicondyle of
humerus
Ulnar head:
coronoid
process
Medial
epicondyle

Base of 2nd
metacarpal

Median n. C6,
C7

Palmaris
Longus

Medial
epicondyle

Palmar
aponeurois

Flexor carpi
ulnaris

Humeral head:
medial
epicondyle
Ulnar head:
olecranon
Humeral head:
medial
epicondyle

Pisiform; hook
of hamate;
base of 5th
metacarpal

Wrist: flexion &

ABD (radial
deviation of
hand)
Elbow: weak
flexion
Wrist: flexion
tightens
palmar
aponeurosis
Wrist: flexion
and ADD (ulnar
deviation)
Elbow: weak
flexor
Wrist: MCP,

Median n. C8,
T1

Muscle
Superfical
Group
Pronator
teres

Intermediate
Group-Flexor

Sides of middle
phalanges of
2nd to 5th digits

Median n. C7,
C8

Ulnar n. C7-T1

digitorum
superficialis
Deep Group-Flexor
digitorum
profundus

Ulnar head:
coronoid
process
Ulna

Distal
phalanges of
2nd to 5th digits
(palmar
surface)
Distal phalanx
of thumb
(palmar
surface)

Flexor
pollicis longs

Radius
(midanterior
surface)

Pronator
quadrates

Distal ulna
(anterior
surface)

Distal radius
(anterior
surface)

Brachioradial
is

Distal humerus

Styloid process
of the radius

Extensor
carpi radialis
longus

Lateral
supracondylar
ridge of distal
humerus

2nd metacarpal
base

Extensor
carpi radialis
brevis

Lateral
epicondyle of
humerus

3rd metacarpal
base

Muscle

Origin

Insertion

and PIP joints

of 2nd to 5th
digits: flexion
Wrist, MCP,
PIP, and DIP of
2nd to 5th digits:
flexion
Wrist: flex, abd
CMC of
thumb:flexion
MCP & IP of
thumb:flexion
Hand:
pronation
Distal
radioulnar
joint:
stabilization
Elbow: flexion
Forearm:
semipronation
Elbow: weak
flexion
Wrist:
extension &
ABD
Elbow: weak
flexion
Wrist:
extension &
ABD

Action

Median n. C8,
T1
Ulanr n. C8, T1
Median n.
C7,C8

Median n. C7,
C8

Radial n. C5,
C6
Radial n. C6,
C7

Radial n. C7,
C8

Innervation

Extensor
digitorum

Lateral
epicondyle

Dorsal digital
expansion of
2nd to 5th digits

Extensor
digiti minimi

Lateral
epicondyle

5th digit

Extensor
carpi ulnaris

Lateral
epicondyle,
ulnar head
Olecranon,
lateral
epicondyle,
annular
ligament
Radius and
ulna

Base of 5th
metacarpal

Extensor
pollicis
brevis

Radius
(posterior
surface)

Base of
proximal
phalanx of
thumb

Extensor
pollicis
longus

Ulna (posterior
surface)

Base of distal
phalanx of
thumb

Supinator

Abductor
pollicis
longus

Wrist:
extension
MCP, PIP, and
DIP of 2nd to 5th
digits:
Extension/ABD
of fingers
Wrist: ext,
ulnar abd of
hand
MCP, PIP, & DIP
of 5th digit: ext
and abd
Wrist: ext, add

Radial n. C7,
C8

Radius

Supination

Radial n. C6,
C7

Base of 1st
metacarpal

Radiocarpal
joint: abd of
hand
Carpometacar
pal joint of
thumb: abd
Radiocarpal
joint: abd
Carpometacar
pal & MCP of
thumb: ext
Wrist: ext, abd
CMC of thumb:
add
MCP & IP of

Radial n C7, C8

Radial n. C7,
C8

Radial n. C7,
C8

Radial n. C7,
C8

Radial n. C7,
C8

Extensor
indicis

Ulna (posterior
surface)

Lumbricals

Tendons of
flexor
digitorum
profundus

Posterior
digital
extension of
2nd digit
2nd-5th digits on
dorsal digital
expansion

Muscle
Iliopsoas
1.Psoas minor
2.Psoas major
3.Iliacus

Origin
1.T12-L1
vertebrae
2.T12-L4 &
associated
vertebral
disks; L1-L5
vertebrae
3.Iliac fossa

Insertion
1.Iliopectineal
arch
2&3. Lesser
trochanter

Gluteus
maximus

Sacrum, ilium

Gluteus
medius

Ilium

Upper
fibers:iliotibial
tract Lower
fibers: gluteal
tuberosity
Greater
trochanter

thumb: ext
Wrist: ext
MCP, PIP, & DIP
of 2nd digit: ext
2nd-5th digits
MCP: flexion
PIP and DIP:
extension

Radial n. C7,
C8
Median n C8,
T1

Action
1.Assists in upward
rotation of the pelvis
2&3:
Hip joint:flex, ER
Lumbar spine:bends
trunk laterally to same
side; contraction raises
the trunk from the
supine position
Entire muscle: ext, ER
of hip in sagittal and
coronal planes
Upper: abd
Lower: add
ABD, stabilizes pelvis
Ant part: flex, IR
Pos part: ext, ER

Innervation
1&2: direct
branches from
the lumbar
plexus (psoas)
L2-L4
3. Femoral n.
L2-L4
Inferior gluteal
n. L5-S2

Superior
gluteal n. L4S1

Gluteus
minimus

Ilium

Greater
trochanter

ABD, stabilizes pelvis

Ant part: flex, IR
Pos part: ext, ER
Tenses the fascia lata
Hip joint: abd, flex, IR

Tensor fasciae
latae

ASIS

Iliotibial tract

Piriformis

Pelvic surface
of sacrum

Greater
trochanter

ER, ABD, ext; stabilizes

hip

Obturator
internus

Inner surface
of obturator
membrane

Medial surface
of greater
trochanter

ER, ADD, and ext

Gemelli

Medial surface
greater
trochanter

ER, ADD, and ext

Quadratus
femoris

Superior:
ischial spine
Inferior: ischial
tuberosity
Ischial
tuberosity

Intertrochanter
ic crest of
femur

ER, ADD of hip

Pectineus

Pecten pubis

Femur

Muscle
Adductor
longus

Origin
Superior pubic
ramus

Insertion
Femur

Adductor
brevis

Inferior pubic
ramus

Femur

Gracilis

Inferior pubic
ramus

Tibia (medial
border of
tuberosity
(SGT)

ADD, ER, & slight

flexion; stabilizes
pelvis
Action
ADD, flex (up to 70
degrees) ext (past 80
degress of flex)
ADD, flex (up to 70
degrees) ext (past 80
degress of flex)
Hip: ADD flex
Knee: flex & IR

Superior
gluteal n. L4S1
Superior
gluteal n. L4S1
Direct
branches from
sacral plexus
S1-S2
Direct
branches from
sacral plexus
L5, S1
Direct
branches from
sacral plexus
L5, S1
Direct
branches from
sacral plexus
L5, S1
Femoral n,
obturator n,
L2, L3
Innervation
Obturator n.
L2-L4
Obturator n.
L2, L3
Obturator n.
L2, L3

Obturator
externus
Adductor
minimus
Adductor
magnus

Outer surface
of obturator
membrane
Inferior pubic
ramus
Inferior pubic
ramus; ischial
tuberosity

Sartorius

ASIS

Rectus femoris

AIIS

Vastus
medialis
Vastus
lateralis
Vastus
intermedius
Biceps femoris

Linea aspera
(medial lip)
Linea aspera
(lateral)
Femoral shaft

Trochanteric
fossa of femur

Hip:ADD & ER;

stabilizes pelvis

Obturator n L3,
L4

Medial lip of
linea aspera
Medial lip of
linea spine;
adductor
tubercle of the
femur
Medial to tibial
tuberosity
Tibial
tuberosity
Both sides of
tuberosity
Both sides of
tuberosity
Tibial
tuberosity
Head of fibula

ADD , EXT, slight

flexion of hip
ADD, EXT, slight
flexion; stabilizes
pelvis

Obturator n.
L2-L4
Obturator L2L4; tibial n. L4

Hip: flex, abd, ER

Knee: flex, IR
Hip: flex
Knee: ext
Knee: ext

Femoral n. L2,
L3
Femoral n. L2L4
Femoral L2-L4

Knee: ext

Femoral L2-L4

Knee: ext

Femoral L2-L4

Hip: extends, stabilizes

pelvis
Knee: flex, ER

Tibial n L5S2/Common
fibular L5-S2

Medial tibial
condyle

Hip: extends, stabilizes

pelvis
Knee: flex, IR
Hip: extends, stabilizes
pelvis
Knee: flex, IR
Talocrural joint:PF
Subtalar:eversion(pron
ation)
Supports transverse
arch of foot
PF; eversion

Tibial n. L5-S2

Semimembran
osus

Iscial
tuberosity;
lateral lip of
linea aspera
Ischial
tuberosity

Semitendinosu
s

Ischial
tuberosity

Medial to tibial
tuberosity

Fibularis
longus

Fibula head

Fibularis

Fibula

Medial
cuneiform
(plantar side);
1st metatarsal
base
5th metatarsal

Tibial L5-S2
Superficial
fibular n. L5,
S1
Superficial

brevis
Tibialis
anterior

Upper 2/3 of
tibia

Extensor
hallucis longus

Fibula-middle
third

base
Medial
cuneiform & 1st
metatarsal
base (plantar
surface)
1st toe at base
of DIP

Extensor
digitorum
longus

Fibula head;
tibia lateral
condyle

2nd to 5th toes

at the base of
DIP

Fibularis
tertius
Gastrocnemuis

Distal fibula

5th metatarsal
base
Calcaneal
tuberosity via
Achilles
Calcaneal
tuberosity via
Achilles
Calcaneal
tuberosity via
Achilles

Soleus

Femur (medial
& lateral
epicondyles)
Fibula head,
tibia

Plantaris

Femur (lateral
epicondyle)

Tibialis
posterior

Adjacent
borders of tibia
& fibula

Flexor
digitorum
longus

Tibia (posterior
surface)

Navicular
tuberosity,
cuneiforms,
2nd-4th
metatarsal
bases
2nd-5th distal
bases

Talocrural: DF
Subtalar: inversion
(supination)
DF, active in
eversion/inversion, ext
of MTP and IP of big
toe
DF, eversion
(pronation); extends
MTP and IP of 2nd-5th
toes
DF, eversion
Talocrural: PF
Knee: flexion

fibular L5, S1
Deep fibular
L4, L5

Deep fibular L5

Deep fibular
L5, S1
Deep fibular
L5, S1
Tibial S1, S2

PF

Tibial S1, S2

Negligible; may
prevent compression
of posterior leg
musculature during
knee flex
PF, inversion
(supination), supports
the longitudinal and
transverse arches

Tibial S1, S2

PF, inversion, MTP and

IP 2nd-5th: PF

Tibial n. L5-S2

Tibial n. L4, L5

Flexor hallucis
longus

Fibula
(posterior
surface)

1st distal base

Popliteus

Lateral femoral
condyle
Zygomatic
arch
Temporal fossa

Posterior tibial
surface
Mandibular
angle
Coronoid
process

Masseter
Temporalis

Lateral
pterygoid

Medial
pterygoid
Sternocleidom
astoid

Longus
Capitis,
Longus Colli,
Rectus Capitis
anterior,
Rectus capitis
lateralis
Scalenes

Sternum
Clavicle

Mastoid
process
Occipital bone

C3-C6, C1-C2,
C5-C7

1st rib, 2nd rib

PF, inversion, MTP and

IP 2nd-5th toes: PF;
supports medial
longitudinal arch
Knee: flexion, IR
(stabilizes knee)
Elevates (adducts) and
protrudes mandible
Elevate (adduct)
mandible
Retract (retrude)
mandible
Unilateral: lateral
movement (chewing)
Bilateral: protrudes
mandible (pulls disk
forward) Unilateral:
lateral movements
(chewing)
Elevates (adducts)
mandible
Unilateral: Tilts head to
same side, rotates
head to opposite side.
Bilateral: extends
head, aids in
respiration
Flexion

Tibial n. L5-S2

Elevates upper ribs,

bends cervical spine to

Direct brances
C3-C8

Tibial n L4-S1
Mandibular (CN
V)
Mandubualr n.
(CN V)

Mandibular N.

Mandibular n.
Accessory (CN
XI)

Rectus capitis
posterior
minor and
major,
Obliquus
capitis inferior
and superior

same side, flexes neck

Extends head, rotates
head to same side

Force Couple- is defined as two forces that act in opposite directions to rotate a segment around its axis of motion.
Ex. Deltoid pulls the humerus up, rotator cuff pulls the humeral head down to allow smooth movement of the
humeral head in the glenoid cavity.
Ex. Trapezius and serratus anterior cause upward rotation of the scapula during arm elevation.
Rhomboids, levator scapulae, and pec minor cause downward rotation with purposeful shoulder extension (chopping
wood)
Ex. Serratus anterior and pec minor result in scapular protraction.
Ex. Rhomboids, middle and lower trap cause scapular retraction.
Ex. Upper trap and levator scap create elevation while pec minor and latissimus dorsi cause depression of the
scapula.
If the muscle is in a shortened position, the overlap of actin and myosin reduces the number of sites available for
cross-bridge formation. Active insufficiency-occurs when the muscle is incapable of shortening to the extent
required to produce full range of motion at all joints crossed simultaneously. Ex: The finger flexors cannot produce a
tight fist when the wrist is fully flexed, as they can when it is in neutral position.
If the muscle is in a lengthened position compared with the optimum length, the actin filaments are pulled away
from the myosin heads such that they cannot create as many cross-bridges.
Passive insufficiency occurs when the two-joint muscle cannot stretch to the extent required for full range of
motion in the opposite direction at all joints crossed. Ex: a larger range of hyperextension is possible at the wrist
when the fingers are not fully extended.

2. MS Tests and Measures

MMT Grades

0 Zero; No evidence of contraction

1 Trace; Slight contraction, no motion
2- Poor minus; Movement through partial test range in gravity eliminated position
2 Poor; Movement through complete test range in gravity eliminated position
2+ Poor plus; Movement through complete test range in gravity eliminated position and through up to one half of
test range against gravity
3- Fair minus; Movement through complete test range in gravity eliminated position and through more than half of
test range against gravity
3 Fair; Movement through complete test range against gravity
3+ Fair plus; Movement through complete test range against gravity and able to hold against minimum resistance
4 Good; Movement through complete test range against gravity and able to hold against moderate resistance
5 Normal; Movement through complete test range against gravity and able to hold against maximum resistance
Normal ROM
Cervical: Flex/Ext/lateral flex/45 degrees; Rotation-60-70
Lumbar: Flex-90; Ext-25; lateral flexion-35; Rotation-45
Shoulder: Flex-180; Ext-60; Abd-180; IR-70; ER-90
Elbow: Flex-150; Ext-0; Pronation/supination-80
Wrist: Flex-80; Ext-70, RD-20; UD-30
1st CMC: Flex-15; Ext-20
MCP Fingers: Flex-90; Ext-45
MCP thumb: Flex-50; Ext-0
PIP: Flex-100; Ext-0
DIP: Flex-90; Ext-0
Hip: Flex-120; Ext-30; Abd-45; Add-30; IR-45; ER-45
Knee: Flex-135; Ext-0-10
Ankle: DF-20; PF-50; Inv-35; Ev-15
1st MTP: Flex-30; Ext-70
Subtalar: Inverstion-5; Eversion-5
End-Feels:
Firm (stretch)-ankle dorsiflexion, finger extension, hip IR, forearm supination, Knee ext
Hard (bone to bone)-elbow extension
Soft (soft tissue approx.)-elbow flexion, knee flexion

Posture:
Ideal plumb line alignment:
-Slightly posterior to coronal suture
-Through external auditory meatus
-Through axis of the odontoid process
-Midway through the tip of the shoulder
-Through the bodies of the lumbar vertebrae
-Slightly posterior to the hip joint
-Slightly anterior to the axis of knee
-Slightly anterior to the lateral malleolus
-Through the calcaneocuboid joint
Mobilizations:
Grade 1-Small amplitude oscillations performed at beginning of range.
Grade 2-Larger amplitude oscillations performed into mid-range of a joint.
Grade 3-Large oscillations performed through the available range of a joint and into the tissue resistance.
Grade 4-Small amplitude oscillations performed into the tissue resistance.
*Grades 1 and 2 maintain joint mobility, relieve pain, and are indicated in the subacute state of joint inflammation or
sprain.
*Grade 3 maintains joint mobility.
* Grade 4 increases joint mobility.
*Grades 3 and 4 are both indicated in more advanced stages of hypomobility or for joint impingement or motion
restrictions. These grades should NOT be used when the joint has inflammation and pain (e.g. with acute
exacerbation with RA)
Types of Fractures:
Avulstion fx-a portion of bone becomes fragmented at the site of tendon attachment due to a traumatic and
sudden stretch of the tendon.
Closed fx-a break in a bone where the skin over the site remains intact
Comminuted fx-a bone that breaks into fragments at the site of injury
Compound fx-a break in a bone that protrudes through the skin
Greenstick fx-a break on one side of a bone that does not damage the periosteum on the opposite side. This type
of fx is often seen in children.
Nonunion fx-a break in a bone that has failed to unite and heal after 9-12 months.
Stress fx- a break in a bone due to repeated forces to a particular portion of the bone.
Spiral fx- a break in a bone shaped like an S due to torsion and twisting.

Types of Muscular Contraction:

Concentric-occurs when the muscle shortens while developing tension
Eccentric-occurs when the muscle lengthens while developing tension
Isometric-occurs when tension develops, but there is no change in the length of the muscle
Isotonic-occurs when the muscle shortens or lengthens while resisting a constant load. (hand held weights)
Isokinetic-occurs when the tension developed by the muscle, while shortening or lengthening at a constant speed
(variable load), is maximal over the full range of motion (Cybex, Biodex, and Lido)
Common DTRs:
-Biceps (C5-C6)
-Brachioradialis (C6)
-Triceps (C7)
-Patellar tendon (L3, L4)
-Achilles tendon (S1, S2

Responses: Areflexia (absent) =0

Hyporeflexia (sluggish) = 1+ (LMN)
Normal =2+
Hyperreflexia (brisk) = 3+ (UMN)

Common Neural tension tests:

-Passive SLR =sciatic nerve
Tibial nerve=passive SLR with DF & eversion
Fibular nerve=passive SLR with PF & inversion
Sural nerve=passive SLR with DF and inversion
Prone knee bend=femoral nerve
Passive neck flexion=spinal dura

Common Disorders/Pathology of the MS system:

Pathology
1.Arthrogryp

What is it
A non

Etiology
-not

Signs &
Symptoms
-

Treatment
-Surgery, ROM

osis

progressive,
nongenetic,
congenital
disorder

inherited

2.Complex
Regional Pain
Syndrome
(CPRS)
Formerly
known as
Reflex
Sympathetic
Dystrophy

Abnormal
sympathetic
reflex
resulting from
a persistent
painful lesion

3.Colles
fracture

Most common
wrist fx
resulting from
a fall on an
outstretched
hand

-Results
from falling
onto
extended
wrist

Characterize
d by rigid
joints of the
extremities
(usually
symmetrical
)
-sausage
like
shapeless
limbs, and
weak/non
functioning
limbs
-Pain,
edema,
decreased
circulation,
osteoporosis
, skin
dryness,
decreased
propriocepti
on, and
atrophy of
muscles in
close
proximity to
involved
area
-The distal
fragment of
the radius
has a dorsal
displacemen
t with a

exercises, splinting,
positioning, ADL
training, use of
adaptive devices

Modalities to decrease
pain, joint mobs, weight
bearing or closed chain
exercise, massage,
manual lymphatic
drainage, splinting

-Casting, early active

ROM and PROM are
essential for functional
recovery, progressive
resistive exercises,
mobs, closed-chain

3A.Smiths
fracture

4.DJD
(Osteoarthriti
s)

Distal fx of
the radius,
which
dislocates in
the ventral
direction.
(reverse
colles fx)
Chronic
disease that
causes
deneneration
of articular
cargilage,
thickening of
subchondral
bone often
affecting
weight
bearing joints

-Results
from a fall
onto a
flexed wrist

-Unknown,
typically
appears
during
middle age
& affects
nearly all
individuals
to some
extent by
age 70.
Occurs
more
common in
men than
women up
to age 55.
Risk
factors:
overweight
, fxs or
other joint
injuries,
athletic
overuse

radial shift
of the wrist
and hand
-Fragment
dislocates in
the ventral
direction

stabilization exercises

-Gradual
onset of
pain present
at the affect
joint,
increased
pain after
exercises,
increased
pain with
weather
changes,
enlarged
joints,
crepitus,
stiffness,
limited joint
ROM,
Heberdens
nodes, &
Bouchards
nodes.

-Reduce pain, promote

joint function, and
protect the joint.
NSAIDS/acetaminophen
, and corticosteroids.
Viscosupplementation
which is administered
into the knee to
improve lubrication. PT:
PROM/AROM, heating
and cooling agents, pt
education,
strengthening, e-stim,
energy conservation,
bracing. Surgical
intervention can
include arthroscopic
surgery to total joint
replacement.

-Casting, early active

ROM and PROM are
essential for functional
recovery, progressive
resistive exercises,
mobs, closed-chain
stabilization exercises

5.Fibromyalgi
a

An immune
system
disorder that
causes
tenderness,
pain, and
stiffness in
the muscles.
11/18 points
throughout
the body

-Unknown
origin;
often
related to
stress,
anxiety,
fatigue,
and
sleeplessne
ss in
women
more than
men.

6.Osteogene
sis
Imperfecta

A connective
tissue
disorder that
affects the
formation of
collagen
during bone
development.
There are 4
classifications
of imperfects
that vary in
level of
severity.

-The cause
is genetic
inheritance
with types I
and IV
considered
autosomal
dominant
traits and
types II and
III
considered
autosomal
recessive
traits.

7.Osteochon
dritis
dissecans

Seperation of
the articular
cartilage from
the
underlying
bone

Osteochon
dral
fracture

Characterize
d by aching
or burning of
the muscles
a migraine
headache of
the
muscles
diffuse pain,
or tender
points on
both sides of
the body.
-Pathological
fractures,
osteoporosis
(brittle
bones),
hypermobile
joints,
bowing of
the long
bones,
weakness,
scoliosis,
impaired
respirator
function
-Usually
involving the
medial
femoral
condyle
near the

-Holistic and
multidisciplinary
approaches are
necessary. ADL
education and training,
Stress management
training, analgesics and
antidepressants, local
modalities and
techniques for muscle
pain relief,
aerobic/conditioning
exercises, improve
sleeping patterns
-Management begins at
birth with caregiver
education on proper
handling and
facilitation of
movement. PT will
focus on AROM
emphasizing
symmetrical
movements,
positioning, functional
mobility, fracture
management, and the
use of orthotics. In
severe cases,
wheelchair prescription.
-If fracture is displaced
then surgery is
indicated. PT after
surgery: gait training,
functional
strengthening,

8.Osteomala
cia

Decalcificatio
n of bones

-Results
from
vitamin D

9.Osteomyeli
tis

Acute or
chronic bone
infection

-Commonly
the result
of
combined
traumatic
injury and
an acute
infection.

intercondyla
r notch and
observed
less
frequently at
the femoral
head and
talar dome
-May cause
deformities,
fractures,
and severe
pain
-In children:
most
common site
includes the
distal femur
and
proximal
tibia,
humerus,
and radius.
In adults,
the disease
commonly
localizes in
the pelvis
and
vertebrae
and is
usually a
result of
contaminati
on related to
surgery or

conditioning.

-Pain control, functional

mobility training

-High doses of IV
antibiotics, the infected
extremity is
immobilized by a cast,
traction or bed rest.

10.Osteoporo
sis

Most common
metabolic
bone disease

11.Pagets
disease(ostei
tis
deformans)

A slowly
progressive
metabolic
bone disease
characterized
by an initial
phase of
excessive
bone
reabsorption
followed by a
reactive
phase of
excessive
abnormal
bone
formation.
The new bone
structure is
fragile and
weak and

trauma
-Common
sites of fx:
thoracic and
lumbar
spine,
femoral
neck,
proximal
humerus,
proximal
tibia, pelvis,
distal radius

-Affects
white
females
most
commonly,
depletes
bone
mineral
density,
which may
predispose
the
indivudal to
fracture
-Unknown
-Usually
affects
several
skeletal
areas
including
spine,
pelvis,
femur, and
skull. The
disease can
be fatal
when
associated
with
congestive
heart failure
(widespread
disease
creates a
continuous

-Pain management,
postural reeducation, ,
breathing exercises,
general conditioning,
pectoral stretching,
abdominal
strengthening(with
cautiondo not want
excessive and repeated
flexion of spine as this
can lead to wedge
fractures in these pts)
-If pt is asymptomatic,
treatment is not
needed. If symptoms
are present, pt will
require drug therapy.

causes painful
deformities of
the external
contour and
the internal
structures.

12.Patellofe
moral
syndrome

The patella
fails to
properly track
in the
trochlear
groove of the
femur

-Repetitive
overuse
disorder,
decreased
quad
strength,
decreased
lower
extremity
flexibility,
patellar
instability,
increased
tibial
torsion or
femoral
anteveriso

need for
high cardiac
output),
bone
sarcoma, or
giant cell
tumors.
Involved
sites can fx
easily and
heal slowly
and usually
incompletely
. Vertebral
collapse or
vascular
changes can
lead to
paralysis.
-Anterior
knee pain,
q-angle
greater than
18,
instability or
pain usually
occurs in the
first 30 of
knee flexion,
stair
climbing,
prolonged
sitting,
squatting, or
jumping

-Modalities to decrease
pain & inflammation,
McConnells taping
technique, stretching of
the iliotibial band and
tensor fascia latae,
strengthening of the
VMO, shoe inserts to
decrease genu valgum
and pes planus, OnTrack Brace to
reposition patella,
transverse friction
massage over the
lateral retinaculum,
patellar mobilization:
medial patellar glide

13.Scleroder
ma

A chronic
disorder
characterized
by fibrosis
and changes
in the internal
organs and
skin

14.Pronator

Median nerve

n.
Increased
risk for
developing:
females,
growth
spurts,
runners
who have
increased
mileage,
overweight
, Positive
chondroma
lacia test
(Clarks
sign)
-Frequently
accompani
ed by
Raynauds
phenomen
on

and stretching deep

fibers of lateral
retinaculum to
decrease patellar tilt.

Polyarthalgi
a is a
prominent
early
symptom,
heartburn
and dyspnea
occasionally
are the first
manifestatio
ns of the
disease.
Positive
rheumatoid
factor test,
other blood
tests
-DD via

-Maintain joint ROM,

medications,
strengthening exercises

-Manual nerve glides,

teres
syndrome

entrapment in
the pronator
teres muscle

15.Rheumato
id Arthritis
(RA)

Chronic,
systemic
inflammatory
disorder, the
disease
presents with
a chronic
inflammatory
reaction in
the synovial
tissues of a
joint that

-Unknown.
Women
more
affected
than men
(40-60
years age)
May
initially
occur at
any joint,
but it is

pronator
teres test:
The clinician
strongly
resists
pronation of
the elbow as
the pts
elbow is
extended
from 90 of
flexion
toward full
extension,
test is + if
tingling or
paraesthesia
is provoked
in the
forearm and
hand in a
median
nerve
distribution
Onset may
be gradual
or
immediate,
symmetrical
involvement
, pain and
tenderness
of affected
joints,
morning
stiffness,

stretching exercises,
AROM exercises,
Ultrasound, NMES for
nerve healing

Reduce inflammation
and pain, promote joint
function, and prevent
joint destruction and
deformity. NSAIDS,
DMARDS are slow
acting and take weeks
or months to become
effective but can slow
the progression. PT:
PROM/AROM, heating
and cooling agents,

results in
erosion of
cartilage and
supporting
structures
within the
capsule.

16.Juvenile
RA

Most common
chronic
rheumatic
disease in
children and
presents with
inflammation
of the joints
and
connective
tissues.
Classification
of JRA
includes
systemic,

common in
the small
joints of
the hand,
foot, wrist,
and ankle.
It has
periods of
exacerbati
on and
remission.
It is
diagnosed
based on
clinical
presentatio
n of
involved
joints &
blood RA
factors.
-Unknown,
is theorized
that an
external
source
such as a
virus,
infection or
trauma
may trigger
an
autoimmun
e response
producing
JRA in a

warm joints,
decrease in
appetite,
malaise,
increased
fatigue,
swan neck
deformity
(DIP flexion,
PIP
hyperextensi
on)
boutonniere
deformity
(DIP ext, PIP
flexion, low
grade fever

splinting, pt education,
energy conservation,
body mechanics, and
joint protection
techniques.

Fever and
Rash.
-Systemic
JRA occurs in
10-20% of
cases and
presents
with acute
onset, high
fevers, rash,
enlargement
of the
spleen &
liver, and
inflammatio

-Pharmacological
management to relieve
pain and inflammation
through NSAIDS,
corticosteroids,
antirheumatics, and
immunosuppressive
agents. PT:
PROM/AROM,
positioning, splinting,
strengthening,
endurance training,
weight bearing
activities, postural
training, functional

polyarticular,
and
oligoarticular.
Onset is prior
to age 16 with
complete
remission in
75% of
children.

17.Gout
(gouty
arthritis)

Metabolic
disease
marked by
elevated level

child with a
genetic
predispositi
on.

n of the
lungs and
heart.
Polyarticular
JRA accounts
for 30-40%
of cases and
presents
with high
female
incidence,
significant
rheumatoid
factor, and
arthritis in
more than
four joints
with
symmetrical
involvement
.
Oligoarticula
r accounts
for 40-60%
of cases and
affects less
than five
joints with
asymmetric
al
involvement
.
Most often
affects the
feet,
especially

mobility. Pain
management includes
the use of modalities
such as paraffin,
ultrasound, warm
water, and cryotherapy.
Surgical intervention
may be indicated
secondary to pain,
contractures or
irreversible joint
destruction.

Anti-inflammatory
medications, daily use
of colchicines, lowering
the urate concentration

of serum uric
acid and
deposition of
urate crystals
in the joints,
soft tissue,
and kidneys.

18.Hemophili
a

Hemorrhagic
disorder that
is hereditary

-Results
from a
deficiency
of specific
clotting
factors

19.Iliotibial
band friction
syndrome

An irritation
caused by the
rubbing of the

-Often
occurs in
runners

the great
toe, ankle,
and midfoot. There
is severe
joint pain
commonly
at night with
warmth,
erythema,
and extreme
tenderness/
hypersensiti
vity.
-Can cause
pain,
swelling,
extreme
tenderness,
and possibly
permanent
deformity.
Bleeding
near
peripheral
nerves can
cause
peripheral
neuropathie
s, pain
parathesia,
and muscle
atrophy.
-Positive
Obers test,
excessive

in body fluids with diet,

weight loss, and
moderation of alcohol
intake, allopurional to
reducehyperuricemia,
rest, elevation, and
joint protection during
acute phase.

-Splinting, Ice, rest, and

elevation are needed in
acute stage. In chronic
situations, joint
protection, maintaining
joint function, daily
exercises for ROM,
endurance and
strength, ADL training,
and the use of
appropriate splints and
Ads should be
addressed.

-Stretching exercise
program, modalities for
pain and inflammation,

ITB over the

lateral
epicondyle of
the femur

from an
overuse
syndrome

20.Myositis
Ossfifcans

Often caused
by trauma to
a muscle
resulting in
hematoma
that may
calcify or
ossify

21.Scoliosis

Lateral
curvature of
the spine.
Most often
quantified
using the
Cobb method
with a
standing
radiograph.
Classified as
functional
(nonstructural
)(results from
leg length

-Can be
induced by
early
mobilizatio
n and
stretching
with
aggressive
PT
following
trauma to
the muscle
-Typically
idiopathic.
It is most
commonly
diagnosed
between
10 and 13
years of
age. Girls
and boys
have a
similar risk
of
developing
a mild

hip IR in
stance,
palpation
over ITB
insertion,
positive
Noble
compression
test
-Frequent
locations:
quads,
brachialis,
and biceps
brachii.
Radiological
studies will
show
calcium
deposits

soft tissue mobilization

techniques, shoe
orthosis may be
necessary.

-Shoulder
level
asymmetry
w/ or w/out
the
presence of
a rib humb.
Pain is not
typically
associated w
the spinal
curvature,
rather it is a
result of the
abnormal

-Based on magnitude of
curve and degree of
progression. If curve
not progressing no
formal action is taken.
PT: muscle
strengthening, and
flexibility exercises,
shoe lifts, and bracing.
A spinal orthosis is
often warranted with a
curve that ranges
between 25-40.
Surgical intervention
may be required with

-Conservative with
gentle active and active
assisted ROM, passive
stretching is not
indicated, NO manual
stretching with
overpressure at endrange.

discrepancy,
muscle
imbalance,
poor posture)
can be
corrected
w/lateral
bending.
Neuromuscula
r scoliosis
results
w/developme
ntal pathology
resulting in
alterations
within the
structure of
the spine.
Observed in
pts w/CP or
Marfan
syndrome.
Degenerative
scoliosis
occurs due to
the normal
aging process
and is
facilitated by
changes such
as osteophyte
formation,
bone
demineralizati
on, and disk
herniation.

curve
(10or
less),
however,
girls have a
significantl
y greater
risk of
acquiring a
curve
greater
than 30

forces
placed on
other tissues
of the body.

curves greater than

40.

Ankylosing
spondylitis

22.Sjogrens
syndrome

Neuromuscula
r and
degenerative
scoliiosis are
considered to
be forms of
structural
scoliosis since
the curves are
inflexible and
do not reduce
w/lateral
bending.
Progressive
inflammatory
disorder of
unknown
etiology that
initially
affects axial
skeleton

A rheumatoidlike disorder
characterized
by dryness of
the mucous

Initial onset
(usually
mid and
low back
pain for 3
months or
greater)
before
fourth
decade of
life

-More
common
than
systemic
lupus

First
symptoms
include mid
and low
back pain,
morning
stiffness,
and
scaroiliitis.
Results in
kyphotic
deformity of
the cervical
& thoracic
spine & a
decrease in
lumbar
lordosis.
-Dryness of
the eyes
and mouth
along with
joint

NSAIDS, corticosteroid
therapy. PT:
implementation of
flexibility exercises for
trunk to
maintain/improve
normal joint motion &
length of muscles in all
directions, especially
extension.

-Sipping fluids
throughout the day,
chewing surgarless
gum, using a
mouthwash for mouth

membranes,
joint
inflammation,
and anemia.

erythemato
sus (SLE)
and less
common
than RA.

23.Achilles
Tendonitis

Is a repetitive
disorder
resulting in
microscopic
tears of
collagen
fibers on the
surface or in
the substance
of the Achilles
tendon. The
tendon is
most often
impacted in
an avascular
zonelocated
two to six
centimeters
above the
insertion of
the tendon.

24.Adhesive
Capsulitis

Results in a
loss of ROM in

-Repetitive
overload of
the tendon
caused by
changes in
training
intensity or
faulty
techniques.
Pts
w/limited
flexibility
and
strength in
the
gastroc/sol
eus and pts
wa
pronated or
cavus foot
are at
increased
risk.
-May be
related to a

inflammatio
n. Arthritis
occurs in
about 33%
of the pts &
is similar in
distribution
to RA, but
milder &
without joint
destruction.
-aching or
burning in
the posterior
heel,
tenderness
of the
Achilles
tendon, pain
w increased
activity,
swelling,
and
thickening in
the tendon
area, muscle
weakness
due to pain,
morning
stiffness

dryness, medications
for pain and
inflammation
occasionally needed,
maintain mobility and
function through a
regular exercise
program.

-Insidious
onset of

-Increase ROM with

glenohumeral

-Initially RICE, NSAIDS,

as needed. A heel lift
and cross training may
be used to limit the
amount of tensile
loading through the
tendon. Prevention
includes heel cord
stretching exercises,
use of appropriate softsoled footwear,
eccentric strengthening
of the gastroc/soleus,
and avoiding sudden
changes in intensity of
training programs.

active and
passive
shoulder
motion due to
soft tissue
contracture.
The condition
is caused by
adhesive
fibrosis and
scarring
between the
capsule,
rotator cuff,
subacromial
bursa, and
deltoid.

25.Anterior
cruciate
ligament
sprain

ACL runs from

the anterior
intercondylar
area of the
tibia to the
medial aspect
of the lateral
femoral

direct
injury to
the
shoulder or
may being
insidiously.
Peak
incidence
occurs in
individuals
40 and 60
years of
age w
females
being
affected
more. Pts w
diabetes
have
increased
incidence.
The
condition is
self-limiting
and
typically
resolves in
1-2 years.
Noncontact
twisting
injury
associated
with
hyperexten
sion, varus

localized
pain often
extending
down the
arm,
subjective
reports of
stiffness,
night pain,
restricted
motion in a
capsular
pattern. (ER
most
limited)

mobilization, ROM
exercises, and palliative
modalities. The
therapist and pt should
AVOID overstretching
and elevating pain
since this can result in
further loss of motion.
Surgical options include
suprascapular nerve
block and closed
manipulation under
anesthesia.

-The pt may
report a loud
pop or
feeling of
the knee
giving way
or
buckling

-Initially RICE, NSAIDS,

and analgesics as
needed. Conservative
treatment includes
lower extremity
strengthening exercises
emphasizing the quads
and hamstrings.

26.Posterior
cruciate
ligament
sprain

condyle in the
intercondylar
notch. The
ligament
prevents
anterior
displacement
of the tibia in
relation to the
femur. The
extent of the
sprain is
classified
according to
the extent of
ligament
damage. A
grade I sprain
involves
microscopic
tears of the
lig, while a
grade III
indicates a
completely
torn ligament.
PCL runs from
the posterior
intercondylar
area of the
tibia to the
lateral aspect
of the medial
femoral
condyle in the
intercondylar

or valgus
stress to
the knee.
An ACL
sprain
often
involves
injury to
other knee
structures
such as the
medial
capsule,
MCL, and
menisci.

followed by
dizziness,
sweating,
and
swelling.
Special
tests:
Lachmans
& lateral
pivot shift
test

Surgery if often
warranted for a
complete tear. A derotation brace may be
beneficial for a pt with
ACL deficient knee, but
has limited benefit for a
pt following surgical
reconstruction. (9040flex)

-Most
common
cause of
injury are
landing on
the tibia
with a
flexed knee
or hitting a
dashboard

-The pt may
report
feeling as if
the femur is
sliding off
the tibia.
Swelling and
mild pain
may be
present, but

-Initially RICE, NSAIDS,

PT: lower extremity
strengthening and
functional progression.
If surgery is performed,
isolated hamstrings
exercises are often
AVOIDED for a
minimum of six weeks.

notch. The
PCL prevents
posterior
displacement
of the tibia in
relation to the
femur

27.Medial
collateral
ligament
sprain

MCL runs
from slightly
above the
medial
femoral
epicondyle to
the medial
aspect of the
shaft of the
tibia. A MCL
sprain often
ivolves injury
to other knee
structures
(ACL/medial
meniscus)

in a MVA w
a flexed
knee.
Isolated
PCL tears
are not
common
and often
involve
other knee
structures
such as the
ACL, MCL,
LCL, and
menisci
-A contact
or
noncontact
, fixed foot,
tibial
rotational
injury
associated
with valgus
force and
external
tibia
rotation
can
damage
MCL. Often
associated
w activities
such as
football,
skiing, and

often the pt
is
asymptomat
ic. Special
tests:
posterior
drawer,
posterior
sag sign

-Clinical
presentation
includes
knee pain,
swelling,
anatlgic
gait,
decreased
ROM, and a
feeling of
instability. A
valgus
stress test
can be used
to assess
the integrity
of the MCL.

-Initially RICE, NSAIDS.

Conservative treatment
includes decreasing
inflammation,
protecting the knee
joint and ligament,
ROM, and
strengthening exercise
as tolerated.
Strengthening exercises
gradually become more
aggressive and
functional activities are
introduced. Surgery is
rarely required since
the MCL is well
vascularized.

28.Meniscus
Tear

The medial &

lateral
menisci are
attached to
the proximal
surface of the
tibia. The
menisci are
thick at the
periphery and
thinner at
their internal
unattached
edges. The
medial
meniscus is
more
commonly
injured than
the lateral bc
it is less
mobile due to
its
attachment to
the joint
capsule. The
incidence of
medial tears
increases
significantly
over time with
ACL
deficiency.
Mensical
injuries are

soccer.
-Associated
with fixed
foot
rotation
while
weight
bearing on
a flexed
knee. This
action
produces
compressio
n and
rotational
forces on
the
meniscus

-Joint
linepain,
swelling,
catching or
a locking
sensation.
Special
tests:
Apleys
compression
test, bounce
home test,
and
McMurray
test.

-Initially RICE, NSAIDS.

Conservative treatment
consists of palliative
modalities and
strengthening exercise.
Surgery ranging from a
partial meniscectomy
to a meniscal repair is
often warranted for
active individuals.
Meniscal repairs are
typically performed on
tears located on the
outer edges of the
meniscus due to the
increased vascularity.

29.Lateral
epicondylitis
tennis
elbow

30.Medial

definitively
diagnosed w
arthroscopy
or MRI.
Refers to an
irritation or
inflammation
of the
common
extensor
muscles at
their origin on
the lateral
epicondyle of
the humerus.
Individuals
who take part
in racquet
sports are at
greatest risks

Usually a

-Caused by
eccentric
loading of
the wrist
extensor
muscles,
usually the
extensor
carpi
radialis
brevis,
resulting in
microtraum
a. Lateral
epicondyliti
s can be
precipitate
d by poor
mechanics
or faulty
equipment
such as too
small of a
handle on
a tennis
raquet.
Most
common in
individuals
between
30-50.
-Occurs w

-Pain is
present
immediately
anterior or
distal to the
lateral
epicondyle
of the
humerus.
Pain
typically
worsens
with
repetition
and resisted
wrist
extension.

-Initially RICE, NSAIDS,

and activity
modification. PT:
attempt to increase
strength(initial
emphasis on eccentric
phase of ex), flexibility,
and endurance of the
wrist extensors. A strap
placed 2-3 inches distal
to the elbow joint can
reduce muscular
tension placed on the
epicondyle and may
diminish or eliminate pt
symptoms. *Resist
wrist extension, wrist
radial deviation, and
forearm pronation with
fingers fully flexed (fist)
simultaneously
=Cozens test.

Clinician:

Same as lateral

epicondylosis
golfers
elbow

degenerative
condition of
the pronator
teres & flexor
carpi radialis
tendons at
their
attachment to
the medial
epicondyle of
the humerus.

31.Congenita
l Hip
dysplasia

Also known as
developmenta
l dysplasia, is
a condition
characterized
by
malalignment
of the femoral
head within
the
acetabulum.
The condition
develops
during the
last trimester
in utero.

overuse in
sports,
such as
baseball,
swimming,
or jobs that
require a
strong
hand grip
and
excessive
pronation
of the
formearm
-Cultural
predispositi
on,
malposition
in utero,
environme
ntal and
genetic
influences

passively
supinate
forearm,
extend
elbow, and
extend
wrist.
Reproduces
pain at
medial
epicondyle.

-Clinical
presentation
includes
asymmetric
al hip
abduction
with
tightness
and
apparent
femoral
shortening
of the
involved
side. Testing
for this
condition
may include
Ortolanis
test,
Barlows
test, and

-Dependent on age,
severity, and initial
attempts to reposition
the femoral head w/in
the acetabulum
through the constant
use of a harness,
bracing, splinting, or
traction. Open
reduction w/
subsequent application
of a hip spica cast may
be required if
conservatice treatment
fails. PT: stretching,
strengthening, and
caregiver education.

32.Congenita
l Limb
Deficiencies

A congenital
limb
deficiency is a
malformation
that occurs in
utero,
secondary to
an altered
developmenta
l course.
Congenital
limb
deficiencies
are classified
as
longitudinal or
transverse. A
longitudinal
limb
deficiency
refers to a
reduction or
absence of an
element or
elements
within the
long axis of
the bone. A
transverse
limb
deficiency
refers to a
limb that has
developed to

-The
majority of
congenital
limb
deficiencie
s are
idiopathic
or genetic
in origin.
Other
possible
etiologies
include
poor blood
supply,
constricting
amniotic
bands,
infection,
and
maternal
drug
exposure.

diagnostic
ultrasound.
-structural
or acquired
abnormality
of a limb,
phantom
limb pain.

-Symmetrical
movements,
strengthening, ROM,
weight bearing
activities, and
prosthetic training
when appropriate.

33.Congenita
l torticollis
wry neck

34.Glenohum
eral
instability

a particular
level beyond
which no
skeletal
elements
exist.
Characterized
by a unilateral
contracture of
the
sternocleidom
astoid muscle.
The condition
is most often
identified in
the first 2
months of life.

-Cause is
unknown,
may be
associated
with
malposition
ing
(breech) in
utero and
birth
trauma.

Refers to
excessive
translation of
the humeral
head on the
glenoid during
active
rotation.
Subluxation
refers to joint
laxity,
allowing for
more than
50% of the

A
combinatio
n of forces
stress the
anterior
capsule,
gelenhume
ral
ligament,
and rotator
cuff,
causing the
humerus to
move

-Clinical
presentation
includes
lateral
cervical
flexion to
the SAME
side as the
contracture,
rotation
toward the
opposite
side, and
facial
asymmetrie
s.
Subluxation:
feeling the
shoulder
popping
out and
back into
place, pain,
paresthesias
, sensation
of the arm
feeling
dead
positive

-Initially-treatment is
conservative with
emphasis on stretching
(ex. Right torticollis: to
stretch, perform left
side bending & right
rotation), AROM,
positioning, and
caregiver education.
Surgical management
is indicated when
conservative options
have failed and the
child is over one year of
age.
-Initial immobilization
with a sling for 3 to 6
weeks. RICE and
NSAIDS. Following
immobilization, ROM,
and isometric
strengthening should
be initiated followed by
progressive resistive
exercises emphasizing
the internal and
external rotators, as
well as the large
scapular muscles.

35.Impingem
ent
Syndrome

humeral head
to passively
translate over
the glenoid
rim w/out
dislocation.
Dislocation is
the complete
separation of
the articular
surfaces of
the glenoid
and the
humeral
head. Approx
85% of
dislocations
detach the
glenoid
labrum
(Bankart
lesion)
Is one of the
most common
injuries of the
shoulder. It is
often caused
by repetitive
microtrauma
from upper
extremity
activity
performed
above the
horizontal
plane.

anteriorly
out of the
glenoid
fossa. An
anterior
dislocation
is the most
common
and is
usually
associated
with
shoulder
abd and
LR.

apprehensio
n test,
capsular
tenderness,
swelling;
Dislocation:
severe pain,
paresthesias
, limited
ROM,
weakness,
visible
shoulder
fullness, arm
supported
by
contralateral
limb.

-Caused by
the
humeral
head and
the
associated
rotator cuff
attachment
s migrating
proximally
and
becoming
impinged
on the

-discomfort
or mild pain
deep within
the
shoulder,
pain with
overhead
activities,
painful arc
of motion
(70-120
abduction),
positive
impingemen

-Initially RICE, NSAIDS,

and activity
modifications. Once
tolerated, treatment
includes rotator cuff
strengthening and
scapular stability
exercises. Long-term
prevention includes
continued
strengthening of the
rotator cuff and scapula
stabilizers, along with
improved biomechanics

undersurfa
ce of the
acromion
and the
coracoacro
mial
igament
36.LeggCalvePerthes
Disease

36A.Slipped
capital
femoral
epiphysis
(SCFE)

Characterized
by
degeneration
of the femoral
head due to a
disturbance in
the blood
supply
(avascular
necrosis). The
disease is
self-limiting
and has four
distinct
stages:
condensation,
fragmentation
, reossification,
and
remodeling.
Most common
hip disorder
observed in
adolescents

-Trauma,
genetic
predispositi
on,
synovitis,
vascular
abnormaliti
es,
infection
(Age of
onset:2 &
13 years
avg.6 yrs)
Males have
4x greater
incidence

-Unknown;
onset in
males: 1017 years,
avg 13.
Onset in
females: 8-

t sign,
tenderness
over the
greater
tuberosity
and the
bicipital
groove
-gradual
onset of
aching
pain at hip,
thigh, and
knee. AROM
limited in
ABDuction &
ext.
Characteristi
c psoatic
limp due to
weakness of
psoas major;
affected LE
moves in
ER, flex, and
adduction

related to sport specific

or relevant work
activity.

-pt describes
pain as
vague at
knee, thigh,
& hip. AROM
is restricted
in ABD, FLEX

NSAIDS for pain, joint

bone protection
strategies,
maintain/improve joint
mechanics,
implementation of
aerobic

-Activities are variable

based on the clinical
presentation, but
primary focus is to
relieve pain, maintain
the femoral head in the
proper position &
improve ROM. PT: may
be required
intermittently for
stretching, splinting,
crutch training, aquatic
therapy, traction, and
exercise. Orthoics and
surgical intervention
may benecessary.

15 years,
avg 11.
Males have
2x the
incidence
of females.

37.OsgoodSchlatter
Disease

AKA traction
apophysitis, is
a self-limiting
condition that
results from
repetitive
traction on
the tibial
tuberosity
apophysis.

38.Plantar
fasciitis

Refers to
inflammation

-Caused by
repetitive
tension to
the patellar
tendon
over the
tibial
tuberosity
in young
athletes.
This can
result in a
small
avulsion of
the
tuberosity
and
subsequent
swelling.
-Often
associated

& IR. With

chronic
conditions,
pt may
demonstrate
a
Trendelenbu
rg gait.
Diagnostic
tests: plain
film shows
displacemen
t of upper
femoral
epiphysis.
-Point
tenderness
over the
patella
tendon at
the insertion
on the tibial
tubercle,
anatalgic
gait, pain
with
increasing
activity

capacity/endurance
(aquatic programs)
Post surgical
interventions include
regaining functional
flexibility, improving
strength/endurance/coo
ridnation, and gait
training.

-Clinical
presentation

-Initially RICE, NSAIDS.

A heel cup, massage

-Conservative
treatment focuses on
education, icing,
flexibility exercises, and
eliminating activities
that place strain on the
patella tendon such as
squatting, running, or
jumping.

39.Talipes

of the plantar
fascia at the
proximal
insertion on
the medial
tubercle of
the
calcaneus.
The plantar
fascia is a
broad
structure
comprised of
connective
tissue which
spans from
the calcaneus
to the
metatarsal
heads. The
structure is
designed to
provide
support to the
arch of the
foot.
Excessive
tension over
time creates
chronic
inflammation
and
microtears at
the proximal
insertion.
Is a deformity

with an
acute
injury from
excessive
loading of
the foot or
chronic
irritation
from an
excessive
amount of
pronation
or
prolonged
duration of
pronation.
The
condition is
most
common in
pts
between
40-60
years of
age.

includes
tenderness
at the
insertion of
the plantar
fascia,
presence of
a heel spur,
pain that is
worse in the
morning or
after periods
of prolonged
inactivity,
difficulty
with
prolonged
standing, &
pain when
walking in
bare feet.

using a tennis ball or

rolling pin, medial
longitudinal arch
taping, and joint mobs
may be helpful.
Prevention includes
heel cord stretching
exercises, use of
appropriate soft-soled
footwear, & avoiding
sudden changes in the
intensity of training
programs. Orthotics
may be used to
minimize
hyperpronation (resting
night splints)

-Unknown,

-Clinical

-Medical management

Equinovarus
clubfoot

characterized
by the heel
pointing
downward
and the
forefoot
turning
inward.

40.Rotator
cuff tear

Can be torn
due to an
acute
traumatic
incident or as
a result of a
chronic
degenerative
pathology. Pts
50 years of
age and older
are

theories
postulate
familia
tendency,
positioning
in utero or
a defect in
the ovum.
This
condition
accompani
es other
NM
abnormaliti
es
including
spina bifida
and
arthrogryp
osis, & may
result from
the lack of
movement
in utero.
-Intrinsic
factors
associated
with rotator
cuff tears
include
impaired
blood
supply to
the tendon,
resulting in
degenerati

presentation
includes
adduction of
the forefoot,
varus
positioning
of the
hindfoot,
and equines
at the ankle
(PF)

begins shortly after

birth and includes
splinting and serial
casting. The goal of
intervention is to
restore proper
positioning of the foot
and ankle. Failed
management or severe
involvement may
require surgical
intervention &
subsequent casting.

-arm
positioned in
internal
rotation and
adduction,
point
tenderness
at the
greater
tubercle and
acromion,
marked

-Conservative
management: RICE,
NSAIDS. Primary focus
of therapy is to prevent
adhesive capsulitis and
strengthen UE
musculature. Surgical
management to repair
the tendon can be
arthroscopic, mini-open
with arthroscopic assist
or a traditional open

41.Total Hip

particularly
susceptible to
tears due to
chronic
degenerative
pathology.
Rotator cuff
tears are
classified as
partial
thinkness or
full thickness.
A partialthickness tear
extends
through only
a portion of
the tendon. A
full-thickness
tear is a
complete tear
of the tendon.
The size of
the tear can
range from
small (1cm or
less) to large
(more than
5cm)
Refers to
removal of
the proximal
& distal
surfaces of
the hip with
subsequent

on.
Extrinsic
factors
include
trauma,
repetitive
microtraum
a, and
postural
abnormaliti
es.

limitation in
shoulder
flexion and
abduction w
upper trap
recruitment
evident,
increased
tone in
anterior
shoulder
structures.

approach. Following
surgery, the pt will be
immobilized in a sling.
The amount of
immobilization time will
vary depending on
surgeon preference,
procedure, and size of
tear. A large tear may
require 4-6 weeks of
immobilization. PT
beings with PROM,
gradually to AAROM.
Active motion &
isometric exercises
begin once approved by
the surgeon. The pt will
gradually become
functional w ADLS and
progress to more
aggressive
strengthening
activities. Return to
functional activities
requiring dynamic over
head motion occurs in
9-12 months.

-Elective
surgical
procedure.
Needs
include OA,
RA,
osteomyelit

-Prior to
surgery,
severe pain
with weight
bearing, loss
of mobility,
gross

-Initially PT focuses on
decreasing
inflammation and
allowing tissues to heal,
emphasizing adherence
to hip precautions,
minimizing muscle

replacement
by an
acetabular
component
and a femoral
implant.
Surgical
procedure can
be
anterolateral,
direct lateral
or
posterolateral
. Fixation can
be cemented
or
cementless.
Cemented
fixation allows
weight
bearing as
tolerated
often
immediately.
Cementless
and hybrid
fixation rely
on bone
growth and
may dictate
partial weight
bearing or
NWB initially.
Cementless is
normally for
young, active

is, and
avascular
necrosis.

instability or
limitation in
ROM, failure
of nonoperative
managemen
t or a
previous
surgical
procedure.

atrophy, and regaining

full PROM. Tx can
include ankle pumps,
quad and glut sets,
active hip flexion w/in
available range,
assistive device
training, and
progressive ambulation.
As the pt progresses,
treatment moves
toward regaining full
strength & endurance
and attaining
independence in the
home setting.
Anterolateral approach:
AVOID-hip flexion
greater than 90, hip
ext, adduction.
Direct lateral
approach:AVOID-hip
flexion beyond 90, hip
ext, ER, and adduction.
Posterolateral
approach:AVOID-hip
flexion beyond 90, IR,
adduction

individuals
(less than 65
years)Average
lifespan of a
total hip is 1520 years.
42.Total knee

43.Temporom
andibular
joint
syndromes

Elective
surgery

Can be
divided into 3
diagnostic
categories: 1.
Joint
abnormalitiestrauma

Severe pain
w weight
bearing, loss
of mobility,
gross
instability or
limitation in
ROM,
marked
deformity of
the knee,
failure of
nonoperative
managemen
t.

-Joint noise,
joint locking,
AROM of the
jaw, lateral
deviation of
the
mandible

Initially, PT treatment
focuses on decreasing
inflammation &
allowing tissues to heal,
emphasizing adherence
to knee precautions,
minimizing muscle
atrophy, and regaining
full PROM. Knee flexion
requires a minimum of
90 for ADLS & 105 to
rise comfortably from
sitting. Theraputic
activities include ankle
pumps, quads and glut
sets, AROM, CPM,
assistive device
training, & progressive
ambulation. Advanced
activities include wall
slides, controlled
lunges, stationary
cycling, & step ups.
-Postural reeducation,
modalities for pain,
inflammation reduction,
biofeedback, joint
mobilization, AROM and
muscle strengthening
exercises, pt education

arthritis,
disease or
neoplasm.
2.Congenital
structural
defects. Can
include
meniscus,
ligaments
that control
movement of
the disc, the
condyles, the
fossa, or the
articular
tubercles. 3.
Loss of
functional
mobility of
unknown
etiology. May
result from
increased
activity in the
muscles of
mastication
as the result
of stress &
anxiety.

during
depression
or elevation,
decreased
strength,
tinnitus,
headaches,
forward
head
posture, and
paint
w/movemen
t.

for eating soft foods

and decreasing habits
that stress the
TMJ(biting nails or
pencils), instruct the pt
in maintaining the rest
position of the tongue
(upright postural
position of the tongue
on the hard palate).

*Specific conditions of TMJ:

1. Synovitis & capsulitis-pain located anterior to ear area, unable to fully close back teeth together, opening less
than 40 mm secondary to pain, pain decreases w rest.
2.TMJ hypermobility-pt reports my jaw feels like it goes out of place, may report joint noises, short term
episodes of jaw catching in fully opened position. Mandibular depression is greater than 40mm and deviates
toward the NONinvolved (contralateral) side, palpable irregularities during closure.

3. Disc displacement w/reduction-Pt reports joint noises with opening and closing equal to pops or clicks.
Palpation over lateral poles reveals an opening click (the reduction of the disc) and a closing click (the disc
displacing anterior to the condyle). These noises equal the reciprocal click.
4. Disc displacement w/out reduction-Pt reports intermittent locking without joint noises. Opening of mandible is
limited to 20-25 mm with deflection toward INVOLVED side. Limited lateral excursion toward the opposite side of the
involved joint.
*primary glide is inferior, which gaps joint, stretches the capsule, and allows relocation of anteriorly displaced disc.
Musculoskeletal Pathologies:
Pathology
Achilles
Tendon
Rupture

Diagnosis
Normally
occurs within
1-2 inches
above its
tendinous
insertion on
the
calcaneus.

Contribut
ing
Factor
Occurs
most
frequently
when
pushing
off a
weight
bearing
extremity
with an
extended
knee,
through
unexpecte
d DF while
WBing or
with a
forceful
eccentric
contractio
n of the
PFors. Poor

Clinical
Presenta
tion
Pt will
present
with
swelling
over the
distal
tendon, a
palpable
defect in
the
tendon
above the
calcaneal
tuberosity
, pain &
weakness
with PF. Pt
will limp
and often
complain
that there
was a

Lab/Imag
ing

Management/O
utcome

X-ray to
rule out
avulsion fx
or bony
injury. MRI
can be
used to
located
the
presence
& severity
of the tear
or rupture.

Immobilization
through casting
or surgical
repair.
Pharmacological
management is
not necessary
except to relieve
pain. Serial
casting for
approx 10 weeks
followed by the
use of a heel lift
to ensure
maximal healing
without stress on
the tendon for 36 months. If pt
requires surgical
intervention
then a cast or
brace is required

stretching
routine,
improper
shoe wear.
A person
over 30 is
at higher
risk,
average
30-50
years who
participate
in
recreation
al
activities.

Adhesive
Capsulitis

frozen
shoulder is
characterize
d by
inflammation
and fibrotic

Primary
adhesive
capsulitis
has no
known
etiology, it

snap or
pop
associate
d with
severe
pain
during
the inury.
A pt will
not be
able to
stand on
their toes.
Thompso
n test will
result in
no
movemen
t into PF.
A
complete
rupture
will result
in a
palpable
gap in the
tendon
prior to
the
insertion.
Restricted
active
and
passive
ROM at
the GH

for 6-8 weeks.

PT includes
ROM, stretching,
icing, gait
training,
strengthening,
plyometrics, and
skill specific
training.
Modalities, pool
therapy, may
assist in
recovery. Pt
should return to
their previous
functional level
within 6-7
months.

An
arthrogra
m can
assist with
the
diagnosis

Self-limiting
process that can
take over 12
months to run its
course. A
physician can

thickening of
the anterior
joint capsule
of the
shoulder. The
capsule
becomes
adherent to
the humeral
head and
under goes
contracture.
This
condition
causes
symptoms of
GH
limitations
and pain.

is
associated
with DM,
hypothyroi
dism or
cardiopul
monary
conditions.
Secondary
adhesive
capsulitis
can result
from
trauma,
immobiliza
tion, reflex
sympathet
ic
dystrophy,
RA,
abdominal
disorders,
and
psychogen
ic
disorders.
Occurs
more in
the middle
aged
population
with
females
having a
greater
incidence

joint. Pain
that
radiates
below the
elbow
and
awakens
the pt at
night.
PROM is
limtied
during
this acute
phase
due to
pain &
guarding.
Pain is
present
with a
loss of GH
motion,
restricted
elevation,
and ER.

by
detecting
a
decreased
volume of
fluid
within the
joint
capsule.
Greatest
restriction
in ER and
abduction.

inject
corticosteroids
to assist with
recovery.
Surgical
intervention to
break up
adhesions or
release adhered
muscles. PT
during acute
phase includes
icing or
superficial heat,
gentle joint
mobs,
progressive
strengthening,
pendulum
exercises, &
isometrics.
During the
chronic phase:
ultrasound,
grade III and IV
mobs, PNF to
restore painless
ROM. PT is
usually
prescribed on an
outpatient basis
3-5 months
after diagnosis.
Follows a
nonlinear
pattern of

than
males.

Ankylosing
Spondylitis

Is a systemic
condition
that is
characterize
d by
inflammation
of the spine
and larger
peripheral
joints. The
chronic
inflammation
causes
destruction
of the
ligamentous
osseous
junction with
subsequent
fibrosis and
ossification
of the area.

Genetic
inheritanc
e. Typically
seen
between
20-40
years of
age, and
men are at
a 2-3x
greater
risk than
women.
More
common
in
Caucasian
s.

Will
present
with
recurrent
&
insidious
epidoses
of low
back
pain,
morning
stiffness,
impaired
spinal
extension
, and
limited
ROM in
the
affected
joints for
over a 3
month
period of
time.
Other
manifesta
tions
include
kyphosis,
fatigue,

X-ray of
the spine
may be
negative
in the
initial
stage of
AS but
with
progressio
n will revel
areas of
erosion,
deminerali
zation,
calcificatio
n, and
syndesmo
phtye
formation.
In later
stages, Xray will
reveal
fusion of
the SI joint
and a
bamboo
appearanc
e of the
spine. Lab

recovery.
Spontaneous
recover is said to
take 12-24
months.
Reduce
inflammation,
maintain
functional
mobility and
relieve pain. PT
should include
postural
exercises
emphasizing
extension,
general ROM,
pain
management,
and energy
conservation.
Low impact and
aerobic exercise
with emphasis
on extension
and rotation are
appropriate for a
pt with AS. High
impact and
flexion exercises
are
contraindicated.
Swimming is
highly
recommended.
AS slowly

ACL sprain
Grade III

Extends from
the anterior
intracondylar
region of the
tibia to the
medial
aspect of the
lateral
femoral
condyle. The
ligament
prevents
anterior
translation of
the tibia on
the fixed
femur and
posterior
translation of
the femur on
the fixed
tibia.Permits
up to 500 lbs
of pressure
prior to
rupture.
Ligament has
poor blood
supply and

Participati
on in
athletic
activities
requiring
high levels
of agility
(soccer,
basketball)
and
contact
sports.
Women
have
higher
incidence
of ACL
injury than
males.

weight
loss, and
peripheral
joint
involvem
ent.

work can
be used to
rule out
other
diseases.

The peak
incidence
of ACL
injury
occurs
between
14 and 29
years. A
grade III
is
characteri
zed by
significan
t pain,
effusion,
and
edema
that
significan
tly limits
ROM. Pt
may be
unable to
WB.

MRI is the
preferred
imaging
tool to
identify
the
presence
of an ACL
tear. Xrays may
be used to
rule out a
fracture.
Subjective
reports
such as
hearing a
pop.

progresses over
a 15-25 year
period and may
remain isolated
to the spine and
SI joint or spread
to larger joints.
Control edema,
increase ROM,
strengthening.
Patellar tendon
graft is the most
commonly used.
Pts often initially
present with a
knee
immobilizer and
crutches to
protect the graft.
Treatment
begins to focus
on strengthening
focusing on
closed chain
exercises.
Closed chain is
considered more
desirable than
open-chain since
they minimize
anterior
translation of
the tibia. Pts
electing to have
surgery can
expect to return

Bicipital
Tendonitis

does not
have the
ability to
heal a
complete
tear. Injuries
to the ACL
most
commonly
occur during
hyperflexion,
rapid
deceleration,
hyperextenio
n, or landing
in an
unbalanced
position
Is an
inflammatory
process of
the tendon of
the long
head of the
biceps.
Impingement
or an
inflammatory
injury can
result in
symptoms of
shoulder
pain.
Repeated full
abduction
and ER of the

to their previous
functional level
in 4-6 months.

Often
caused
through
repetitive
overhead
activity
and
motion.
There is
usually
direct
trauma to
the tendon
as the
shoulder
motion
approache
s

Pts report
a deep
ache
directly in
the front
and on
top of the
shoulder.
The ache
may
spread
down into
the
biceps
muscle
and is
usually
made

No lab
tests to
assist with
diagnosis.
Plain xrays do
not
diagnosis
bicipital
tendonitis,
but may
show
calcificatio
n the
groove or
subacromi
al
spurring.

Generally the pt
should avoid all
overhead
movement,
reaching, and
lifting of objects.
Active PT is not
often initiated
immediately,
however, the pt
may be referred
for instruction in
general
education of the
pathology,
guidelines for
restrictions,
pendulum

humeral
head can
lead to
irritation that
produces
inflammation
, edema,
microscopic
tears within
the tendon,
and
degeneration
of the
tendon.Com
mon in
overhead
activities.
Individuals
who throw,
swim, or
swing a
racquet or
club are at
greatest risk.

excessive
abduction
and ER.
High
risk:baseb
all
pitchers,
tennis
players,
gymnastic
s, rowers,
and
swimmers.
Can also
be caused
secondary
to rotator
cuff
disease,
impingem
ent, labral
tears.

worse
with
lifting
heavy
objects.
Resting
the
shoulder
typically
reduces
the pain.
Bicipital
tendinopa
thy, pain
to
palpation
over the
anterior
sholulder
in the
area of
the
biciptial
groove,
pain with
the
biceps
resistance
test
(shoulder
flexion
against
resistance
with the
elbow
extended

MRI can
view the
tendon,
but is
expensive
and not
usually
used
unless the
pt is not
respondin
g to
conservati
ve
treatment.

exercises, and
the use of TENS.
Pt may benefit
from
iontophoresis or
phonophoresis.
As pt progresses
out of acute
stage therapy
should focus on
an exercise
program that
stretches and
strengthens the
affected muscle
groups. This can
restore the
tendons ability
to function
properly,
improve healing,
and prevent
future injury.
Once pt doesnt
experience pain
they can slowly
return to activity.
Most pts can
return to their
activities after
an average of 68 weeks of PT.

Carpal
Tunnel
Syndrome

The carpal
tunnel is
created by
the
transverse
carpal
ligament, the
scaphoid
tuberosity
and
trapezium,
the hook the
hamate and
pisiform, and
the volar
radiocarpal
ligament and
volar
ligamentous
extensions
between the
carpal bones.
The median
nerve, for

Any
condition
such as
edema,
inflammati
on, tumor
or fibrosis,
may cause
compressi
on of the
median
nerve.
Repetitive
use, RA,
pregnancy
, DM,
trauma,
tumor,
hypothyroi
dism, and
wrist
sprain or
fracture.

and
forearm
supinated
) and a
positive
Yerganson
s or
Speeds
are
positive
indicators
.
Most pts
are
diagnose
d
between
35-55
years
with a
greater
prevalenc
e in
women. A
pt will
present
with
sensory
changes
along the
median
nerve
distributio
n in the
hand.
Night

Electromy
ography
and
electroneu
rographic
studies
can be
used to
diagnose a
motor
conductio
n delay
along the
median
nerve. MRI
is
sometime
s used to
identify
inflammati
on of the
median
nerve,
altered

Local
corticosteroid
management,
splinting, and PT.
Pt includes
splinting, carpal
mobilization,
and gentle
stretching. May
require surgery
if conservative
treatment fails.
Post surgical
should include
heat with e-stim,
iontophoresis,
cryotherapy,
gentle ROM. Pt
should initially
avoid wrist
flexion and a
forceful grasp.
After 4 weeks, a
pt can progress

Congenital
Torticollis

flexor
digitorum
profundus
tendons, and
the flexor
polllicis
longus
tendon pass
through the
carpal
tunnel.Carpal
tunnel
syndrome
occurs as a
result of
compression
of the
median
nerve. The
increase in
pressure
produces
ischemia in
the nerve
and results in
sensory and
motor
disturbances.
Is a condition
that causes
the neck to
involuntarily
unilaterally
contract to
one side
secondary to

May be
caused by
local
trauma to
the soft
tissues of
the neck
just before

pain,
weakness
of the
hand,
muscle
atrophy,
grip
strength,
clumsines
s and
wrist
mobility.

tendon or
nerve
positionin
g. Positive
Tinels
sign,
Positive
Phalens

with active wrist

flexion, gentle
stretching, putty
exercises, light
progressive
resistive
exercise, and
modification of
body mechanics.
Radial deviation
against
resistance
should be
avoided due to
the tendency for
irritation. Rehab
usually lasts 6-8
weeks.

Pts head
is
laterally
flexed
towards
the
shortened
muscles

Cervical
spine Xrays are
used to
assess
potential
fracture or
subluxatio

Typically treated
with nonoperative
intervention for
12-24 months
before
considering
surgical

contraction
of the
sternocleido
mastoid
muscle. The
head is
laterally
flexed
toward the
contracted
muscle, the
chin faces
the opposite
direction,
and there
may be facial
asymmetries
.

or during
delivery.
Malpositio
ning in
utero.

side and
chin is
pointed
toward
the
opposite
shoulder.

n. A CT
scan or
MRI of the
cervical
spine can
identify
the
presence
of a
potential
neck
mass.
Electromy
ography
study may
be useful
in defining
the degree
of muscle
or nerve
involveme
nt.

intervention. PT
includes
family/caregiver
education and
teaching,
passive
stretching, local
heat, analgesics,
sensory
biofeedback,
and TENS. AROM
with subsequent
strengthening is
also indicated to
correct the
infants
positioning of
their head. PT is
indicated after
surgery and
should include
manual
stretching of the
neck to maintain
the
overcorrected
position. Manual
stretching
should be
continued 3x
daily for 3-6
months. A
cervical collar
may be used for
first 6-12 weeks
after surgery.

Degenerati
ve
Spondylolis
thesis (DS)

Is the
forward
slippage of
one vertebra
on the
vertebra
below.
Classification
s include
congenital,
isthmic,
degenerative
, posttraumatic,
and
pathologic.
Degenerative
is caused by
the
weakening of
joints that
allows for
forward
slippage one
vertebral
segment on
the one
below due to
degenerative
changes. Can
result in
stenosis of
the spinal
canal.

Most
common
site is L4L5 level.
DS is
caused by
arthritis
and
degenerati
ve
changes in
the spine.
Usually
affects
individuals
over 50.
More
common
in African
females.

Back pain
is a
primary
symptom
that is
said to
increase
with
exercise,
lifting
overhead,
prolonged
standing,
getting
out of bed
or car,
walking
up stairs
on an
incline,
and
positionin
g in
extension
. Pain
maybe
severe
and
radiate
dependin
g on the
area of
stenosis.
Sensory
and
motor

Plain
radiograph
s of the
vertebral
column
are
adequate
to confirm
the
diagnosis
of DS. CT
scan or
MRI may
be
indicated
to rule out
any other
contributin
g
conditions
or to
further
assess
nerve
impingem
ent.

Management
should initially
include
education,
medication,
activity
modification,
and PT. Activity
modification and
rest should be
instituted to
further allow
inflammation to
subside and
improve overall
symptoms.
Williams flexion
exercises should
be performed to
strengthen the
abdominals and
reduce lumbar
lordosis.
External support
may relive
intradiscal
pressure.
Majority of pts
with DS are
successful with
conservative tx.

Fibromyalgi
a Syndrome
(FMS)

Is classified
as a
rheumatolog
y syndrome
or a
nonartiicular
rheumatic
condition.
Pain the
primary
symptom
caused by
tender points
within
muscles,
tendons, and
ligaments.

Diet, sleep
disorders,
viral
infections,
psychologi
cal
distress,
occupation
al &
environme
ntal
factors,
hypothyro
dism,
trauma,
and
hereditary
links.

loss may
be
significan
t and
follow a
myotomal
or
dermato
mal
distributio
n.
Greater
incidence
in
females
and can
affect any
age but
most
frequently
diagnose
d
between
14-68
years.
Widespre
ad hx of
pain,
11/18
tender
points.
Fatigue,
memory
and visual
impairme
nt, sleep

No specific
tests to
diagnose
FMS.
Radiograp
hs are
negative
and blood
work often
appears
normal
except for
a possible
alteration
in the
levels of
substance
P. this
substance
is a
chemical
involved
with pain
transmissi
on.

Education,
medical
management,
and exercises.
Physicians must
address
hormonal
imbalances,
sleep
disturbances.
Psychotherapy
may be
warranted for
anxiety/depressi
on. PT includes
relaxation, heat,
ultrasound,
posture and
body mechanics,
biofeedback,
improve a pts
fitness level.
These pts
require short
exercise

disturban
ces,
irritable
bowel
syndrome
,
headache
s, and
anxiety/d
epression.
Juvenile RA

JRA is a form
of arthritis
found in
children less
than 16.
Causes
inflammation
& stiffness to
multiple
joints for a
period of
greater than
6 weeks. An
autoimmune
disorder
occurs when
the immune
cells
mistakenly
being to
attack the
joints and
organs.

Develops
in children
with a
genetic
predisposit
ion for the
disease.
May be
triggered
by
environme
ntal
factors or
a
viral/bacte
rial
infection.
Girls have
a higher
incidence
of JRA and
most
commonly
in the

3 types of
JRA and
classified
by
number
of joints
involved,
symptom
s,
presence
of RF.
Symptom
s include
persistent
joint
swelling,
pain, and
stiffness.

There is
not a
single test
to identify
the
presence
of JRA.
Blood
tests may
include
serum
evaluation
to
measure
inflammati
on and
detect RF.

sessions initially
(3-5 minutes)
due to a low
tolerance for
exertion. FMS is
not curable,
likely to
experience
these symptoms
for years or even
their entire
lifetime.
A pediatric
rheumatologist
is ideal to direct
a team in the
complex care of
JRA. Primary
goals are to
maintain a high
level of physical
functioning and
quality of life. PT
should include
ROM, exercise,
pain control,
functional
mobility,
strengthening,
endurance,
aerobic trainng.
Modalities,
splints and
orthotics,
pt/family
education will

toddler or
adolescent
.

Lateral
Epicondyliti
s

Tennis elbow,
is
characterize
d by
inflammation
or
degenerative
changes at
the common
extensor
tendon that
attatches to
the lateral
epicondlye of
the elbow.
Primary
symptom is
pain.

Repetitive
wrist
action
against
resistance
during
extension
and
supination
appear to
produce
this
condition.
Continued
microtrau
ma
Men are
more likely
to develop
lateral
epicondylit
is and in
individuals
in their
late 30s &
40s.

Unilateral
involvem
ent, pain
along the
lateral
aspect of
the elbow
and
sometime
s radiates
into the
dorsum of
the hand.
Pain will
increase
with wrist
flexion
with
elbow
extension
, resisted
wrist
extension
, and
resisted
radial

No lab or
imaging
studies
are
required
to
diagnose.
X-ray or
MRI to rule
out other
conditions.

optimize the
quality of life.
Surgical
intervention is
sometimes
warranted. Some
pts outgrow JRA
while others will
be on a long
term basis.
RICE, avoid all
activities that
aggravate the
injury. NSAIDS.
Modalities or
iontophoresis
with
dexamethasone.
Phonophoresis
with
hydrocortisone.
Resting splints
may be used
during acute
stage to relieve
tension in the
involved
muscles. PT
should use
stretching &
strengthening.
All exercise must
remain pain free.
Counter-force
bracing may be
indicated.

MCL Sprain
Grade II

Resists
medially
directed
force at the
knee.
Primary
stabilizer
against
valgus force
and ER of the
tibia
(especially
during knee
flexion). A
grade II is
characterize
d by partial
tearing of
the
ligaments
fibers
resulting in
joint laxaity
when the
ligament is
stretched.

Individuals
participati
ng in
contact
activities
requiring a
high level
of agility
or
susceptibl
e. MOI is
usually a
blow to
the
outside of
the knee
joint. Can
also be
injured by
twisting of
the knee.

deviation.
The pain
usually
with
activity
and is
noted at
night.
Will
present
with an
inability
to fully
extend
and flex
the knee,
pain and
significan
t
tendernes
s along
the
medial
aspect of
the knee,
possible
decrease
in
strength,
potential
loss of
proprioce
ption, and
an
antalgic
gait.

Overall outcome
is favorable and
should return to
previous
activities.

MRI is
extremely
expensive
and
therefore
may not
be
commonly
employed
with a
suspected
MCL injury
without
other
extenuatin
g
circumsta
nces. A
valgus
stress test
will help
detect
medial
instability.
A pt with a
grade II
MCL
sprain

Conservative
management
including RICE.
Pharm
intervention for
pain
management.
May utilize a full
length knee
immobilizer or a
hinge brace and
crutches to limit
WBing. PT
should increase
ROM, light
resistive
exercises. Heel
slides, stationary
cycling without
resistance.
Resistive
exercises should
be directed
towards the
quads and may
include
isometrics and
closed kinetic

Osteoarthri
tis

OA is a
degenerative
chronic
disorder
resulting
from the
biochemical
breakdown
of articular
cartilage in
the synovial
joints.

Primary
OA is
idiopathic
occurring
within
intact
joints and
no history
that
supports
the
initiation
of this
condition.
Primary
OA is
related to
the aging
process
and
typically
occurs in

Slight to
moderate
swelling
around
the knee.

may
exhibit 515 of
laxity with
valgus
stress at
30 of
flexion.

Joints of
the
hands,
knees,
hips, and
spine.
Decrease
in ROM,
crepitus,
deep and
aching
pain. Pts
have pain
during
activity
that is
alleviated
by rest
and
respond
to
analgesic

OA is
typically
diagnosed
on the
basis of
clinical
examinati
on and xray
findings.
Lab tests
will not
diagnose
OA.

chain ex. Gait

and stair
climbing. E-stim,
transverse
friction massage
to the healing
ligament so it
doesnt adhere
down. Pt should
be able to return
to previous
functional level
within 4-8 weeks
following injury.
Pharm
intervention,k
glucocorticoid
intra-articiular
injections may
improve
symptoms.
Nutritional
education and
weight reduction
may be
indicated to
reduce stress on
joints. Posture
retraining, work
site eval,
strengthening,
relaxation and
hydrotherapy,
modalities, pt
education,
aquatic therapy,

Osteogenes
is
Imperfecta
(OI)

A rare
congenital
disorder of
collagen
synthesis
that affects
all
connective
tissue in the
body.
Reduces
collagen
from 2050%.

older
adults.
Secondary
OA results
from
trauma
that has
adversely
affected
the
cartilage.
In pts
greater
than 55,
the
prevalence
of OA I
higher in
women
then men.
Most
children
inherit OI
from
parents as
either an
autosomal
dominant
or
autosomal
recessive
trait. 25%
of the time
the
genetic
defect

s.
Morning
stiffness,
deviated
gait
pattern,
muscle
atrophy.

4 types
that have
a wide
range of
clinical
presentati
ons. Type
I is the
mildest
form &
presents
with easy
bruising,
triangular
face, and
possible

and functional
activities. If
conservative
magnt fails, joint
replacement
therapy may be
indicated.

A skin
biopsy is
used to
examine
the
collagen
and
determine
what type
of OI is
present. Xrays and
bone
scans may
be used
for

Goals include
maximizing
independence
with mobility,
improving
optimal bone
mass and
muscle strength,
and prevention
of fxs. Pharm
intervention has
no strong effect.
Children should
not be given
steroids since it
may deplete

occurs by
spontaneo
us
mutation
of the
genes.

hearing
loss. Type
II is most
severe
form
where a
child dies
in utero
or early
childhood
. Type III
is severe,
presents
with
retardatio
n,
progressi
ve
deformtie
s,
ongoing
fxs,
severe
osteoporo
sis,
triangular
face,
significica
nt
limitation
s in
functional
mobility.
Type IV is
usually
milder

evidence
of
deformitie
s and old
fxs. Bone
densitome
try may
also be
used to
measure
bone mass
and
estimate
the risk of
fx.

bone and
increase fragility.
Light weight
orthotics may be
indicated early
to support the
extremities and
assist with
ambulation. Pt
initially focuses
on parent
handling
techniques,
recognition of
fxs, positioning,
and activities
that facilitate
safe movement.
Swimming is
agood
alternative for
strengthening
and exercise. All
strengthening
exercises should
avoid rotational
forces, placing
weights/resistan
ce near a joint,
and using long
lever arms.
Surgical
procedures
known as
rodding may
also be indicated

and
experienc
e fxs
easily
prior to
puberty,
shorter
stature,
bowing of
long
bones,
possible
hearing
loss,
brittle
teeth.

Osteoporosi
s

Metabolic
bone
disorder
where the
rate of bone
resorption
accelerates
while the
rate of bone
formation
slows down;
osteoclast
activity
exceeds

Risk
factors
include
inadequat
e dietary
calcium,
smoking,
excessive
caffeine,
high
intake of
alcohol or
salt, small
stature,

Low
thoracic
or lumbar
pain,
experienc
e
compressi
on fxs of
the
vertebrae
and
complain
of back
pain. Pain

No
accurate
measure
of overall
bone
strength,
X-rays are
taken to
investigat
e the
amount of
degenerati
on and the
decrease

if child has more

than 2 fxs to the
same bone
within 6 months.
PT may be
required
intermittently
over the pts
childhood. A
strong predictor
of a childs
ability to
ambulate in the
future also lies in
the childs ability
to sit by 10
months. Some
have minimal
involvement
while others use
power
wheelchairs.
Vitamin &
supplemental
management.
Hormone
replacement
therapy is
recommened. PT
should include pt
education
regarding
exercise,
positioning, pain
management,
nutrition, and

osteoblast
activity. This
decreases
the overall
bone density
and strength.
Primarily
affects
trabecular
bone in
postmenopa
usal pt.

Patellofemo
ral
Syndrome

Is caused by
abnormal
tracking of
the patella
between the
femoral
condyles.
Most
commonly
occurs when
the patella is
pulled too far
laterally
during knee
extension.

Caucasian
race,
inactive
lifestyle,
family
history or
chronic
disease.
Postmenop
ausal
osteoporos
is targets
women
50-60
years.
Senile
osteoporos
is targets
men and
women
>70 years.
Adolescen
ce, More
prevalent
in females
than
males, and
has a
direct
associated
with the
activity
level of
the pt.
Patella
alta,

is acute
and
with
WBing
and
palpation.
Pt may
also
present
with
deformitie
s such as
kyphosis,
Dowager
s hump, a
decrease
in height.

in density.
A bone
mineral
test
accounts
for 70% of
bone
strength
and is the
easiest
way to
determine
osteoporo
sis.

fall prevention. A
PT may require a
corset our
lumbar support
if at risk for fxs.
Aquatic tx will
help but should
not replace
WBing activity.
Surgical
intervention may
be required for
fxs. Pts should
be educated to
avoid heavy
resistance,
excessive flexion
during exercise,
or use of ballistic
movements.

Often
describes
a gradual
onset of
anterior
knee pain
following
an
increase
in
physical
activity.
Located
behind
the

Laboratory
or imaging
studies
are not
commonly
used to
diagnose
PF
syndrome.
X-rays are
used to
rule out a
fx.
Arthrogra
m and

Conservative
maganment is
usually
successful,
surgery is rare.
PT includes
controlling
edema,
stretching
(hams, IT band,
TFL and rectus
femoris),
strengthening
(VMO in WBing
and non-WBing

Damage can
range from
softening of
the cartilage
of complete
cartilage
destruction
resulting in
exposure of
subchrondral
bone.

insufficnet
lateral
femoral
condyle,
weak
vastus
medialis
obliquus,
excessive
pronation,
excessive
knee
valgus,
and
tightness
in LE
muscles
(iliopsoas,
hamstring
s, gastroc,
and vastus
lateralis.

patella
and may
be
exacerbat
ed with
activities
that
increase
compressi
ve forces
(stair
climbing,
jumping)
and also
sitting
with knee
flexed 90
for
prolonged
period.
Point
tendernes
s is
common
over the
lateral
border of
the
patella
and
crepitus
may be
elicted
when the
patella is
manually

arthroscop
y can used
to
examine
the
articular
cartilage.
Clarkes
sign can
be useful.
Pts often
have an
increased
Q angle
(13 in
males, 18
in
females) Q
angle is
measured
using the
ASIS,
midpoint
of patella,
and tibial
tubercle.

positions; quad
setting, SLR and
mini squats)
Deep squats
should be
avoided),
improving ROM,
and activity
modification.
Mob activity to
medial glide
can be beneficial
to increase the
flexibility of the
lateral fascia.
Patellar taping
can improve
position and
tracking. An
active pt must
their level of
activity to
relieve
additional stress.
Pt that
undergoes
conservative
mangt can
return to
previous
activities within
4-6 weeks.
Prognosis is a
full recovery
unless failure to
adequately

Plantar
Fasciitis

Imflammator
y process at
its origin on
the
calcaneus.
PF is a
chronic
overuse
condition
that
develops
secondary to
repetitive
stretching of
the PF
through
excessive
foot
pronation
during the
loading
phase of
gait.

Excessive
pronation
during
gait,
tightness
of the foot
calf
muscles,
obesity,
and
possessing
a high
arch.
Running or
dancing,
prolonged
walking or
standing
are at an
increased
risk.

compress
ed into
the
trochlear
groove.
Severe
pain in
the heel
when first
standing
up in the
morning.
Pain
typically
subsides
for a few
hours
during
the day,
but
increases
with
prolonged
activity.
Described
as pain
that
moves
around
Point
tendernes
s, usually
unilateral
and
tightness
in the

address the
cause of PF
syndrome.
Initially
treated
based on
symptoms
and
physical
exam. If
pain
persists
after 6-8
weeks of
PT, MRI
may be
used to
confirm
the
diagnosis.

Medical and
pharm mangt.
Requires
corticosteroid
injections or
antiinflammatory
medications. PT
consists of ice
massage, deep
friction
massage, shoe
modification,
heel insert, foot
orthotic
prescription,
modifications of
activity, gentle
stretching.
Muscle
strengthening
for the intrinsic
and extrinsic
muscles should
be implemented
once the acute
symptoms have
subsided. Night
tension splints
may be
indicated is

Achilles
tendon.

Reflex
Sympatheti
c Dystrophy

Also known
as complex
regional pain
syndrome.
Type I
(occurring
subsequent
to trauma)
type II
(associated
with
peripheral
nerve injury)
is usually
found in an
extremity
that has
experience
some form of
trauma.
Symptoms
result from a
disturbance
in the
functioning
of the
sympathetic

Trauma,
surgery,
CVA, TBI,
repetitive
motion
disorders,
and LMN
and
periperhal
nerve
injuries.
Most likely
found in
35-60
years of
age with
females 3x
more likely
to be
affected
than
males.

symptoms
persist. Pt
should return to
functional level
within 8 weeks.
Total resolution
of symptoms
can take up to
12 months.
Intense
X-rays
RSD requires
burning
may
prolonged
and
reveal
medical
chronic
bone less, management. Tx
pain in
osteoporo
is based on
the
sis,
identifying the
affected
erosion.
underlying cause
extremity Thermogra and stage of
that will
phic
RSD at the time
eventuall
studies,
of diagnosis.
y spread
laser
Surgical
proximally Doppler
interventions
. Edema,
flowmetry. such as
thermal
sympathetic
changes,
blocks, or a
discolorat
sympathectomy
ion,
are used to
stiffness,
alleviate pain. PT
and
includes pain
dryness
control, pt
are seen
education, skin
during
care, joint mob,
stage I
desensization,
(acute
functional
stage).
activity training.
Progressi
Overall
on to
prognosis is

nervous
system. This
causes a
release of
norepinephri
ne in the
periphery
and
subsequent
vasoconstrict
ion of blood
vessels. This
results in
pain and in
sensitivity to
peripheral
stimulation

RA

Rheumatoid
Arthritis is an
autoimmuine
disorder of
the
connective
tissue that is
characterize
d by chronic
inflammation

Genetic
predisposit
ion with
viral or
bacterial
triggers.
The
incidence
of RA in
women is

stage II
(dystrophi
c stage) is
characteri
zed by
worsenin
g and
constant
pain,
tropic
skin
changes.
Stage III
(atrophic
stage) is
characteri
zed by
continued
pain,
hardened
edema,
atropic
changes
to
fingertips
or toes.
RA will
vary in
onset and
progressi
on from
pt to pt.
May be
sudden or
develop
over a

better for a pt
that beings tx
early in the
cycle. RSD can
spontaneously
resolve, continue
with ongoing
symptoms that
can last for
years or follow a
pattern of
remissions.
Research
indicates a
better prognosis
if treatment is
initiated within
the first 6
months of the
disease.

Blood
work
assists
with the
diagnosis
of RA
through
evaluation
of the RF,
white

Early medical
mangt is critical
to improve the
long term
outcomes of the
disease. It will
focus on pain
relief, reduction
of edema, and
preservation of

within the
synovial
membranes,
tendon
sheaths, &
articular
cartilage.
Smaller
peripheral
joints are
usually the
first to be
affected.

3x greater
than in
men.
Diagnosed
most
frequently
between
30-50
years of
age.

period of
weeks.
Early
signs
include
fatigue,
bilateral
involvem
ent,
tendernes
s of
smaller
joints, &
low grade
fever. Pts
experienc
e pain
with
motion,
stiffness,
progressi
on of
symptom
s to larger
synovial
joints. In
later
stages
the heart
can
become
affected
and
deformitie
s,
subluxati

blood cell
count,
erythrocyt
e
sedimenta
tion rate,
hemoglobi
n, and
hematocrit
values. A
synovial
fluid
analysis
evaluates
the
content of
synovial
fluid
within the
joint. Xrays can
be used to
evaluate
the joint
space and
the extent
of
decalcifica
tion.

joint integrity. PT
includes pt
education
regarding
regular rest, pain
relief, relaxation,
positioning, joint
protection
techniques,
gentle massage,
hydrotherapy,
hot pack,
paraffin, or cold
modalities,
gentle
isometrics, and
instruction in
use of assistive
devices. Low
impact
conditioning,
endurance and
strength during
remission. PT
cannot halt RA
but can improve
a pts ability to
function. No
known cure that
creates
irreversible
damage and
deformity and
results in
disability.

Rotator Cuff
Tendonitis

Repetitive
overload can
produce
impingement
of the
supraspinatu
s tendon
immediately
proximal to
the greater
tubercle of
the humerus.
The
impingement
is caused by
an inability
of a weak
supraspinatu
s muscle to
adequately
depress the
head of the
humerus in
the glenoid
fossa during
elevation of
the arm. As a
result the
humerus
translates
superiorly
due to the

ons and
contractu
res can
occur.
Individuals Often
participati reports
ng in
difficulty
activities
with
that
overhead
require
activities
excessive
and a dull
overhead
ache
activity
following
such as
periods of
swimming, activity.
tennis,
The pt
baseball,
may
painting,
experienc
and other
ea
manual
feeling of
labor.
weakness
Individuals and
from 25-40 identify
years of
the
age are
presence
the most
of a
likely to
painful
develop
arc of
this
motion
condition.
most
commonl
y
occurring
between
60-120
of active

MRI can
be used to
identify
the
presence
of rotator
cuff
tendonitis,
however,
due to the
high cost
is not
commonly
employed
prior to
formal
treatment.
X-rays
with the
shoulder
laterally
rotated
can be
used to
identify
the
presence
of calcific
deposits
or other
bony
abnormalit

Early PT:
cryotherapy,
activity
modification,
ROM, & rest.
After pain
subsides pt is
instructed in
strengthening
exercise. All
ROM should be
pain free. ROM
using a pulley
system or a
cane can serve
as an effective
intervention.
Elastic tubing
and hand held
weights are
often preferred.
Shoulder shrugs
and push-ups
with arms
abducated to
90 can
effectively be
used to
strengthen the
upper trap and
serraus anterior.
Pt should be

disproprotion
ate action of
the deltoid.

abduction
. Pt
usually
presents
with pain
with
palpation
of the
musculot
endinous
junction
of the
involved
muscle or
with
stretching
or
resisted
contractio
n of the
muscle.
Pain often
increases
at night
resulting
in
difficulty
sleeping
on the
affected
side.
Difficulty
with
dressing,
and
repetitive

ies.
Special
tests
including
the empty
can, jobe
test,
neers,
Hawkinskennedy
can be
used to
confirm.

able to return to
previous level of
functioning
within 4-6
weeks. Also
depends on
classification of
stage. Stage I is
population less
than 25 years.
Stage II is 25-40
years. Stage III
end stage and
likely over 40.

Sciatica
Secondary
to a
herniated
Disk

A herniated
disk is an
intervertebra
l disk that
bulges and
protrudes
posterolatera
lly against a
nerve root.
Sciatica is
the diagnosis
of
compression
of the sciatic
nerve (L4,
L5, S1, S2,
S3)
secondary to
a herniated
disk causing
pts
symptoms.
Other causes
of sciatica
include
tumor,

The
natural
aging
process.
Each
decade
the
compositio
n of the
annulus
fibrosus
and
nucleus
pulposus
is altered
and
decreases
in overall
stability.
Once there
is
adequate
structural
breakdown
within the
disk, a pt

motions
such as
lifting,
reaching,
throwing,
swinging
or
pushing
and
pulling.
Low back
& gluteal
pain that
typically
radiates
down the
back of
the thigh
along the
sciatic
nerve
distributio
n. Sciatic
pain
occurs
from
nerve
root
compressi
on and
can be
dull,
aching or
sharp.
Pain may
have a

Radiologic
testing of
the spine
and
electrophy
siologic
studies
are
initially
performed
to assist
with
diagnosis.
Other
imaging
may
include
myelogra
m,
discograp
hy, CT
scan or
MRI. Blood
work may
assist with
differential

Short-term bed
rest, overall
reduction of
intradiskal
pressure, pt
education, PT,
meds and in rare
instances
surgical
intervention. PT
will include pain
mangt, traction,
heat, lumbar
endurance
activities,
mckenzie
exercises,
stretching, and
walking are
indicated with
tolerance.
Lifting,
squatting, and
climbing are
contraindicated
due to the

infection,
spondyloisth
esis,
narrowing of
the canal,
and blood
clots.

becomes
high risk
for injury.
As
expected,
sciatica
secondary
to a
hearniated
disk is
most often
seen in pts
between
40 and 60
years.

sudden
onset or
develop
gradually
over time.
Early
sciatica
may
involve
discomfor
t or pain
limited to
the low
back and
gluteal
region.
Leg pain
can
become
greater
than the
back pain
and can
radiate
the entire
length of
the nerve
to the
toes. The
pt may
also
experienc
e
intermitte
nt
numbnes

diagnosis.
The SLR
will
reproduce
symptoms
in the case
of a
herniated
disk.

significant in
intradiskal
pressure.Most
herniations will
spontaneously
decrease in size
with
conservative
treatment.
Research
indicates
majority of pts
will improve with
2-4 months of
conservative tx,
however 2%
undergo surgery.
Pts needs
stabilization
exercises at
home. This
condition can be
corrected
through rest and
PT. Healing of
the disk can also
occur and
scarring can
reinforce the
posterior aspect
and annular
fibers so that it
is protected from
further
protrusion.

Scoliosis

Pt presents
with lateral
curvature of
the spine.
The curve is
usually found
in the
thoracic or
lumbar area.
The curve of
the spine
may be
towards the

Idiopathic
scoliosis,
accounts
for 80% of
all cases.
Upwards
of 1:10
children
are
affected
by some
form of
scoliosis

s and
tingling
localized
to the
dermato
mal
distributio
n, limited
thoracolu
mbar
range of
motion in
all planes,
tendernes
s to
palpation
at the
segment
of
herniation
and
muscle
guarding.
A pt with
a
structural
curve will
present
with
asymmetr
ies of the
shoulders
,
scapulae,
pelvis,
and

X-ray
should be
taken in
an
anterior
and lateral
view with
the pt
standing
and with
the pt
bending
over. A

Based on the
type and
severity of the
curve. E-stim to
alleviate pain
and biofeedback
for education
with proper
posture and
positioning. A pt
with scoliosis
that is less than
25 should be

right or left &

with our
without
rotation.
Typically, the
rotation will
occur
towards the
convext side
to the major
curve.

with 1:4
requiring
treatment
for the
curve.
Infantile
(0-3),
juvenile
(4puberty),
adolescent
(12 for
girls, 14
for boys),
or adult
(skeletal
maturation
) scoliosis.
Nonstructural
scoliosis is
a
reversible
curve that
can
change
with
repositioni
ng. Thisi
type of
curve is
non
progressiv
e and is
usually
cased by

skinfolds.
Juvenile
idiopathic
scoliosis
is
characteri
zed by a
thoracic
curve
with
convexity
towards
the right.
As the
curve
progresse
s there
will be a
rib hump
posteriorl
y over the
thoracic
region on
the
convex
side of
the curve.
Adolescen
t scoliosis
of greater
than 30
is seen
more in
females
than
males.

device
called a
scoliomete
r can be
used to
measure
the angle
of trunk
rotation.
The Cobb
method
can be
used to
determine
the angle
of
curvature.
A bone
scan or
MRI can
be used to
determine
and rule
out
conditions
such as
infections,
neoplasms
,
spondylosi
s, disk
herniation
s, or
compressi
on
fractures.

monitored every
3 months.
Breathing
exercises & a
strengthening
program for the
trunk and pelvic
muscles are
indicated. A pt
with scoliosis
that ranges
beween 25 &
40 requires a
spinal orthosis
and PT for
posture,
flexibility,
strengthening,
respiratory
function, and
proper utilization
of the spinal
orthosis. A pt
with scoliosis
greater than 40
usually requires
surgical spinal
stabilization.
One method is
spinal fusion and
stabilization with
a Harrington
Rod. Prognosis
for structural
scoliosis is
based on the

Spondylolis
thesis

Refers to
forward
slippage of
one vertebral
body with
respect to
the vertebral
body below
it. In many
cases there
can be
symptoms
that range
from
localized or
radiating

poor
posture or
leg length
discrepanc
y.
Structural
scoliosis
cannot be
corrected
with
movement
and can
be caused
by
congenital,
musculosk
eletal, and
neuromus
cular
reasons.
A defect in
the pars
interarticul
aris that
may
produce
the
forward
slippage of
a
vertebrae
as found
with
spondyloli
stheiss.
High risk

Curves
that are
less than
20 rarely
cause a
person to
experienc
e
significan
t
problems
or
impairme
nts.

Pain is
the most
common
symptom.
If the pt is
young,
pain is
usually
confined
to the
area of
slippage
and may
occasiona
lly
radiate.

age of onset and

severity of the
curve. Early
intervention
results in the
best possible
outcome. If the
curvature is over
50 there likely
will be ongoing
progression of
the curve each
year of life.

Lateral
and
anteropost
erior plain
x-rays of
the
lumbar
spine
should be
obtained.
The
oblique
view can
show the
pars as
having the

Initially treated
conservatively
regardless of the
type or
causative
factors. PT is
indicated with
emphasis on
activity
modification, pt
education on
disease process,
bracing, and
therapeutic
stretching and
strengthening.

Temporoma
ndibular
Joint
Dysfunction

pain to
significant
nerve
compression,
radiculopath
y or
neurogenic
claudication.
Spondylosis
has a 2:1
male to
female
predominanc
e compared
to all forms
of
spondylolisth
esis, which
indicated a
female to
male
predominanc
e of 2:1.
Overall,
females tend
to me more
prone to
progressive
spondyloisth
esis and
require
surgery.
TMJ is a
complex joint
that is
classified as

activities
include
gymnastic
s,
wrestling,
football,
and
weight
lifting.

Progressi
on
involves
neurologi
cal,
motor,
sensory,
and reflex
changes.
Pain is
usually
provoked
with
activity
especially
when it
involves
extension
of the
spine.

appearanc
e of a
Scottie
dog with a
collar
when a
spondylosi
s is
present.
Other
studies
may
include a
bone scan,
CT scan
and
myelogra
m. Lab
studies
will not
assist with
diagnosis.

Exercise
protocols should
include exercise
and activity that
reduces stress
with spinal
extension.
Conservative
treatment is
very successful
especially with
the younger pt,
however,
surgery may be
indicated for
unsuccessful
pts.

Predisposi
ng factors,
triggering
factors,

A pt will
present
with
symptom

May
include xray, MRI,
mandibula

Pharm
management,
splint to assist
with realignment

a condylar,
hinge, and
synovial
joint. The TMJ
contains
fibrocartilagi
nous
surfaces &
articular
discs. TMJ
dysfunction
occurs due
to a change
in the joint
structure
that can
cause
multiple
symptoms
and a
limitation in
function. In
many
instances
inflammation
& muscle
spasm
surrounding
the joint
produces
symptoms
for the pt.

and
perpetuati
on/sustaini
ng factors.
Can occur
due to
injury or
trauma to
the joint,
congenital
abnormalit
ies,
internal
derangem
ent of joint
structure,
arthritis,
dislocation
, disk
degenerati
on,
metabolic
conditions
or stress.
Habits of
gum
chewing
and nail
biting may
increase
the
incidence
of injury.
Pts are
typically
between

s that
include
pain,
muscle
spasm,
abnormal
or limited
jaw
motion,
headache
, and
tinnitus.
Pt will
often
complain
of feeling
and
hearing a
clicking
or
popping
sound
with
motion at
the TMJ.

r
kinesiogra
phy, CT
scan, and
a dental
examinati
on.

of the joint and a

guard or bite
plate to maintain
proper position.
PT is based on
the exact
etiology of the
dysfunction. It
includes pt
education,
postural
retraining, moist
heat, ice,
biofeedback,
ultrasound, estim, TENS,
stretching, joint
mobs, ROM and
relaxation. PT
intervention
should improve
a pts condition
and decrease
the symptoms. If
conservative
treatment fails,
surgery may be
required.

Total Hip

Warranted
secondary to
progressive
and severe
osteoarthritis
or RA,
development
al dysplasia,
tumors,
nonuntion fx,
avascular
necrosis.
Destruction
of cartilage
resuls in
bone to bone
contact.

20-40
years with
a greater
incidence
in women.
Intraarticular
disease or
the
destructio
n of
articular
cartilage
may come
for
arthritis,
repetive
microtrau
ma,
obesity,
nuturitiona
l
imbalance
s, falls or
abnormal
joint
mechanics
.

Pt will
present
with
decrease
d ROM,
impaired
mobility
skills, and
persistent
pain that
increases
with
motion
and
weight
bearing.
The pt is
usually
over 55
years of
age and
has
experienc
ed
consistent
pain that
is not
relieved
through
conservat
ive

X-ray, CT
and MRI
procedure
s may be
used to
view the
integrity
of the
joint.
These
procedure
s are also
used to
rule out a
fx or
tumor.
Contraindi
cations for
surgery
include
active
infection,
severe
obesity,
arterial
insufficien
cy, NM
disease,
and
certain
mental

A THA that
utilizes a
posteriorlateral
approach allows
the abductor
muscles to
remain intact,
however there
may be a higher
incidence of joint
instability due to
the interruption
of the posterior
capsule.
Management will
include pharm
(anticoagulant),
hip precautions,
ankle pumps,
quad sets,
gluteal sets, heel
slides, and
isometric
abduction, scar
management. At
the time of
hospital
discharge the pt
should be able
to extend the hip
to neutral and

Total Knee

May be
warranted
secondary to
progressive
and disabling
pain within
the knee
joint.

Destructio
n of
articular
cartilage
secondary
to OA.

measures
.

illness.

Severe
knee pain
that
worsens
with
motion
and
weight
bearing,
limited
ROM,
possible
deformity
and
impaired
mobility.

X-ray, CT,
and MRI
imaging
are used
to
determine
the extent
of
deteriorati
on. A pain
assessme
nt scale
and the
Arthritis
Impact
Measurem
ent tool
may be
used.

flex the hip to

90. The pt
should have
diminished to no
pain, increased
strength and
endurance, and
improved
mobility within
6-8 weeks after
surgery.
Post-operative
care includes a
knee
immobilizer,
elevation of the
limb, crotherapy,
CPM, and
initiation of knee
protocol
exercises. A
noncemented
knee requires
toe touch weight
bearing for up to
6 weeks to allow
the bone to grow
and affix to the
prosthesis. PT
should focus on
mobility training
with the AD.
Early ambulation
is encouraged in
order to avoid
Deconditioning

and the risk of

DVT. PT should
include ankle
pumps, quad
sets, and
hamstring sets
as well as ROM
and stretching. A
goal of 90 of
knee flexion and
0 knee
extension is
often
established prior
to discharge.
Precautions
follow surgery
for several
months: avoid
squatting, avoid
quick pivoting,
do not use
pillows under
the knee while in
bed, and avoid
low seating. The
pt should
experience relief
of pain that will
allow a full
return to
previous
functional
activities within
8-12 weeks after
surgery.

Total
Shoulder

Sever pain
and impaired
shoulder
motion due
to
deterioration
of the GH
joint. These
candidates
have
undergone
conservative
treatment
measures
that have
failed to
improve their
condition.

Degenerat
ive joint
disease,
pain and
limited
ROM
secondary
to OA, RA,
avascular
necrosis,
fracture or
rotator
cuff
arthropath
y. Others
are bone
tumor,
Pagets
disease or
with
recurrent
dislocation
s.

Pt will
exhibit
impaired
ROM at
the
shoulder,
may lack
independ
ence with
functional
mobility
and ADLs,
and
severe
pain. It is
this
unremitti
ng pain
(with
failed
conservat
ice
treatment
) that is
the
primary
indication
for TSA.
Usually
performe
d on pts
between
55-70
years.

X-ray will
reveal the
level of
degenerati
on within
the
shoulder
complex.
MRI or CT
will allow
the
physician
to assess
the
integrity
of the
rotator
cuff and
deltoid
muscles
surroundin
g the joint.

A pt status post
TSA will remain
hospitalized for
an average of 25 days. A CPM
may be
prescribed by
the surgeon for
the use during
the pts
hospitalization.
PT is initiated
the day after
surgery and
should follow the
shoulder rehab
protocol
designed by the
surgeon. The
shoulder usually
remains
immobilized
using a sling
during initial
rehab. The Neer
shoulder
protocol
advocates
initiating
isometric
shoulder
exercise approx.
3 weeks after
surgery and
active shoulder
exercises 6

Transfemor
al

Osteosarcom
a is the 2nd

Osteosacr
omas can

Found
most

X-ray, MRI
and

weeks after
surgery. PROM
and AAROM are
indicated but
AROM at the
shoulder is
contraindicated
during the first
phase of rehab.
PT includes pain
mgnt, AROM,
therapeutic ex,
edema
management, pt
education in selfROM and
wand/pendulum
ex and use of
modalities. A pt
must not
perform any
form of medial
rotation or
lateral rotation
beyond 35-40
during the first
2-3 weeks post
surgery. PT
should assist the
pt to meet goals
of relieving pain
and regaining
functional
motion.
Physical &
occupational

Amputation
due to
Osteosarco
ma

most
common
primary bone
tumor and is
a highly
malignant
cancter that
begins in the
medullary
cavity of a
bone and
leads to the
formation of
a mass. It
usually
affects bones
with an
active
growth
phase such
as the femur
or tibia and
is often
located in
the
metaphysic.
Amputation
may be
necessary to
remove the
tumor and
surrounding
tissues to
avoid
metastic
disease.

occur as a
primary or
secondary
cancer
and the
etiology is
unknown.
This form
of tumor
primarily
affects
young
children
(especially
males),
adolescent
s, and
young
adults
under 30
years of
age. A
peak time
for
incidence
is during a
growth
spurt.

often in
long
bones at
the site of
the most
active
epiphysea
l growth
plate, the
distal
femur,
proximal
tibia,
proximal
humerus,
and
pelvis.
The knee
region
accounts
for approx
50% of
osteosarc
omas. Pts
that
require
amputatio
n
secondar
y to an
osteosarc
oma will
present
with a
mass
often

scintigrap
hy allow
the
physician
to
determine
the
presence,
location,
and size of
a tumor.
The
Codmans
triagle
can be
seen on xray
indicating
reactive
bone at
the site
where the
periosteu
m has
been
elevated
by the
neoplasm.
Definitive
diagnosis
for an
osteosarco
ma is
made
through
tissue

therapies should
begin
immediately
after the
transfemoral
amputation.
Preprosthetic
intervention
should focus on
ROM,
positioning,
strengthening,
desensitization,
and pt education
for care of the
residual limb. Pts
with a
transfemoral
amputation
should lie prone
for period of
time each day to
prevent a hip
flexion
contracture.
Modalties may
be used to
improve ROM
and decrease
pain. Serial
casting may be
indicated if a
contracture
develops.
Without
complication the

Transtibial
Amputation
due to
Arterioscler
osis
Obliterans

Arteriosclero
sis obliterans
(AKA
peripheral
arterial
disease;
PAD) is a
form of
peripheral
vascular
disease that
produces
thickening,
hardening,
and eventual
narrowing
and
occlusion of
the arteries.
This results

Risk
factors
associated
with
arterioscle
rosis
obliterans
include
age,
diabetes,
sex, HTN,
high
serum
cholesterol
and lowdensity
lipid
levels,
smoking,
impaired

found in
the tibia
or femur.
Most
common
symptom
s are pain
and
swelling,
pain
worse at
night or
with
exercise a
lump may
develop.
The pt
that
requires a
transtibial
amputatio
n
secondar
y to this
condition
is
typically
an
individual
over 45
years that
smokes
and will
present
with
intermitte

biopsy of
the tumor.

pt should be
able to return
home with
support and
receive short
term physical
therapy for
prosthetic
training.

Arterioscle
rosis
obliterans
can be
diagnosed
using
Doppler
ultrasonog
raphy, MRI
or
arteriogra
phy. These
diagnostic
tests
examine
the degree
of blood
flow
throughou
t the

A pt should be a
candidate for
inpatient PT
services
immediately
after the
transtibial
amputation.
Preprosthetic
intervention
should focus on
strength, ROM,
functional
mobility, use of
Ads,
desensitization,
and pt
education. A pt
should be able
to achieve

in ischemia
and
subsequent
ulceration of
the affected
tissues. The
affected area
may become
necrotic,
gangrenous,
and require
amputation.

glucose
tolerance,
obesity,
and
sedentary
lifestyle.
Unsuccess
ful mangt
of PVD
may
ultimately
lead to
uncontroll
ed
infection,
gangrene,
necrosis,
and
amputatio
n. Males
have an
overall
higher
incidence
of
arterioscle
rosis than
females.

nt
claudicati
onthat
produces
cramps
and pain
in the
affected
areas.
Resting
pain,
decrease
d pulses,
ischemia,
pallor
skin, and
decrease
d skin
temp.

extremitie
s.

estabilished
goals and
function with a
prosthesis and
an AD if
warranted.

Pharmacological Management of the MS System:

Drug
Nonopiod
Agents

Action

Indications

Provide
analgesia
and pain
relief,
produce
antiinflammator
y effects,
and initiate
anti-pyretic
properties.
These drugs
promote a
reduction of
prostaglandi
n formation
that
decreases
the
inflammator
y process,
decreases
uterine
contractions
, lowers

Mild to
moderate
pain of
various
origins,
fever,
headache,
muscle
ache,
inflammatio
n (except
acetaminop
hen),
primary
dysmenorrh
eal,
reduction of
risk of
myocardial
infaction
(aspirin
only)

Side
Effects
Nausea,
vomiting,
vertigo,
abdominal
pain,
gastrointes
tinal
distress or
bleeding,
ulcer
formation,
potential
for Reye
syndrome
in children
(aspirin
only)

Implicatio
ns for PT
Pts are at
increased
risk for
masked
pain that
would allow
for
movement
beyond
limitation
or false
understand
ing of their
level of
mobility.
Complaints
of stomach
pain should
be taken
seriously
with a
subsequent
referral to a
physician.

Examples
Tylenol
(acetamino
phen);
Nonsteroida
l antiinflammato
ries
(NSAIDS):
Aspirin
(acetylsalic
ylic acid),
Aleve
(naproxen),
Advil
(ibuprofen,
Celebrex
(celecoxib)

Opioid
Agents
(narcotics)

fever, and
minimizes
impulse
formation of
pain fibers.
Opioid
agents
provide
analgesia
for acute
severe pain
managemen
t. The
medication
stimulates
opioid
receptors
within the
CNS to
prevent pain
impulses
from
reaching
their
destination.
Certain
drugs are
also used to
assist with
dependency
and
withdrawal
symptoms.

Moderate to
severe pain
of various
origins,
induction of
conscious
sedation
prior to a
diagnostic
procedure,
managemen
t of opiod
dependence
, relief of
severe and
persistent
cough
(codeine)

Mood
swings,
sedation,
confusion,
vertigo,
dulled
cognitive
function,
orthostatic
hypotensio
n,
constipatio
n,
incoordinati
on,
physical
dependenc
e, tolerance

A therapist
must
monitor the
pt for
potential
side
effects,
especially
signs of
respiratory
depression.
Treatment
that is
otherwise
painful
should be
scheduled
approximat
ely 2 hours
after
administrat
ion to
maximize
the
analgesic
benefit. A
pt may not
accurately
report if a
particular
technique

Roxanol
(morphine),
Demerol
(meperidine
), Oxycontin
(oxycodone
),
Sublimaze
(fentanyl),
Paveral
(codeine)

Glucocorticoi
d Agents
(Corticosterio
ds)

Glucocortico
ids provide
hormal,
antiinflammator
y, and
metabolic
effects
including
suppression
of articular
and
systemic
diseases.
These
agents
reduce
inflammatio
n in chronic
conditions
that can
damage
healthy
tissue
through a
series of
reactions.
Vasoconstric
tion results
from
stabilizing
lysosomal
membranes
and
enhancing

Replacemen
t therapy for
endocrine
dysfunction,
anti
inflammator
y and
immunosup
pressive
effects;
treatment of
rheumatic,
respiratory,
and various
other
diseases

Muscle
atrophy, GI
distress,
glaucoma,
adrenocorti
cal
suppressio
n, drug
induced
Cushing
syndrome,
weakening
with
breakdown
of
supporting
tissue
(bone,
ligament,
tendon,
skin) mood
changes,
HTN

is painful.
A therapist
must wear
a mask
when
working
with pts on
glucocortic
oid therapy
since their
immune
system is
weakened.
A therapist
must be
aware of
signs of
toxicity
including
moon face,
buffalo
hump, and
personality
changes.
Pts are at
risk for
osteoporosi
s and
muscle
wasting.
Treatment
of an
injected
joint will
require
special

Deermacort
(hydrocortis
one or
cortisol),
Cordrol
(prednisone
),
Prediapred
(prednisolo
ne), Medrol
(methylpre
disolone),
Decadrol
(dexametha
sone),
Nasonex
(mometaso
ne)

the effects
of
catecholami
nes.
Diseasemodifying
Antirheumati
c Agents

DMARDS
slow or halt
the
progression
of rheumatic
disease.
They are
used early
during the
disease
process to
slow the
progression
prior to
widespread
damage of
the affected
joints. They
act to
induce
remission by
modifying
the
pathology
and
inhibiting
the immune
response
responsible
for
rheumatic

Rheumatic
disease,
preferably
during early
treatment

Nausea,
headache,
joint pain
and
swelling,
toxicity, GI
distress,
sore throat,
fever, liver
dysfunction
, hair loss,
potential
for sepsis,
retinal
damage

care due to
ligament
and tendon
laxity or
weakening.
Therapists
should
recognize
that many
of the
gents have
a high
incidence
of toxicity.

Rheumatre
x
(methotrex
ate), Arava
lefunomide)
,
Antimalari
a: Aralen
(chloroquin
e),
Plaquenil
(hydroxychl
oroquine);
Gold
compound
s: Ridaura
(auranofin),
Solganal
(aurothiogl
ucose);
Tumor
necrosis
factor
inhibitors:
Humira
(adalimuma
b), Enbrel
(etanercept
)

disease.
Individual Joints MS:

Shoulder:

Upward rotators: Upper trap, lower trap, serratus anterior

Downward rotators: Levator scapulae, rhomboids
External rotators: Infraspinatus, teres minor, deltoid
Internal rotators: Subscapularis, Latissimus, teres major, pec major & minor
Abductors: deltoid, supraspinatus
Adductors: subscapularis, pec major, lat, teres major & minor
ROM:
FLEX/ABD: 180
ER: 90
IR: 90
EXT: 60
Arthrokinematics:
Motion to Increase
Abduction
Early flexion (0-45)
Internal rotation
Horizontal adduction
Extension/lateral rotation
Horizontal abduction
Late flexion (120-180)

Mobilization Glide
Inferior or caudal glide
Posterior glide
Posterior glide
Posterior glide
Anterior glide
Anterior glide
Anterior glide

Degree of Abduction:
First 20 degrees: Supraspinatus
90-150 degrees: serratus anterior and trapezius
Degree of Elevation:
0-60 degrees: anterior delt, coracobrachialis, pec major

60-120 degrees: serratus anterior, and trap

Force couple of the shoulder:
-Downward rotation: levator and rhomboids vs. lat, pec major and minor
-Upward rotation: serratus (most effective rotator) and upper trap vs. lower trap that contributes during later phase
of shoulder abduction
Peripheral Nerve Tests:
Spinal Accessory nerve-Inability to abduct the arm beyond 90 degree, Pain in shoulder with abduction
Musculocutaneous nerve- Weak elbow flexion with forearm supinated
Long thoracic nerve- Pain on flexing fully extended arm, inability to flex fully on extended arm, winging of scapula
at 90 degree of forward flexion
Suprascapular nerve- Increased pain on forward shoulder flexion, pain increased with scapular abduction, pain
increased with cervical rotation to opposite side
*Painless weakness is usually due to neurologic problems or myopathies.
* Shoulder weakness may be caused by a rotator cuff tear or nerve injury.
* Symptoms that are not associated with movement should alert the clinician to a more serious condition.
* Pain that is worse at night, but increased when rolling onto the shoulder, points to periarticualr mechanical
problems.
* Pain that occurs between 70-110 degrees of abduction is deemed a painful arc and may indicate rotator cuff
impingement, or tearing, or subacromial bursitis. Pain which occurs in the 120-160/160-180 degrees range, may
indicate involvement of the A-C joint.
* Loss of ACTIVE motion with preservation of PASSIVE motion is likely caused by rotator cuff tear.
* A severely restricted active abduction pattern with NO pain is suggestive of a rupture of the supraspinatus or
deltoid.
* Loss of BOTH active AND passive motion is usually caused by adhesive capsulitis.
* A loss of passive OR active ROM may be associated with a loss of flexibility in the passive restraints to motion.
Muscles prone to tightness-Upper trap, levator, pec major and minor, upper cervical extensors, sternocleidomastoid,
scalene, teres major and minor, subscapularis
Muscles prone to lengthening-Middle and lower trap, rhomboids, serratus anterior, deep neck flexors, supraspinatus,
infraspinatus
Closed packed position-90 degress of GH ABD & full ER

Capsular pattern: Most limited: ER, ABD, & IR (least)

Common MMT for the shoulder:
1. Scapular Elevation (Upper trap, Levator Scap): Sitting, apply resistance over superior aspect of shoulders in
inferior direction. Gravity Eliminated: Pt prone
2. Scapular Adduction (Middle trap): Pt prone and performs active scapular adduction. Examiner applies
resistance over lateral aspect of scapula in direction of scapular abduction. Gravity eliminated: Seated c
shoulder abducted to 90 degrees and full lateral rotation.
3. Scapular adduction and depression (Lower trap): Prone c upper extremity in ~130 abd and 0 degrees
elbow extension. Apply resistance over lateral aspect of scapula. Gravity eliminated: No separate test.
4. Scapular adduction and downward rotation (Rhomboid major and minor): Pt prone with upper extremity
behind back. Shoulder in medial rotation and adduction (dorsum of hand on gluteal region). Apply resistance
on vertebral border of scapula in direction of scapular abduction and upward rotation. Gravity eliminated: Pt
seated with arm behind back.
5. Scapular abduction and upward rotation (Serratus Anterior): Pt supine with UE in 90 degrees shoulder
flexion and elbow extension. Apply resistance by grasping wrist and pushing down. Gravity eliminated: Seated
with UE in 90 degrees shoulder flexion with arm supported on flat surface.
6. Shoulder flexion (anterior delt, coracobrachialis): Pt seated with UE in 0 degrees flexion and adduction,
palm facing trunk. Apply resistance proximal to elbow. Gravity eliminated: Side-lying with arm to be tested
uppermost and supported.
7. Shoulder extension (Lat, Teres major, pos delt): Pt prone, with palm facing ceiling. Pt raises arm through
range, apply resistance just proximal to elbow. Gravity eliminated: Side-lying with arm to be tested uppermost
and supported.
8. Shoulder abduction (Middle delt, supraspinatus): Seated. Apply resistance proximal to elbow. Gravity
eliminated: Supine on firm surface.
9. Shoulder horizontal abduction (posterior delt): Pt prone with upper extremity in 90 degree shoulder
abduction, 90 degree elbow flexion, arm hanging off table. Apply resistance over distal humerus. Gravity
eliminated: Seated
10.Shoulder horizontal adduction (Pec major): Supine with UE in 90 degrees shoulder abd, 90 degree elbow
flexion. Have pt horizontally adduct shoulder; apply resistance just proximal to elbow in direction of abduction.
Gravity eliminated: Seated
11.Shoulder Internal rotation (Subscapularis, Pec major, Lat, Teres major): Prone with UE in 90 degrees
shoulder abduction, 90 degrees elbow flexion, arm hanging down. Pt moves through full range of IR, apply

resistance just proximal to wrist in direction of ER. Gravity eliminated: Prone, with arm hanging off side of
table, rotate humerus along long axis.
12.Shoulder external rotation (Infraspinatus, teres minor): Prone with UE in 90 degrees shoulder abduction,
90 degrees elbow flexion, arm hanging down. Pt moves through full range of ER, apply resistance just
proximal to wrist in direction of IR. Gravity eliminated: Prone, with arm hanging off side of table, rotate
humerus laterally along long axis.

Special tests for the Shoulder:

Dislocation:
1. Apprehension test for anterior shoulder dislocation: The pt is positioned in supine with arm in 90 degrees
abduction. Therapist laterally rotates pts shoulder. A positive test is indicated by a look of apprehension or a
facial grimace prior to reaching end point.
2. Apprehension test for posterior dislocation: The pt is positioned in supine with the arm in 90 degrees of flexion
and medial rotation. The therapist applies a posterior force through the long axis of humerus. A positive test is
indicated by a look of apprehension.
Biceps tendon Pathology:
1. Ludingtons test: The pt is positioned in sitting and is asked to clasp both hands behind the head with the
fingers interlocked. The pt is then asked to alternately contract and relax the biceps muscles. A positive test is
indicated by absence of movement in the biceps tendon and may be indicative of a rupture of the long head
of the biceps.
2. Speeds test: The pt is positioned in sitting or standing with the elbow extended and the forearm supinated.
The therapist places one hand over the bicipital groove and the other hand on the volar surface of the
forearm. The therapist resists active shoulder flexion. A positive test is indicated by pain or tenderness in the
bicipital groove region.
3. Yeargasons test: The pt is positioned in sitting or standing with the arm in 90 degrees of elbow flexion and
forearm pronated. The humerus is stabilized against the pts thorax. The therapist places on hand on the
patients forearm and the other hand over the bicipital groove. The patient is directed to actively supinate and

laterally rotate against resistance. A positive test is indicated by pain or tenderness in the bicipital groove and
may be indicative of bicipital tendonitis.
Rotator Cuff Pathology/Impingement:
1. Drop arm test: The pt is positioned in sitting or standing with the arm in 90 degrees of abduction. The pt is
asked to slowly lower the arm to their side. A positive test in indicated by the patient failing to slowly lower
the arm to their side or by the presence of severe pain and may be indicative of a tear in the rotator cuff.
2. Hawkins-Kennedy Impingement test: The pt is positioned in sitting or standing. The therapist flexes the pts
shoulder to 90 degrees and then medially rotates the arm. A positive test is indicated by pain and may be
indicative of shoulder impingement involving the supraspinatus tendon.
3. Neer impingement test: The pt is positioned in sitting or standing. The therapist positions one hand on the
posterior aspect of the patients scapula and the other hand stabilizing the elbow. The therapist elevates the
patients arm through flexion. A positive test is indicated by a facial grimace or pain and may be indicative of
shoulder impingement involving the supraspinatus tendon.
4. Supraspinatus test(empty can): The pt is positioned with the arm in 90 degrees of abduction followed by 30
degrees of horizontal adduction with the thumb pointing downward. The therapist resists the patients
attempt to abduct the arm. A positive test is indicated by weakness or pain and may be indicative of a tear of
the supraspinatus tendon, impingement, or suprascapular nerve involvement.
Thoracic Outlet Syndrome:
1. Adson maneuver: The pt is positioned in sitting or standing. The therapist monitors the radial pulse and asks
the pt to rotate their head to face the test shoulder. The pt is then asked to extend their head while the
therapist laterally rotates and extends the pts shoulder. A positive test is indicated by an absent or diminished
radial pulse and may be indicative of thoracic outlet syndrome.
2. Allen test: The pt is positioned in sitting or standing with the test arm in 90 degrees of abduction, lateral
rotation, and elbow flexion. The pt is asked to rotate the head away from the test shoulder while the therapist
monitors the radial pulse. A positive test is indicated by an absent or diminished pulse when the head is
rotated away from the test shoulder. A positive test may be indicative of thoracic outlet syndrome.
3. Costoclavicular syndrome test (military brace): Pt positioned in sitting. The therapist monitors the pts radial
pulse and assists the pt to assume a military posture. A positive test is indicated by an absent or diminished
radial pulse and may be indicative of thoracic outlet syndrome caused by compression of the subclavian
artery between the first rib and the clavicle.

4. Roos test: The pt is positioned in sitting or standing with the arms positioned in 90 degrees of abduction,
lateral rotation, and elbow flexion. The pt is asked to open and close their hands for three minutes. A positive
test is indicated by the inability to maintain the test position, weakness of the arms, sensory loss or ischemic
pain. A positive test may be indicative of thoracic outlet syndrome.
5. Wright (hyperabduction test): The pt is positioned in sitting or supine. The therapist moves the pts arm
overhead in the frontal plane while monitoring the pts radial pulse. A positive test is indicated by an absent or
diminished radial pulse and may be indicative of compression in the costoclavicular space.
Miscellaneous:
1. Glenoid Labrum tear test clunk test: The pt is positioned in supine. The therapist places one hand on the
posterior aspect of the pts humeral head while the other hand stabilizes the humerus proximal to the elbow.
The therapist passively abducts and laterally rotates the arm over the patients head and then proceeds to
apply an anterior directed force the humerus. A positive test is indicated by a clunk or grinding sound and
may be indicative of a glenoid labrum tear.
2. Upper limb tension tests: Neural provocation maneuvers. Symptoms and relevant changes in symptoms
should be identified after each step. Non-involved side tested first.

Joint
position

Sensitizat
ion Test

ULTT 1
Shoulder
depression with
110 abd, elbow
ext, forearm
supination, wrist
ext, finger and
thumb ext yay
position

ULTT 2
Shoulder
depression with
10 abd, elbow
ext, forearm
supination, wrist
ext, finger and
thumb ext,
shoulder lateral
rotation

ULTT 3
Shoulder
depression with
10 abd, elbow
ext, forearm
pronation, wrist
flexion, ulnar
deviation, finger
and thumb
flexion, shoulder
medial rotation
waiters tip

Contralateral
cervical lateral

Contralateral
cervical lateral

Contralateral
cervical lateral

ULTT 4
Shoulder
depression with
10-90 abd,
elbow flexion,
forearm
supination, wrist
ext, radial dev,
finger and
thumb ext,
shoulder lateral
rotation
waiters tray
position
Contralateral
cervical lateral

Nerve
Bias

flexion
Median nerve,
anterior
interosseous
nerve

flexion
Median nerve,
musculocutaneou
s nerve, axillary
nerve

flexion
Radial nerve

flexion
Ulnar nerve

Shoulder conditions:
1. Glenohumeral subluxation and dislocation:
Most dislocations (95%) occur in anterior-inferior direction.
Anterior-inferior dislocation occurs when abducted upper extremity is forcefully, externally rotated, causing
tearing of the inferior glenohumeral ligament, anterior capsule, and occasionally glenoid labrum.
Posterior dislocations are rare, and occur with multidirectional laxity of glenohumeral joint.
Posterior dislocation occurs with horizontal adduction and internal rotation of glenohumeral joint.
Complications include compression fracture of posterior humeral head (Hill-Sachs lesion), tearing of superior
glenoid labrum from anterior (front) to posterior (back) (aka SLAP superior labrum, anterior to posterior)
lesion, an avulsion of anteroinferior capsule and ligaments associated with glenoid rim (Bankarts lesion), and
bruising of axillary nerve.
Following surgical repair for dislocation/chronic subluxation, pts should avoid apprehension position (flexion
to 90 or greater, horizontal abduction to 90 or greater, and ER to 80)
Diagnostic tests utilized: plain film, CT, or MRI
Diagnosis made by clinical examination. Apprehension tests will be positive.
Goals, outcomes, interventions: PT intervention is varied, depending on if surgery is indiciated. Biomechanical
faults caused by joint restriction should be corrected with joint mobs.
2. Instability:
Divided into two categories: traumatic (common in young throwing athletes), and atraumatic (individuals
with congenitally loose connective tissue around the shoulder).
Characterized by popping/clicking and repeated dislocation/subluxation of the GH joint.
Unstable injuries require surgery to reattach the labrum to the glenoid.
Bankarts lesions require surgery.
Diagnosis made by clinical exam by comparing results of pt history with the AROM, PROM, resistive tests,
and palpation.
MRI arthrograms are VERY effective in identifying labral tears.

Meds: acetaminophen for pain, NSAIDS for pain/inflammation

Goals, outcomes, interventions: Intervention emphasizes return of function without pain. Functional training
and restoration of muscle imbalances using exercise to normalize strength.
For patients requiring surgery, the shoulder is usually kept in a sling for 3-4 weeks. After 6
weeks, more sports-specific training can be done, although full fitness may take 3-4 months.
3. Labral tears:
Glenoid labrum injuries are classified as either superior (toward the top of the glenoid socket) or inferior
(toward the bottom of the glenoid socket). A SLAP lesion is a tear of the rim above the middle of the socket
that may also involve the biceps tendon. A tear of the rim below the middle of the glenoid socket is called a
Bankarts lesion, and also involves the inferior glenohumeral l igament. Tears of the glenoid labrum may often
occur with other shoulder injuries, such as a dislocated shoulder.
Characterized by the following signs and symptoms:
-Shoulder pain that cannot be localized to a specific point
-Pain is made worse by overhead activities or when the arm is held behind the back
-Weakness
-Instabilitiy in the shoulder
-Pain on resisted flexion of the biceps
-Tenderness over the front of the shoulder
Unstable injuries require surgery to reattach the labrum to the glenoid. Bankarts lesions require surgery.
Diagnosis made by clinical exam, through comparing results of AROM, PROM, resistive tests, and palpation.
MRI arthrograms are very effective in identifying labral tears.
The gold standard for identifying a labral tear is through arthroscopic surgery of the shoulder.
Meds: acetaminophen, NSAIDS
Goals, Outcomes, Interventions: Return to function without pain, normal strength, endurance, coordination,
and flexibility.
Following surgery, the shoulder is usually kept in a sling 3-4 weeks. After 6 weeks, more sports specific
training can be done.
4. Thoracic Outlet Syndrome (TOS):
Compression of neurovascular bundle (brachial plexus, subclavian artery and vein, vagus and phrenic
nerves, and the sympathetic trunk) in thoracic outlet between bony and soft tissue structures.
Compression occurs when size or shape of thoracic outlet is altered.

Common areas of compression: Superior thoracic outlet, Scalene triangle, between clavicle and first rib,
between pectoralis minor and thoracic wall.
Surgery may be performed to remove a cervical rib or a release of anterior and/or middle scalene muscle.
Diagnostic tests utilized: plain film imaging to identify abnormal bony anatomy and MRI to identify abnormal
soft tissue anatomy. Electro diagnostic test to assess nerve dysfunction.
Clinical exam of special tests will be helpful to make diagnosis: Adsons, Roos test, Wright test,
Costoclavicular test.
Medications: acetaminophen, NSAIDS
Goals, Outcomes, Interventions: Postural reeducation, functional training of muscle imbalance, flexibility. Joint
mobs, Manipulations (1st rib articulation)
5. Acromioclavicular and sternoclavicular joint disorders:
Mechanism of injury is a fall onto shoulder, with UE adducted, or a collision with another individual during a
sporting event.
Traditionally, degree of injury is grated from first to third degree. Rockwood classification scales uses grades
from I to IV, with grades IV-VI as variations of the traditional grade III.
UE is positioned in neutral with use of sling in acute phase. AVOID shoulder elevation during the acute phase
of healing.
Diagnostic tests: plain film imaging
Special test useful in making diagnosis: Shear test
Surgical repair is rare, due to tendency of acromioclaviculr joint degeneration following the repair.
Meds: acetaminophen, NSAIDS
Goals, Outcomes, Interventions: Return of function without pain. Functional training and restoration of muscle
imbalances using exercise to normalize strength, endurance, coordination, and flexibility.
Manual therapy techniques to AC and SC joints such as soft tissue/massage, joint oscillations, and
mobilizations to normalize soft tissue and joint biomechanics.

*Arthrokinematics for Sternoclavicular joint: (Protraction=same direction)( Elevation=opposite)

Motion to Increase
SC elevation
SC protraction

Mobilization Glide
Inferior glide
Anterior glide

6. Subacromial/subdeltoid bursitis:
Subacromial and subdeltoid bursae (which may be continuous) have a close relationship to rotator cuff
tendons, making them susceptible to overuse.
Palpable by extending the humerus.
The bursa is located over the bicipital groove under the deltoid muscle, separating this muscle from the
rotator cuff and allowing for free motion of the deltoid over the humerus.
They can also become impinged beneath the acromial arch.
Diagnosis made by clinical exam. Differentiate from contractile condition by comparing results of AROM,
PROM, and resistive tests
7. Rotator cuff tendonosis/tendonopathy:
Tendons of the rotator cuff are susceptible to tendonitis, due to relatively poor blood supply near insertion of
muscles.
Results from mechanical impingement of the distal attachment of the rotator cuff on the anterior acromion
and/or coracoacromial ligament with repetitive overhead activities.
Diagnostic tests utilized: MRI may be used, but sometimes not sensitive enough for accurate assessment.
Clinical exam include the following special tests: Supraspinatus test, Neers impingment test
8. Impingement syndrome:
Characterized by soft tissue inflammation of the shoulder from impingement against the acromion with
repetitive overhead AROM.
Diagnostic tests utilized: arthrogram or MRI
Clinical exam will include the following: Neers, Supraspinatus test, Drop arm test
Surgical repair of shoulder impingement. The pt should avoid shoulder elevation greater than 90.
Goals, Outcomes, Interventions: Restoration of posture, correction of muscle imbalance
9. Bicipital tendonosis/tendonopathy:
Most commonly an inflammation of the long head of the biceps.
Results from mechanical impingement of the proximal tendon, between the anterior acromion and the
bicipital groove of the humerus.
Diagnostic tests utilized: MRI may be used, but sometimes not sensitive enough.
Clinical exam will include Speeds test.
Meds: acetaminophen and NSAIDS
10.Proximal humeral fractures:

Humeral neck fractures frequently occur with a fall onto an outstretched UE among older osteoporotic
women. Generally does not require immobilization or surgical repair, since it is a fairly stable fx.
Greater tuberosity fractures are more common in middle-aged and elder adults. Usually related to a fall onto
the shoulder, and does not require immobilization for healing.
Diagnostic tests utilized: plain film radiographs.
Early PROM is important in preventing capsular adhesions.
11.Adhesive Capsulitis (frozen shoulder):
Characterized by a restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder
capsule, usually due to disuse following injury or repetitive microtrauma.
Restriction follows a capsular pattern of limitation: Greatest limitation in ER, followed by abduction, and
flexion, and least restricted in IR.
Commonly seen in association with diabetes mellitus.

Elbow:
Supination: (Supinator, biceps) C5-C6
Pronation: (Pronator quadrauts, pronator teres, flexor carpi radialis) C8-T1, C6,C7
Extension of wrist: (ECRL, ECRB, ECU) C6-C7, C7-C8
Flexion of wrist: (FCR, FCU) C6-C7, C7-C8
UD of wrist: (FCU, ECU) C7-C8, C7-C8
RD of wrist: (FCR, ECRL, abd pollicis longus, ext pollicis brevis) C6-C7, C7-C8
Ext of fingers: (Extensor digitorum communis, ext indicis, extensor digiti minimi) C7-C8
Flexion of fingers: (flex digit profundus, superficialis, lumbricals, interossei, flexor digit minimi): C8-T1
Abduction of fingers: (Doral interossei, abductor digiti minimi) C8-T1
Adduciton of fingers: (palmar interossei) C8, T1
Ulnar nerve (C8-T1) *Largest branch of the medial cord of the brachial plexus. Entrapment site: cubital tunnel and
Guyons canal. Intervention: splint wrist in neutral position at night, elbow pad. Education-positioning in elbow ext
and decreasing direct pressure on nerve; stretch flexor carpi ulnaris
Median nerve (C5-T1) *AIN branches off median nerve and supplies motor innervation to the index and middle
flexor digitorum profundus, the flexor pollicis longus, and the pronator quadrates. Entrapment site: carpal tunnel,
proximal forearm. Intervention: splint wrist in neutral position at night, stretching exercises for pronator teres, rest
periods in supination.

Radial nerve (C5-T1) Entrapment site: arcade of froshe, forearm. Intervention: positioning in supination and avoid
repetitive pronation and supination activities.

ROM:
Flexion: 5 hyperextension to 145 flexion
Extension: 0 to 5-10 hyperextension
Arthrokinematics:
Joint
Ulnohumeral (same)
Proximal radioulnar
(opposite)

Motion to Increase
Elbow flexion
Elbow extension
Pronation

Mobilization Glide
Anterior
Posterior
Posterior (lateral)

Supination
Pronation
Supination

Anterior (medial)
Anterior (medial)
Posterior (lateral)

Distal radioulnar (same)

Force couples:
The triceps/biceps during elbow extension and flexion
pronator teres and pronator quadratus/supinator during forearm pronation and supination
FCR, FCU, flexor digitorum communis/ERCL, ECRB, and extensor communis during wrist flexion and extension
triceps/biceps and brachioradialis; pronator teres/supinator/ and FCR, FCU/ECRB, and ECRL during activities
requiring elbow stabilization
Closed-pack position: Humeroulnar-full extension and maximum forearm supination;
open-packed position: 70 of flexion with 10 supination
Capsular pattern: flexion more limited than extension
Common MMT for the elbow:

1. Elbow flexion (biceps brachii): Seated, with UE in 0 shoulder add, 0 elbow ext, forearm supination. Apply
resistance just proximal to wrist in direction of elbow extension. Gravity eliminated: seated w arm supported
on table.
2. Elbow flexion (brachialis): Seated, same position except forearm PRONATION. Apply resistance just
proximal to wrist in direction of elbow extension. Gravity eliminated: seated with arm supported (hand thumb
side down)
3. Elbow flexion (brachioradialis): Seated, same position except NEUTRAL forearm rotation. Gravity
eliminated: Seated, with arm supported (palm face down on table)
4. Elbow extension (triceps, anconeus): Supine w UE in 90 shoulder flexion, full elbow flexion, full forearm
supination. Flex pts elbow slightly, then apply resistance just proximal to wrist in direction of elbow flexion.
Gravity eliminated: Seated w arm supported, shoulder abducted to 90, elbow full flexed, forearm supinated
(pinky on table)
5. Forearm supination (supinator, biceps): Seated w UE in 0 shoulder abd, 90 elbow flexion, full forearm
pronation. Apply resistance over volar surface of ulna and dorsal surface of radius in direction of pronation.
Gravity eliminated: Seated w UE in 90 shoulder flex, 90 elbow flexion, full forearm pronation
6. Forearm pronation (pronator quadraus, pronator teres): Seated, w UE in 0 shoulder abd, 90 elbow
flex, full forearm supination. Apply resistance over volar surface of radius and dorsal surface of ulna in
direction of supination. Gravity eliminated: Same except full forearm supination.
Special tests for the elbow:
Ligamentous Instability
1. Varus stress test: The pt is sitting w the elbow in 20-30 of flexion. Therapist places one hand on the elbow
and the other proximal to the pts wrist. The therapist applies a varus force to test the LCL while palpating
lateral joint line. A positive test is indicated by increased laxity in the LCL when compared to the contralateral
limb, apprehension or pain. A positive test may be indicative of a LCL sprain.
2. Valgus stress test: Same position as varus, except therapist applies a valgus force to test the MCL while
palpating the medial joint line. A positive test is indicated by increased laxity in the MCL when compared to
the contralateral limb, apprehension or pain. A positive test may be indicative of a MCL sprain.
Epicondylitis

1. Cozens test: Pt is positioned in sitting w the elbow in slight flexion. Therapist places his/her thumb on the
patients lateral epicondyle while stabilizing the elbow joint. The pt is asked to make a fist, pronate the
forearm, radially deviate, and extend the wrist against resistance. A positive test is indicated by pain in the
lateral epicondyle region or muscle weakness and may be indicative of lateral epicondylitis.
2. Lateral epicondylitis test: The pt is positioned in sitting. The therapist stabilizes the elbow w one hand and
places the other hand on the dorsal aspect of the pts hand distal to the proximal interphalangeal joint. The pt
is asked to extend the third digit against resistance. A positive test is indicated by pain in the lateral
epicondlye region or muscle weakness and may be indicative of lateral epicondylitis.
3. Medial epicondylitis test: Pt positioned in sitting. The therapist palpates the medial epicondyle and supinates
the pts forearm, extends the wrist, and extends the elbow. A positive text is indicated by pain the medial
epicondyle region and may be indicative of medial epicondylitis.
4. Mills test: Pt positioned in sitting. The therapist palaptes the lateral epicondyle, pronates the pts forearm,
flexes the wrist, and extends the elbow. A positive test is indicated by pain in the lateral epicondyle region and
may be indicative of lateral epicondylitis.
Neurological Dysfunction
1. Tinels sign: Pt positioned in sitting w the elbow in slight flexion. Therapist taps with the index finger between
the olecranon process and the medial epicondyle. A positive test is indicated by a tingling sensation in the
ulnar nerve distribution of the forearm, hand, and fingers. A positive test may be indicative of ulnar nerve
compression or compromise.
2. Pronator teres syndrome test: Pt sitting w elbow in 90 flexion and supported. Therapist resists forearm
pronation and elbow extension simultaneously. A positive test reproduces a tingling or parestheisa within the
median nerve distribution. A positive test may be indicative of median nerve entrapment within pronator
teres. Occurs with repetitive gripping activities.

Elbow conditions: (See chart for common MS diagnosis)

1. Distal humeral fractures:
Complications can include loss of motion, myositis ossificans, malalignment, neurovascular compromise,
ligament injury, and CRPS.

Supracondylar fxs must be examined quickly for neurovascular status, due to high number of neurological
(typically radial nerve involvement) and vascular structures that pass through this region (may lead to
Volkmanns ischemiaI. In youth, it is important to assess growth plate as well. These fxs have a high incidence
of malunion.
*Volkmanns Contracture=severe pain in forearm, sensation of pressure if compartment syndrome. Onset
is nerve and muscle ischemia, secondary to arterial compromise. Pt has pain w/in 2 hrs increase by passive
finger ext, pallor, paresis, pulselessness, pt has wrist ext, and finger flex contractures.
Lateral epicondyle fxs are fairly common in young people, and typically require an open reduction internal
fixation (ORIF) to ensure absolute alignment.
Diagnostic tests utilized: plain film
Goals, outcomes, Interventions: pain reduction and limiting the inflammatory response following
trauma/surgery. Improving flexibility of shortened structures, strengthening, and training to restore functional
use of UE.
2. Osteochondrosis of humeral capitellum:
Osteochondritis dissecans affects central and/or lateral aspect of capitellulm or radial head. An
osteochondral bone fragment becomes detached from articular surface, forming a loose body in joint. Caused
by repetitive compressive forces between radial head and humeral capitellum. Occurs in adolescents between
12 and 15 years of age.
3. Panners disease:
Is a localized avascular necrosis of capitellum leading to loss of subchondral bone, with fissuing and
softening of articular surfaces of radiocapitellar joint. Etiology is unknown, but occurs in children age 10 or
younger.
Diagnostic tests: plain film
Goals, outcomes, Interventions: PT includes rest with avoidance of any throwing or upper extremity loading
activities (gymnastics) When pt is pain-free, initiate flexibility and strengthening/endurance/coordination ex.
During late phases of rehab, a program to slowly increase load on joint it initiated. If symptoms persist,
surgical intervention is necessary. After surgery initial focus of rehab is to minimize pain and swelling using
modalities.
4. Radial nerve entrapment:
Occurs within radial tunnel as a result of overhead activities and throwing. Clinical signs include lateral elbow
pain that can be confused with lateral epicondylitis, pain over supinator muscle, and presthesias in a radial
nerve distribution. Tinels sign may be positive.
Diagnostic tests utilized: electrodiagnositc tests.

Goals, outcomes, and interventions: Early intervention includes rest, avoiding exacerbating activities, use of
NSAIDS, modalities and soft tissue massage. If abnormal neurotension is present, neurodynamic mobilization
may be indicated. Protective padding and night splints to maintain slackened position of involved nerves.
5. Elbow dislocations:
Posterior dislocations account for most dislocations occurring at the elbow. Posterior dislocations are defined
by position of olecranon relative to the humerus.
Posterolateral dislocations are most common, and occur as the result of elbow hyperextension from a fall on
the outstretched UE.
Posterior dislocations frequently cause avulsion fxs of medial epicondyle secondary to traction pull of medial
collateral ligament.
Anterior and radial head dislocations account for only 1-2% of all elbow dislocations. With a complete
dislocation, ulnar collateral ligament will rupture, with possible rupture of anterior capsule, lateral collateral
ligament, brachialis muscle, and/or wrist flexor and extensor muscles.
Clinical signs include rapid swelling, severe pain at the elbow, and a deformity with the olecranon pushed
posteriorly
Goals, outcomes, and interventions: Initial intervention includes reduction of the dislocation. If elbow is stable,
there is an initial phase of immobilization, followed by rehab focusing on regaining flexibility within limits of
stability and strengthening.
*Nurse-maids (pulled) Elbow-pain localized to superior radioulnar joint, caused by longitudinal pull on
forearm, a partial slippage of the annular ligament over the head of the radius pt will avoid use of arm, arm
held in pronation, pt has inability to supinate w/out pain. Special tests: palpate sulcus proximal to radial head.
Wrist & Hand
*The wrist is positioned in slight extension to allow effective hand function.
*Wrist extension of 20-30 is needed for optimal use of the hand.
*The most active muscle in grasping is the extensor carpi radialis brevis, which holds the wirst in extension.
Two types of functional grasp:
1. The power grip is used to exert force on an object and maintain it against the palm. This requires finger
flexion and wrist extension with ulnar deviation.
2. The precision (prehension) grip is used for accurate functions with the object held between the fingertips.
Four stages of gripping: Opening the hand, closing the fingers, exerting force, and releasing the object. The
thumb, wrist, hand, and fingers control the gripping actions with varying ranges of precision or power.

ROM:
Flex-80
Ext-70
RD-20
UD-30

MCP flex-90
MCP hyperextension-45
PIP flex-100
DIP flex-90

DIP hyperextension-10

The wrist joint comprises the distal radius & ulna, 8 carpal bones, and the bases of 5 metacarpals. The carpal
bones lie in two transverse rows. The proximal row contains (lateral to medial) scaphoid (navicular), lunate,
triquetrum, and pisiform. The distal row holds the trapezium, trapezoid, capitate, and hamate.
Arthrokinematics:
Joint
Radiocarpal (opposite)

Mid carpal (same)

Metacarpophalangeal
(same)

Motion to increase
Wrist extension
Wrist flexion
Wrist ulnar deviation
Wrist radial deviation
Wrist extension
Wrist flexion
Finger flexion

Mobilization glide
Anterior
Posterior
Lateral
Medial
Anterior
Posterior
Anterior (Ventral)

Finger extension

Posterior (Dorsal)

Closed pack position: Extension with radial deviation

Loose pack position: neutral with slight ulnar deviation
Capsular pattern: (wrist)=Flexion and extension equally limted (MCP and IP)=flexion more limited than
extension
Common MMT for the wrist/hand:
1. Wrist flexion and radial deviation (flexor carpi radialis): Seated w forearm supinated and supported
on a flat surface. Pt flexes and deviates wrist to radial side while examiner maintains stabilization of
forearm. Apply resistance along volar aspect of bases of first and second metacarpals in direction of wrist

2.

3.

4.

5.

ext and ulnar deviation. Gravity eliminated-seated w arm in neutral (halfway between pronation and
supination)
Wrist flexion and ulnar deviation (flexor carpi ulnaris): Seated w forearm supinated and supported.
Pt flexes and deviates wrist to ulnar side while examiner maintains stabilization of forearm. Apply
resistance along volar aspect of 5th MC bone in direction of wrist ext. Gravity eliminated-Same as other.
Wrist extension and radial deviation (extensor carpi radialos longus and brevis): Seated with
forearm pronated and supported on a flat surface. Pt extends and deviates wrist to radial side. Apply
resistance along dorsal aspect of 1st and 2nd metacarpals in direction of wrist flexion and ulnar deviation.
Gravity eliminated-seated w forearm in neutral rotation, wrist in neutral position, forearm supported.
Wrist extension and ulnar deviation (extensor carpi ulnaris): Seated with forearm pronated and
supported. Pt extends and deviates wrist to ulnar side. Apply resistance along dorsal aspect of 5 th
metacarpal in direction of wrist flexion and radial deviation. Gravity eliminated-Seated w forearm in neutral
rotation, and supported on surface.
Finger flexion(lumbricals, palmar and dorsal interossei): Seated with forearm fully supinated and
supported, wrist in neutral, fingers extended. Pt flexes MCP joints while extending IP joints. Apply
resistance with one finger along volar surface of proximal phalanx of 2 nd-5th digits individually in direction
of MCP extension. Gravity eliminated-Seated w forearm in neutral rotation and supported on flat surface.

Special tests for the wrist/hand:

Ligamentous Instability
1. Ulnar collateral ligament instability test-The pt is positioned in sitting. The therapist holds the pts thumb in
extension and applies a valgus forace to the metacarpophalangeal joint of the thumb. A positive test is
indicated by excessive valgus movement and may be indicative of a tear of the ulnar collateral and accessory
collateral ligaments. This type of injury is referred to as gamekeepers or skiers thumb.
Vascular Insufficiency
1. Allen test-Pt is positioned in sitting or standing. Pt is asked to open and close the hand several times in
succession and then maintain the hand in a closed position. Therapist compresses the radial and ulnar
arteries. Pt is then asked to relax the hand and the therapist releases the pressure on one of the arteries while

observing the color of the hand and fingers. A positive test is indicated by delayed or absent flushing of the
radial or ulanr half of the hand and may be indicative of an occlusion in the radial or ulnar artery.
Contracture/Tightness
1. Bunnel-Littler test-Pt is positioned in sitting with the metacarpophalangeal joint held in slight extension.
Therapist attempts to move the PIP joint into flexion. If the PIP joint does not flex with the MCP joint
extended, there may be a tight intrinsic muscle or capsular tightness. If the PIP joint fully flexes with the
MCP joint in slight flexion, there may be intrinsic muscle tightness without capsular tightness.
2. Tight retinacular ligament test-The PIP joint is held in a neutral position while the therapist attempts to flex
the DIP joint. If the therapist is unable to flex the DIP joint, the retinacular ligaments or capsule may be
tight. If the therapist is able to flex the DIP joint with the PIP joint in flexion, the retinacular ligaments may
be tight and the capsule may be normal.
Neurological Dysfunction
1. Froments sign-Pt is positioned in sitting or standing and is asked to hold a piece of paper between the
thumb and index finger. The therapist attempts to pull the paper away from the pt. A positive test is
indicated by the pt flexing the distal phalanx of the thumb due to adductor pollicis muscle paralysis. If at
the same time, the pt hyperextends the metacarpophalangeal joint of the thumb, it is termed Jeannes
sign. Both objective findings may be indicative of ulnar nerve compromise or paralysis.
2. Phalens test-Pt is positioned in sitting or standing. Therapist flexes the pts wrists maximally and asks the
pt to hold the position for 60 seconds. A positive test is indicated by tingling in the thumb, index finger,
middle finger, and lateral half of the ring finger and may be indicative of carpal tunnel syndrome due to
median nerve compression.
3. Tinels sign-Pt is positioned in sitting or standing. Therapist taps over the volar aspect of the pts wrist. A
positive test is indicated by tingling in the thumb, index finger, middle finger, and lateral half of the ring
finger distal to the contact site at the wrist. A positive test may be indicative of carpal tunnel syndrome
due to median nerve compression.

Miscellaneous

1. Finkelstein test-Pt is positioned in sitting or standing and is asked to make a fist with the thumb tucked
inside the fingers. Therapist stabilizes pts forearm and ulnarly deviates the wrist. A positive test is
indicated by pain over the abductor pollicis longs and extensor pollicis brevis tendons at the wrist and may
be indicative of tenosynovitis in the thumb (De Quervains disease)
2. Grind test- Pt positioned in sitting or standing. The therapist stabilizes the pts hand and grasps pts thumb
on the metacarpal. Therapist applies compression and rotation through the metacarpal. A positive test is
indicated by pain and may be indicative of degenerative joint disease in the CMC.
3. Murphy sign-Pt is positioned in sitting or standing and is asked to make a fist. A positive test is indicated by
the pts third metacarpal remaining level with the second and fourth metacarpals. A positive test may be
indicative of a dislocated lunate.
Wrist/hand conditions: (See chart for common MS pathologies)
1. Dupuytrens Contracture:
Observed as banding on palm and digit flexion contractures, resulting from contracture of palmar fascia that
adheres to skin.
Affects men more than women
Contracture usually affects the MCP and PIP joints of 4 th and 5th digits in nondiabetic individuals and affects
3rd and 4th digits most often in individuals with diabetes.
Goals, outcomes, and Interventions-flexibility ex, splint application, promote restoration of normal hand
function
2. Boutonniere deformity:
Results from rupture of central tendinous slip of extensor hood.
Observed deformity is extension of MCP and DIP with flexion of PIP.
Commonly occurs following trauma, or in rheumatoid arthritis with degeneration of the central extensor
tendon.
3. Swan neck deformity:
Results from contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons.
Observed deformity is flexion of MCP and DIP with extension of PIP.
Commonly occurs following trauma, or with RA following degeneration of lateral extensor tendons.
4. Ape hand deformity:
Observed as thenar muscle wasting, with first digit moving dorsally until it is in line with second digit.
Results from median nerve dysfunction.
5. Mallet finger:

Rupture or avulstion of extensor tendon at its insertion into distal phalanx of digit.
Observed deformity is flexion of DIP joint.
Usually occurs from trauma, forcing distal phalanx into a flexed position.
6. Gamekeepers thumb:
A sprain/rupture of ulanr collateral ligament of MCP joint of first digit.
Results in medial instability of thumb.
Frequently occurs during a fall wile skiing, when increasing forces are placed on thumb through ski pole.
Immobilized for 6 weeks.
7. Boxers fx:
Fx of neck of 5th metacarpal
Frequently sustained during a fight, or from punching a wall in anger
Casted for 2-4 weeks

Hip:
Flexors: Psoas, Iliacus, Pectineus, Rectus femrois
Extensors: Glut max, semitendinosus, semimembranosus, biceps femoris (long head)
Abductors: glut med. Assist movers: glut min, TFL, Sartorius, rectus, piriformis (at 90 hip flex)
Adductors: Adductor magnus, adductor longus, adductor brevis, gracilis, pectineus
ER: Glut max, gemellus inferior & superior, obturator externus & internus, quadratus femoris, piriformis (at less than
60 hip flexion)
IR: TFL, glut min Assist movers: semitendinosus, semimembranosus, gracilis, piriformis (at 90 hip flexion)
ROM:
Flex-110-120
Ext-10-15
Abd-30-40
Add-25-30
ER-40-60
IR-30-40
Arthrokinematics:
Joint
Hip

Motion to increase
Abduction
ER/extension
IR/flexion

Mobilization Glide
Inferior
Anterior
Posterior

Closed packed position: full ext, medial rotation

Loose packed position: 30 flex, 30abd, slight lateral rotation
Capsular pattern: most limited flexion, abduction, and medial rotation (sometimes medial rotation is most limited)
End-feels for the hip: Tissue stretch/approximation (flexion and adduction)
Common MMT of the hip:
1. Hip flexion (Iliacus and Psoas Major)-Seated with legs off side of treatment table, holding on to table edge
with hands. Pt flexes hip through range while keeping knee flexed. Apply resistance over anterior aspect of
distal thigh in direction hip ext. Gravity eliminated-Sidelying on side of lower extremity to be tested.
2. Hip flex, abd, and external rotation(Sartorius)-Seated with legs off side table, holding on to table. Pt will
slide heel of limb being tested up shin of opposite leg. Pt flexes, abducts, and externally rotates hip while
flexing knee. Apply resistance. Gravity eliminated-Supine with heel of lower extremity to be tested on ventral
surface of contralateral ankle, contralateral lower extremity extended.
3. Hip extension (glut max, semitendinosus, semimembranosus, and biceps femoris)-Prone with lower
extremities extended. Apply resistance over posterior aspect of distal thigh in direction of hip flexion. Gravity
eliminated-Sidelying on side of lower extremity to be tested.
4. Hip abduction (glut med and min)-Sidelying with limb to be tested uppermost. Apply resistance over
lateral aspect of distal thigh in direction of hip adduction. Gravity eliminated-Supine with hips fully adducted.
5. Hip abduction with flexion (tensor fascia lata)-Sidelying with limb to be tested uppermost, hip or upper
limb in 45 flexion an neutral rotation, lower limb flexed for balance. Abduct pts hip 30, maintaining hip in
flexion, apply resistance over lateral aspect of distal thigh in direction of hip adduction. Gravity eliminatedLong sitting, hips flexed to 45, knees extended. Pt supports trunk by learning back on extended arms.
6. Hip adduction (magnus, longus, brevis, pectineus, and gracils)-Sidelying on side of limb to be tested,
pt may hold table for support. Pt adducts hip of test limb, apply resistance on medial aspect of distal thigh in
direction of hip abduction. Gravity eliminated-Supine with non-test limb in full abduction.
7. Hip medial rotation(TFL, glut min and med)-Seated with legs hanging over table, with towel under knee
of limb to be tested. Medially rotate pts hip by moving foot laterally; resistance is applied in medial direction
on lateral aspect of distal leg. Gravity eliminated-Supine with limb to be tested in full hip lateral rotation.
8. Hip lateral rotation(piriformis, gemellus superior & inferior, obturator internus & externus, and
quadratus)-Seated with legs off table, towel under knee of test limb. Laterally rotate pts hip by moving foot
medially. Apply resistance in lateral direction on medial aspect of distal leg. Gravity eliminated-Supine with
limb to be tested in full medial rotation.

Special tests for the hip:

Contracture/Tightness
1. Elys test-Pt is prone while the therapist passively flexes the pts knee. A positive test is indicated by
spontaneous hip flexion occurring simultaneously with knee flexion and may be indicative of a rectus femoris
contracture.
2. Obers test-Pt is positioned in side-lying with the lower leg flexed at the hip and knee. The therapist moves the
test leg into hip extension and abduction and then attempts to slowly lower the test leg. A positive test is
indicated by an inability of the test leg to adduct and touch the table and may be indicative of a tensor
fasciae latae contracture.
3. Piriformis test-Pt is positioned in sidelying with the test leg positioned toward the ceiling and the hip flexed to
60. Therapist places one hand on the pts pelvis and the other hand on the pts knee. While stabilizing the
pelvis, the therapist applies a downward (adduction) force on the knee. A positive test is indicated by pain or
tightness, and may be indicative of piriformis tightness or compression on the sciatic nerve caused by the
piriformis.
4. Thomas test-Pt is positioned in supine with the legs fully extended. The pt is asked to bring one of their knees
to the chest in order to flatten the lumbar spine. The therapist observes the position of the contralateral hip
while the pt holds the flexed hip. A positive test is indicated by the straight leg rising from the table and may
be indicative of a hip flexion contracture.
5. 90-90 straight leg raise test-The pt is positioned in supine and asked to stabilize the hips in 90 of flexion with
the knees relaxed. The therapist instructs the pt to alternately extend each knee as much as possible while
maintaining the hips in 90 of flexion. A positive test is indicated by the knee remaining in 20 or more of
flexion and is indicative of hamstrings tightness.
Pediatric Tests
1. Barlows test-The pt is positioned in supine the hips flexed to 90 and knees flexed. The therapist tests each
hip individually by stabilizing the femur and pelvis with one hand while the other hand moves the test leg into
abduction while applying forward pressure posterior to the greater trochanter. A positive test is indicated by a

click or clunk and may be indicative of a hip dislocation being reduced. The test is considered to be a variation
of Ortolanis test.
2. Ortolanis test-The pt is positioned in supine with the hips flexed to 90 and knees flexed. The therapist grasps
the legs so that their thumbs are placed along the pts medial thighs and the fingers are placed on the lateral
thighs toward the buttocks. The therapist abducts the pts hips and gentle pressure is applied to the greater
trochanters until resistance is felt at approx 30. A positive test is indicated by a click or a clunk and may be
indicative of a dislocation being reduced.

Miscellaneous
1. Craigs test-Pt is positioned in prone with the test knee flexed to 90. The therapist palpates the posterior
aspect of the greater trochanter and medially and laterally rotates the hip until the greater trochanter is
parallel with the table. The degree of femoral anteversion corresponds to the angle formed by the lower
leg with the perpendicular axis of the table. Normal anteversion for an adult is 8-15.
2. Patricks test (FABER test)-The pt is positioned in supine with the test leg flexed, abducted, and externally
rotated at the hip onto the opposite leg. The therapist slowly lowers the test leg through abduction toward
the table. A positive test is indicated by failure of the test leg to abduct below the level of the opposite leg
and may be indicative of iliopsoas, sacroiliac or hip joint abnormalities.
3. Quadrant scouring test-The pt is positioned in supine. The therapist passively flexes and adducts the hip
with the knee in maximal flexion. The therapist applies a compressive force through the shaft of the femur
while continuting to passively more the pts hip. A posistive test is indicated by grinding, catching or
crepitation in the hip and may be indicative of pathologies such as arthritis, avascular necrosis or an
osteochondral defect.
4. Trendelenburg test-Pt is positioned in standing and is asked to stand on one leg for approx 10 seconds. A
positive test is indicated by a drop of the pelvis on the unsupported side and may be indicative of
weakness of the gluteus medius muscle on the supported side.
Conditions of the hip (see MS chart):
1. Avascular necrosis (AVN)
Multiple etiologies resulting in an impaired blood supply to the femoral head.

Hip ROM is decreased in flexion, IR, and abduction

Diagnositc tests utilized: plain film imaging, bone scans, CT, and MRI
Symptoms include pain in the groin and/or thigh, and tenderness with palpation at the hip joint
Coxalgic gait
Corticosteriods contraindicated since they may be causative factor
Goals, outcomes, interventions-Joint/bone protection strategies, maintain joint mechanics and connective
tissue functions. Implementation of aerobic capacity/endurance conditioning, such as aquatics. Post
surgical intervention includes regaining functional flexibility, improving strength, and gait training.
2. Piriformis Syndrome
Piriformis muscle is an external rotator of the hip and can become overworked with excessive pronation of
the foot, causing abnormal femoral internal rotation.
Considered a tonic muscle that is active with motion of sacroiliac joint, particularly sacrum
Tightness or spasm of the piriformis muscle can result in compression of sciatic nerve and/or sacroiliac
dysfunction.
Diagnostic tests utilized: possibly electrodiagnostic tests for sciatic nerve
Signs & symptoms include: restriction in internal rotation, pain with palpation of piriformis muscle,
referral of pain to the posterior thigh, weakness in external rotation, positive piriformis test, uneven sacral
base
Perform lower extremity biomechanical examination to determine if abnormal biomechanics are the
cause. Must rule out involvement of lumbar spine and or SI joint.
NSAIDS and neurontin
Goals, outcomes, interventions-Reduction of pain using modalities and manual therapy techniques, such as
soft tissue massage to piriformis, joint oscillations to hip or pelvis to inhibit pain, correction of muscle
imbalances and biomechanical faults using strengthening. Restore muscle balance and pt education
regarding protection of the SI joint (instruction not to step off a curb onto the dysfunctional LE)

Knee
Screw home mechanism-describes the 5 of tibial external rotation, which occurs during terminal knee extension.
Occurs as closed-chain internal femoral rotation during weight bearing to provide increased stability of knee joint
during weight-bearing activities. Can also occur as open-chain external tibial rotation. Unlocking occurs through
action of popliteus. Open-chain unlocking occurs primarily with popliteal action.
Internal rotation of femur is the same as external rotation of tibia.

ROM:
Flex-135
Closed pack position-full extension, lateral rotation of tibia
Loose-pack position-25 flex
Capsular pattern: flexion more limited than extension
Arthrokinematics:
Joint
Tibiofemoral (knee)
Patellofemoral

Motion to increase
Knee extension
Knee flexion
Knee extension
Knee flexion

Mobilization glide
Anterior/medial/lateral
Posterior
Superior
Inferior

Common MMT of the knee:

1. Knee extension (quadriceps femoris)-Seated with legs off side of table and towel under knee of test limb.
Pt extends knee through full range, apply resistance over anterior aspect of distal leg in direction of knee
flexion. Gravity eliminated-Side lying on side to be tested, knee fully flexed.
2. Knee flexion(biceps femoris, semitendinosus, and semimembranosus)-Prone with lower extremities
extended. Flex pts knee to 90, rotating knee laterally. Apply resistance over posterior aspect of distal leg in
direction of knee extension.(Biceps femoris) Prone with lower extremities extended, flex pts knee to 90,
rotating knee medially (semitendinous and semimembranosus) Gravity eliminated-Sidelying on side to be
tested.
Special tests for the knee:
Ligamentous Instability
1. Anterior drawer test-Pt is positioned in supine with the knee flexed to 90 and the hip flexed to 45. The
therapist stabilizes the lower leg by sitting on the forefoot. The therapist grasps the pts proximal tibia with
two hands, places their thumbs on the tibial plateau, and administers an anterior directed force to the tibia on
the femur. A positive test is indicated by excessive anterior translation of the tibia on the femur with a
diminished or absent end-point and may be indicative of an anterior cruciate ligament injury.

2. Lachman test-Pt is positioned in supine with the knee flexed to 20-30. The therapist stabilizes the distal
femur with one hand and places the other hand on the proximal tibia. The therapist applies an anterior
directed force to the tibia on the femur. A positive test is indicated by excessive anterior translation of the
tibia on the femur with a diminished or absent end-point and may be indicative of an ACL injury.
3. Lateral pivot shift test-Pt is positioned in supine with the hip flexed and abducted to 30 with slight medial
rotation. The therapist grasps the leg with one hand and places the other hand over the lateral surface of the
proximal tibia. The therapist medially rotates the tibia and applies a valgus force to the knee while the knee is
slowly flexed. A positive test is indicated by a palpable shift or clunk occurring between 20 and 40 of flexion
and is indicative of anterolateral rotator instability. The shift or clunk results from the reduction of the tibia on
the femur.
4. Posterior drawer test-Pt is positioned in supine with the knee flexed to 90 and the hip flexed to 45. The
therapist stabilizes the lower leg by sitting on the forefoot. The therapist grasps the pts proximal tibia with
two hands, places their thumbs on the tibial plateau, and administeres a posterior directed force to the tibia
on the femur. A positive test is indicated by excessive posterior translation of the tibia on the femur with a
diminished or absent end-point and may be indicative of a PCL injury.
5. Posterior sag sign-Pt is positioned in supine with the knee flexed to 90 and the hip flexed to 45. A positive
test is indicated by the tibia sagging back on the femur and may be indicative of a PCL injury.
6. Slocum test-Pt is positioned in supine with the knee flexed to 90 and the hip flexed to 45. Therapist rotates
the pts foot 30 medially to test anterolateral instability. The therapist stabilzes the lower leg by sitting on the
forefoot. Therapist grasps the pts proximal tibia with two hands, places their thumbs on the tibial plateau, and
administers an anterior directed force to the tibia on the femur. A positive test is indicated by movement of
the tibia occurring primarily on the lateral side and may be indicative of anterolateral instability. The test can
also be performed to assess anteromedial instability by rotating the pts foot 15 laterally.
7. Valgus stress test-Pt is positioned in supine with the knee flexed to 20-30. The therapist positions one hand
on the medial surface of the pts ankle and the other hand on the lateral surface of the knee. The therapist
applies a valgus force to the knee with the distal hand. A positive test is indicated by excessive movement
and may be indicative of a MCL sprain. A positive test with the knee in full extension may be indicative of
damage to the MCL, PCL, posterior oblique ligament, and posteromedial capsule.
8. Varus stress test-Pt is positioned in supine the knee flexed to 20-30. The therapist positions one hand on the
lateral surface of the pts ankle and the other hand on the medial surface of the knee. The therapist applies a
varus force to the knee with the distal hand. A positive test is indicated by excessive varus movement and

may be indicative of a LCL sprain. A positive test with the knee in full extension may be indicative of damage
to the LCL, PCL, arcuate complex, and posterolateral capsule.
Meniscal Pathology
1. Apleys compression test-The pt is positioned in prone with the knee flexed to 90. The therapist stabilzes the
pts femur using one hand and places the other hand on the pts heel. The therapist medially and laterally
rotates the tibia while applying a compressive force through the tibia. A positive test is indicated by pain or
clicking and may be indicative of a meniscal lesion.
2. Bounce home test-The pt is positioned in supine. The therapist grasps the pts heel and maximally flexes the
knee. The pts knee is extended passively. A positive test is indicated by imcomplete extension or a rubbery
end-feel and may be indicative of meniscal lesion.
3. McMurray test-The pt is positioned in supine. The therapist grasps the distal leg with one hand and palpates
the knee joint with the other. With the knee fully flexed, the therapist medially rotates the tibia and extends
the knee. The therapist repeates the same procedure while laterally rotating the tibia. A positive test is
indicated by a click or pronounced crepitation felt over the joint line and may be indicative of a posterior
meniscal lesion.

Swelling
1. Brush test-Pt is positioned in supine. The therapist places one hand below the joint line on the medial surface
of the patella and strokes proximally with the palm and fingers and far as the suprapatellar pouch. The other
hand then strokes down the lateral surface of the patella. A positive test is indicated by a wave of fluid just
below the medial distal border of the patella and is indicative of effusion in the knee.
2. Patellar tap test-Pt is positioned in supine with knee flexed or extended to a point of discomfort. The therapist
applies a slight tap over the patella. A positive test is indicated if the patella appears to be floating and may
be indicative of joint effusion.
Miscellaneous

1. Clarkes sign-The pt is positioned in supine with the knees extended. The therapist applies slight pressure
distally with web space of their hand over the superior pole of the patella. The therapist then asks the pt to
contract the quads muscle while maintaining pressure on the patella. A positive test is indicated by failure to
complete the contraction without pain and may be indicative of patellofemoral dysfunction.
2. Hughstons plica test-The pt is positioned in supine. The therapist flexes the knee and medially rotates the
tibia with one hand while the other hand attempts to move the patella medially and palpate the medial
femoral condyle. A positive test is indicated by a popping sound over the medial plica while the knee is
passively flexed and extended.
3. Noble compression test-Pt positioned in supine with the hip slightly flexed and the knee in 90 of flexion. The
therapist places the thumb of one hand over the lateral epicondyle of the femur and the other hand around
the pts ankle. The therapist maintains pressure over the lateral epicondyle while the pt is asked to slowly
extend the knee. A positive test is indicated by pain over the lateral femoral epicondlye at approximately 30
of knee flexion and may be indicative of iliotibial band friction syndrome.
4. Patellar apprehension test-The pt is positioned in supine with the knees extended. The therapist places both
thumbs on the medial border of the patella and applies a laterally directed force. A positive test is indicated
by a look of apprehension or an attempt to contract the quads, in an effort to avoid subluxation and may be
indicative of patella subluxation or dislocation.

Knee conditions (see MS chart)

1. Classification of ligament injuries:
Tissue Healing:
Acute Inflammatory Phase (2-3 days)
Proliferative/Repair Phase (Day 3-Week 8)
Remodeling Phase (Week 6-Month 12)
Grades of sprain:
Grade I-Mild stretch, no macroscopic tear, no functional instabililty; Healing time: 1-2 weeks
Grade II-Moderate stretch, partial tear, some functional instabililty; Healing time: 2-3 weeks

Grade III-Severe, complete tear/rupture; Healing time: 3-6 weeks (requires external bracing)
Repairs:
(Depending on the choice of graft, these healing times will follow these general guidelines)
0-2 weeks-Maximum protection phase
-Focus on muscular control/proprioception
-Inflammatory/proliferative phase
2-6 weeks-Moderate protection phase
-Restore normal gait, ROM
-Protect graft
-Proliferatieve phase
6-12 weeks-Gradually-less-protection phase
-Improve confidence
-Progress strength, power, and proprioception
-Maturation phase
12-24 weeks-Graded return to sport phase
-Return to former levels of function in a graded fashion
-Continue strength/flexibility/power
-Maturation p hase
24 weeks-Return to sport
2. Tendon Healing:
Inflammatory phase-3-7 days
Proliferative phase-day 5-week 5
Remodeling phase-week 6-month 6
Tendonitis/overuse injuries:
-Remove offending activity
-Follow tissue healing guidelines
Days 1-7
PROM, AAROM (if tolerated), no loading
Modalities (stop the bleeding)
Days 7-Week 5
Progressive addition of load from PROM to AAROM to AROM as tolerated

Avoid adhesions between tendon and paratenon

Provide cardiovascular perfusion to area (train well-leg/arm, increase heart rate and perfusion)
Weeks 6-Month 6
Progressively load tendon from AROM to resisted ROM
This can include isometric, isotonic, isokinetic, and eccentric work
GRADUAL and progressive loading as tolerated
3. Genu varum & valgum
Normal tibiofemoral shaft angle is 6 of valgum
Genu varum is an excessive medial tibial torsion, commonly referred to as bowlegs
Genu varum results in excessive medial patellar positioning and the pigeon-toed orientation of the feet
Genu valgum is an excessive lateral tibial torsion commonly referred to as knock knees
Genu valgum results in excessive lateral patellar positioning

4. Anterior compartment syndrome

Increased compartmental pressure resulting in a local ischemic condition
Multiple etiologies: direct trauma, fracture overuse, and/or muscle hypertrophy
Symptoms of chronic or exertional compartment syndrome are produced by exercise or exertion and
descriped as a deep, cramping, feeling
Symptomes of acute ACS are produced by sudden trauma causing swelling within the compartment
Diagnosis made by clinical exam
Acute ACS is considered a medical emergency and requires immediate surgical intervention with fasciotomy.
5. Anterior tibial periostitis (shin splints)
Musculotendinous overuse condition
Three common etiologies:
1. Abnormal biomechanical alignment
2. Poor conditioning
3. Improper training methods
Muscles involved include anterior tibialis and extensor hallucis longus
Pain elicited with palpation of lateral tibia and anterior compartment

Goals, outcomes, interventions: correction of muscle imbalances and biomechanical faults using
strengthening, endurance, and coordination exercises. Flexibililty exercises for anterior compartment muscles,
as well as the tricpes surae, to gain restoration of normal function
Ankle/foot
-The talocrural joint is formed between the talus and the distal tibia.
-The posterior talofibular ligament (PTFL) is the strongest of the lateral ligament complex. It is rarely injured except
in severe ankle sprains.
-The strength of the ankle ligaments from weakest to strongest is the ATFL, PTFL, CFL, and deltoid complex.
-The fibular (peroneal) muscles serve as both plantar flexors and evertors of the foot. The peroneus longus also
abducts the forefoot in the transverse plane, thereby serving as a support for the medial longitudinal arch.
ROM (ankle):
DF-0-20
PF-0-50
INV-0-35
EVR-0-15

ROM (subtalar):
INV-0-5
EVR-0-5

Closed pack position (talocrural): maximum DF

Loose pack position: 10 PF, midway between maximum inversion and eversion
Capsular pattern: Plantar flexion more limited than dorsiflexion
Closed packed position of (Subtalar, Midtarsal, and tarsometatarsal): Supination
Loose packed position: midway between extremes of range of movement
Capsular pattern of subtalar: limitation of varus range of movement
Capsular pattern of midtarsal: DF, PF, ADD, MR
Closed packed position of metatarsophalangel and interphalangeal: full extension
Loose packed position: Neutral(MTP); slight flexion (IP)

Arthrokinematics:
Joint
Talocrural

Motion to Increase
Plantarflexion

Mobilization Glide
Anterior

Subtalar

Dorsiflexion
Inversion
Eversion

Posterior
Lateral
Medial

Common MMT of the Ankle/foot:

1. Ankle plantarflexion: Weight-bearing test (Gastrocnemius and Soleus)-Standing on one leg (test
limb), knee extended, foot flat on floor. Pt rises on toes of weight bearing leg through range of plantar
flexion, keeping knee extended. Pt repeats motion until fatigued or stopped by examiner. (Soleus)-pt is
standing on one limb, knee flexed, foot flat on floor. Pt demonstrates movement of rising on toes with knee
flexed. Gravity eliminated-side-lying on side to be tested.
2. Ankle plantarflexion: Non-weight bearing test (Gastroc & Soleus)-Prone with knee extended, foot
off end of table, ankle neutral. Pt plantarflexes ankle through ROM, apply resistance on superoposterior
aspect of calcaneus in direction of ankle DF. Soleus-prone with knee flexed to 90, ankle neutral.
3. Ankle dorsiflexion and subtalar inversion-Seated with legs off table, ankle neutral. Dorsiflex and
invert pts ankle through ROM, apply resistance over dorsal surface of medial side of foot in direction of PF
and eversion. Gravity eliminated-Supine with LEs extended, ankle of test limb in neutral, foot extended
beyond edge of table.
Special tests of the ankle/foot:
Ligamentous Instability
1. Anterior Drawer test-Pt is positioned in supine. The therapist stabilizes the distal tibia and fibula with one
hand, while the other hand holds the foot in 20 of plantar flexion and draws the talus forward in the ankle
mortise. A positive test is indicated by excessive anterior translation of the talus away from the ankle
mortise and may be indicative of an anterior talofibular ligament (ATFL) sprain.
2. Talar tilt-Pt is positioned in sidelying with knee flexed to 90. The therapist stabilizes the distal tibia with
one hand while grasping the talus with the other hand. The foot is maintained in a neutral position. The
therapist tilts the talus into abduction and adduction. A positive test is indicated by excessive adduction
and may be indicative of a calcaneofibular ligament sprain.
Miscellaneous

1. Thompson test-Pt is positioned in prone with the feet extended over the edge of a table. The therapist asks
the pt to relax and proceeds to squeeze the muscle belly of the gastrocnemius and soleus muscles. A positive
test is indicated by the absence of plantar flexion and may be indicative of a ruptured Achilles tendon.
2. Tibial torsion test-Pt is positioned in sitting with the knees over the edge of a table. The therapist places the
thumb and index finger of one hand over the medial and lateral malleolus. The therapist then measures the
acute angle formed by the axes of the knee and ankle. Normal lateral rotation of the tibia is considered to be
12-18 in an adult.
3. True leg length discrepancy test-Pt is positioned in supine with the hips and knees extended, the legs 15-20
cm apart, and the pelvis in balance with the legs. Using a tape measure, the therapist measures from the
distal point of the ASIS to the distal point of the medial malleoli. A positive test is indicated by a bilateral
variation of greater than 1 cm and may be indicative of a true leg length discrepancy.
Conditions of the Foot/ankle (see MS chart):
1. Ligament sprains:
95% of all ankle sprains involve lateral ligaments
With lateral sprains, foot is plantar flexed and inverted at time of injury
Diagnostic test utilized: MRI
2. Tarsal tunnel syndrome:
Entrapment of the posterior tibial nerve or one of its branches within the tarsal tunnel
Over/excessive pronation, overuse problems resulting in tendonitis of the long flexor and posterior tibialis
tendon, and trauma may compromise space in the tarsal tunnel
Symptoms include pain, numbness, and paresthesias along the medial ankle to the plantar surface of the
foot
Diagnostic tests utilized: electrodiagnostic tests
Positive Tinels sign at the tarsal tunnel
Goals, Outcomes, interventions: Use of orthoses to maintain neutral alignment, neurodynamic mobilization
may be indicated
3. Charcot-Marie-Tooth Disease:
Peroneal muscular atrophy that affects motor and sensory nerves
May begin in childhood or adulthood
Initially affects muscles in lower leg and foot, but eventually progresses to muscles of hands and forearm
Slowly progressive disorder with varying degrees of involvement, depending on degree of genetic
dominance.
No specific treatment to prevent, since it is an inherited disorder.

4. Rearfoot varus (subtalar varus, calcaneal varus):

Etiology-abnormal mechanical alignment of tibia, shortened rearfoot soft tissues, or malunion of calcanus.
Deformity observed: rigid inversion of calcaneus when subtalar joint is in neutral position
5. Rearfoot valus:
abnormal alignment of the knee (genu valgum) or tibial valgus
Deformity observed: eversion of calcaneus with a neutral subtalar joint
6. Forefoot varus: inversion of forefoot
7. Forefoot valgus: eversion of forefoot
Cervical Spine
ROM:
Flex-45
Ext-45
Lateral flex-45
Rotation-60
Capsular pattern: Full flexion most limited followed by limited extension, and symmetric limitation of rotation and
sidebending.
*Limitation of or pain on cervical rotation usually suggests pathology at the C1-C2 (atlantoaxial) segment, because
most rotation occurs here.
Special tests of cervical region:
1. Foraminal compression test (Spurlings)-Pt is positioned in sitting with the head laterally flexed. The therapist
places both hands on top of the subjects head and exerts a downward force. A positive test is indicated by
pain radiating into the arm toward the flexed side and may be indicative of nerve root compression.
2. Vertebral artery test-Pt is positioned in supine. The therapist places the pts head into extension, lateral
flexion, and rotation to the ipsilateral side. A positive test is indicated by dizziness, nystagmus, slurred speech
or loss of consciousness and may be indicative of compression of the vertebral artery. **Performing
mobilization/manipulation within cervical region w/out performing this test beforehand would be considered a
breach in standard care.
3. Hautants test-Differentiates vascular versus vestibular causes of dizziness/vertigo.
Two steps to this test:

1. Pt sitting with shoulders at 90 and palms up. Have pt close eyes and remain in this position for 30
seconds. If arms lose their position, there may be a vestibular condition.
2. Pt sitting with shoulders at 90 and palms up. Have pt close eyes, and cue pt into head and neck ext with
rotation right, then left, remaining in each position for 30 seconds. If arms lose their position, the condition
may be vascular in nature.
4.Transverse Ligament stress test (sharp-purser)-Tests integrity of transverse ligament. Pt supine, with head
supported on table. Glide C1 anterior. Should be firm end-feel. Positive findings: soft end-feel, dizziness, nystagums,
lump sensation in throat, nausea.
5. Lhermittes sign-Identifies dysfunction of spinal cord and/or an upper motor neuron lesion. Pt in long sitting on
table. Passively flex pts head and one hip, while keeping knee in extension. Repeat with other hip. Positive finding is
pain down the spine and into the upper or lower limbs.
6. Romberg test-Identifies upper motor neuron lesion. Pt standing, and closes eyes for 30 seconds. Excessive
swaying during test indicates positive finding.
Conditions of the cervical spine:
1. Whiplash acceleration/deceleration injury-occurs when excess shear and tensile forces are exerted on
cervical structures. Structures injured may include facets/articular processes, facet joint capsules, ligaments,
disc, anterior/posterior muscles, fracture to odontoid process and spinous processes, TMJ, sympathetic chain
ganglia, spinal and cranial nerves.
Signs and symptoms-early include headaches, neck pain, limited flexibility, reversal of lower cervical lordosis
and decrease in upper cervical kyphosis, vertigo, change in vision and hearing, irritability to noise and light,
dysesthesias of face and bilateral upper UEs, nausea, difficulty swallowing, and emotional lability.
Late include chronic head and neck pain, limitation in flexibility, TMJ dysfunction, limited tolerance to ADLs,
disequilibrium, anxiety, and depression.
Common clinical findings include postural changes, excessive muscle guarding with soft tissue fibrosis,
segmental hypermobility, and gradual development of restricted segmental motion, crainial and caudal to the
injury.
Medications: NSAIDS, muscle relaxants, trigger point injections, corticosteroid injection or by mouth
Goals, outcomes, interventions: Spinal manipulation, correction of muscle imbalance, joint mobs, pt education
on elimination of harmful positions, postural education. Manual or mechanical traction: cervical spine
positioned at 15 of flexion to provide optium intervertebral foraminal opening. Contraindications: joint

hypermobility, pregnancy, RA. Down syndrome, or any other systemic disease that affects ligamentous
integrity.
Thoracic and Lumbar Spine
ROM:
Flex-80
Ext-25
Lateral flex-35
Rotation-45
Capsular pattern for both: lateral flexion and rotation equally limited, extension
Lumbar special tests:
1. Stork standing test-Identifies sponlylolisthesis. Pt standing on one leg, cue pt into trunk extension. Repeat
with opposite leg on ground. Positive finding is pain in low back with ipsilateral leg on ground.
2. McKenzies slide glide test-Differentiates between scoliotic curvature versus neurological dysfunction
causing abnormal curvature (lateral shift) of trunk. Test is performed if lateral shift of trunk is noted. Pt
standing, stand on one side of pt so that upper trunk is shifted toward you. Place your shoulders into pts
upper trunk and wrap your arms around pts pelvis. Stabilize upper trunk and pull pelvis, to bring pelvis and
trunk into proper alignment. Positive test is reproduction of neurological symptoms as alignment of trunk is
corrected.
3. Bicyle (van Gelderens test)-Differentiates between intermittent claudication and spinal stenosis. Pt seated on
stationary bike. Pt rides bike while witting erect. Time how long they can ride at a set pace/speed. After a sufficient
rest period, have pt ride bike at same speed while in a slumped position. Determination is based on length of time
pt can ride bike in sitting upright vs sitting slumped. If pain is related to spinal stenosis, pt should be able to ride
bike longer while slumped.
4. Standing flexion test-Tests the iliosacral motion and determines if there is a joint dysfunction and the side of
involvement. The clinician palpates both the PSISs and asks the pt to bend forward. The PSIS that either moves
cranially first or farthest is considered the blocked or positive side.
Spinal conditions:
1. Spondyloysis/spondyloisthesis: Thought to congenitallyl defective pars interarticularis.
Spondylolysis is a fracture of the pars interarticularis with positive Scotty dog sign on oblique
radiographic view of spine.

Spondylolisthesis is the actual anterior or posterior slippage of one vertebra on another, following bilateral
fracture of pars interarticularis. It can be graded according to amount of slippage from 1 (25% slippage) to
4 (100% slippage).
Diagnostic tests utilized: plain film (oblique to see fracture and lateral views to see slippage)
Clinical exam including stork test, helps identify this condition.
Goals, outcomes, and interventions: Dynamic stabilization of trunk, with particular emphasis on
abdominals. AVOID EXTENSION and/or other positions that add stress to the defect (extension,
ipsilateral side-bending, and contralateral rotation). Braces such as Boston brace and TLSO. Spinal
manipulation may be contraindicated for this condition, particularly at the level of defect.
2. Spinal or intervertebral stenosis-Congenital narrow spinal canal or intervertebral foramen, coupled
with hypertrophy of the spinal lamina and ligamentum flavum or facets, as the result of age-related
degenerative processes or disease. Results in vascular and/or neural compromise.
Signs and symptoms: Bilateral pain and paresthesia in back, buttocks, thighs, calves, and feet. Pain
decreases in spinal flexion, increases in extension. Pain increases with walking. Pain relieved with
prolonged rest.
Diagnostic tests utilized: plain films, MRI, and/or CT scan
Clinical exam including bicycle.
Goals, outcomes, and interventions: Perform flexion-based exercise, and exercises that promotes dynamic
stability throughout the trunk and pelvis. Avoid extension and/or other positions that narrow the spinal
canal (ipsilateral sidebending or rotation)
3. Disc Conditions-Internal disc disruption: Internal structure of disc annulus is disrupted; however,
external structures remain normal. Most common in lumbar region.
Symptoms include constant deep, achy pain, and increased pain with movement. No objective neurological
findings, although pt may have referred pain in LE.
Regular CT or myelogram will not demonstrate any abnormal findings. Can be diagnosed by CT discogram
or an MRI.
Goals, outcomes, interventions: Spinal manipulation may be contraindicated for this condition. Limit
repetitive bending and twisting movements, limiting UE overhead and sitting activities, and carrying heavy
loads.
Posterolateral bulge/herniation-Most commonly observed disc disorder of lumbar spine due to three
structural deficiencies: Posterior disc is narrower in height than anterior disc, Posterior longitudinal
ligament is not as strong and only centrally located in lumbar spine, posterior lamellae of annulus are
thinner.

Etiology-overstretching and/or tearing of annular rings, vertebral endplate and /or ligament structures,
from high compressive forces or repetitive microtrauma.
Results in loss of strength, radicular pian, paresthesia and inability to perform ADLS.
Goals, outcomes, interventions-exercise program to promote dynamic stability throughout trunk and pelvis
and to provide optimal stimulus for regeneration of disc. Positional gapping for 10 minutes to increase
space within region of space occupying lesion.
If left posterolateral lumbar herniation is present:
-Have pt side-lying on right side, with pillow under right trunk, flex both hips and knees, rotate trunk to left
(or pelvis to right), pt can be taught to perform this at home.
Spinal manipulation may be contraindicated for this condition.
Sacroiliac Joint:
Special tests:
1. Gillets test (march test)-After palpating the PSISs, the pt stands on one leg and pulls the opposite knee
toward the chest. The blocked or dysfunctioning joint will not move while the normal joint will move inferiorly.
2. Long-sitting test-Used to determine if there is a posteriorly or anteriorly rotated innominate based on
apparent leg length differences. If the lower limb on the affected side appears longer with a pt lies supine, but
shorter when sitting, the test is positive, indicating an anterior innominate rotation on the affected side.
Long to short=anterior
If the lower limb is shorter in supine and appears to get longer when sitting, then a posterior innominate
rotation exists on the affected side.
Short to long=posterior
3. Sitting flexion test-therapist localizes the PSISs as the pt, in a sitting position, bends forward with arms
across the chest and passes elbows between the knees as if to touch the floor. The pts feet should be in
contact with the floor or resting on a stool. A positive test occurs when a blocked joint moves first and/or
farther cranially.
4. Straight leg raise-Used to evaluate low back pain and can indicate the unilateral dysfunction of the SI joint.
The test is positive if pain extends from the back down the leg in the sciatic nerve distribution.
The cluster of 5 tests (3/5 to be positive) have a sensitivity of .91 and specificity of .87 related to SI joint pain.
The tests are:
1. Distraction (applies cross arm pressure to both ASIS, + if increased pain)

2. Thigh thrust (pt supine with hip flexed to 90, examiner applies posteriorly directed force through the femur,
+ if pain or symptoms reproduced)
3. Gaenslens test (pt supine with one leg hanging over edge of table, other if flexed toward chest. Examiner
applies firm pressure to both the hanging leg and flexed, + if symptoms increase or reproduced)
4. Sacral thrust (pt lies prone and examiner applies a force vertically downward to the center of the sacrum, + if
symptoms increased or reproduced)
5. Compression test (pt positioned in sidelying with affected side up, hips are flexed approx 45 and knees flexed
to 90. Examiner applies a force vertically downward on ASIS, + if symptoms increase or reproduced)
TMJ (see MS chart)
Capsular pattern: limitation of mouth opening
Closed packed position: Clenched teeth
Loose packed position: mouth slightly open
ROM:
Opening: 40mm
Rotation: 25mm
Translatory glide:15mm

GAIT:
Standard Terminology
Stance Phase (60% of
gait cycle)

Swing Phase (40% of

Heel strike
Foot flat
Midstance
Heel off
Toe Off
Acceleration

Rancho Los Amigos

Terminology
Initial Contact
Loading response
Midstance
Terminal Stance
Pre-Swing
Initial Swing

gait cycle)

Midswing
Deceleration

Midswing
Terminal Swing

= Standard terminology
(

) =Rancho terminology

Stance Phase:
Heel strike: is the instant that the heel touches the ground to begin stance phase.
(Initial Contact): is the beginning of the stance phase that occurs when the foot touches the ground
Foot flat: is the point in which the entire foot makes contact with the ground and should occur directly after heel
strike.
(Loading response): corresponds to the amount of time between initial contact and the beginning of the swing phase
for the other leg.
Midstance: is the point during the stance phase when the entire body weight is directly over the stance limb.
(Midstance): corresponds to the point in stance phase when the other foot is off the floor until the body is directly
over the stance limb.
Heel off: is the point in which the heel of the stance limb leaves the ground.
(Terminal stance): begins when the heel of the stance limb rises and ends when the other foot touches the ground.
Toe off: is the point in which only the toe of the stance limb remains on the ground.
(Pre-swing): begins when the other foot touches the ground and ends when the stance foot reaches toe off.
Swing phase:
Acceleration: beings when toe off is complete and the reference limb swings until positioned directly under the
body.
(Initial swing): beings when the stance foot lifts from the floor and ends with maximal knee flexion during swing.
Midswing: is the point when the swing limb is directly under the body.
(Midswing): begins with maximal knee flexion during swing and ends when the tibia is perpendicular with the
ground.

Deceleration: begins directly after midswing, as the swing limb begins to extend, and ends just prior to heel strike.
(Terminal swing): beings when the tibia is perpendicular to the floor and ends when the foot touches the ground.

Phase

Hip

Knee

Tibia

Ankle

Foot

Heel Strike

Begins to
extend
from a
position
of 20-40
of
flexion.
Hip in
slight
add &
ER.

Full
knee
extensio
n before
heel
contact,
but
flexing
as heel
makes
contact.

ER

Moving
into PF

Supination
(rigid at
heel
contact)

Foot Flat

Hip
moving
into ext,

20
flexion,
moving

IR

PFDF

Pronation
(adapting
to support

Muscle
Activity
Ant tib:
eccentric
(to control
pronation)
EHL & ED:
eccentric
(decelerate
PF)
Pos tib,
soleus,
gastroc:
eccentric
(decelerate
pronation)
G max &
hams:
eccentric
(resist
flexion)
Erector
spinae:
eccentric
(control
trunk
flexion).
G max &
hams:
concentric

Midstance

add & IR.

towards
extensio
n.

Neutral
position,
pelvis
rotates
posteriorl
ly.

15
flexion
(moving
toward
extensio
n)

surface)

Neutral

3 DF

Neutral

(to move
hip into
extension).
After foot is
flat, quads
activity
becoming
concentric
to bring
femur over.
Pos tib,
soleus,
FHL, FDL:
eccentric to
decelerate
movement
Pos tib,
soleus, &
gatroc:
concentric
(to supinate
subtalar
and
metatarsal
joint)
Iliopsoas:
eccentric.
Glut med:
creating
reverse
action to
stabilize
opposite
pelvis.
Quad
activity

Heel Off

Toe Off

10-15
extension
, abd, &
ER.
Moving
towards
10 ext,
abd, &
ER.

4
flexion

ER

15 DF

Supination
(rigid for
push-off)

Moving
from full
ext to
40
flexion.

ER

20 PF

Supination

decreasing
Quads
activity
decreasing
Peroneus
longus &
abd
hallucis:
concentric
(to PF 1st
ray)
Peronus
brevis:
antagonist
to
supinators
of subtalar
and
metatarsal
joints. FHL,
EHL, EHB,
&
intrinsics:
concentric
stability.
Adductor
magnus:
eccentric
(to control
pelvis)
Reaction
forces
moving
posterior to
knee.

Quadseccentric

Phase
Acceleration to
Midswing

Hip
Slight flexion
(0-15) moving
at 30 flexion
and external
rotation to
neutral

Knee
30-60 knee
flexion and
external
rotation of tibia
moving toward
neutral.

Ankle& Foot
20 DF and
slight
pronation

Midswing to
Deceleration

Continued
flexion at
about 30 to
40

Moving to near
full extension
& slight lateral
tibial rotation

Ankle in
neutral; foot in
slight
supination

Muscle Activity
Hip: flexors
working
concentrically
to bring limb
through;
contralateral
glut med
concentrically
contracting to
maintain pelvis
position.
Hamstrings
concentrically
contracting.
Dorsiflexors
contracting
concentrically.
Glut max
contracting
eccentrically to
slow hip
flexion. Quads
contracting

concentrically
& hamstrings
eccentrically.
Dorsiflexors
contracting
isometrically.
Peak Muscle Activity During the Gait cycle:
Tibialis
anterior:
Gastroc-soleus
group:
Quadriceps
group:
Hamstrings
group:

Peak activity is just after heel strike. Responsible for

eccentric lowering of the foot into plantar flexion.
Peak activity is during late stance phase. Responsible for
concentric raising of the heel during toe off.
Two periods of peak activity. In periods of single support
during early stance phase and just before toe off to
initiate swing phase.
Peak activity is during late swing phase. Responsible for
decelerating the unsupported limb.

ROM Requirements for Normal gait:

Hip flexion
Hip
extension
Knee
flexion
Knee
extension
Ankle DF
Ankle PF

0-30
0-10
0-60
0
0-10
0-20

Gait terminology:
Base of support-the distance measured between the left and right foot during progression of gait. The distance
decreases as cadence increases. The average base of support for an adult is 2-4 inches.

Cadence-the number of steps an individual will walk over a period of time. The average value for an adult is 110120 steps per minute.
Degree of toe-out-the angle formed by each foots line of progression and a line intersecting the center of the heel
and second toe. The average degree of toe-out for an adult is 7
Step length-the distance measured between right heel strike and left heel strike. The average for an adult is 28
inches.
Stride length-the distance measured between right heel strike and the following right heel strike. The average for
an adult is 56 inches.

Abnormal gait patterns:

Antalgic-a protective gait pattern where the involved step length is decreased in order to avoid weight bearing on
the involved side, usually secondary to pain.
Ataxic-a gait pattern characterized by staggering and unsteadiness. There is usually a wide base of support and
movements are exaggerated.
Cerebellar-a staggering gait pattern seen in cerebellar disease.
Circumduction-a gait pattern characterized by a circular motion to advance the leg during swing phase; this may be
used to compensate for insufficient hip or knee flexion or dorsiflexion.
Double step-a gait pattern in which alternate steps are of a different length or at a different rate.
Equine-a gait pattern characterized by high steps; usually involves excessive activity of the gastrocnemius.
Festinating-a gait pattern where a pt walks on toes as though pushed. It starts slowly, increases, and may continue
until the pt grasps an object in order to stop.
Hemiplegic-a gait pattern in which pts abduct the paralyzed limb, swing it around, and bring it forward so the foot
comes to the ground in front of them.

Parkinsonian-a gait pattern marked by increased forward flexion of the trunk and knees; gait is shuffling with quick
and small steps; festinating may occur.
Scissor-a gait pattern in which the legs cross midline upon advancement
Spastic-a gait pattern with stiff movement, toes seeming to catch and drag, legs held together, and hip and knee
joints slightly flexed. Commonly seen in spastic paraplegia.
Steppage-a gait pattern in which the feet and toes are lifted through hip and knee flexion to excessive heights;
usually secondary to dorsiflexor weakness. The foot will slap at initial contact with the ground secondary to the
decreased control.
Tabetic-a high stepping ataxic gait pattern in which the feet slap the ground.
Trendelenburg-a gait pattern that denotes gluteus medius weakness; excessive lateral trunk flexion and weight
shifting over the stance leg.
Vaulting-a gait pattern where the swing leg advances by compensating through the combination of elevation of the
pelvis and plantar flexion of the stance leg.
MS Interventions:
Orthopaedic Surgical Repairs:
1. Surgical repairs of upper extremity:
a. Rotator Cuff tears
i. Usually degenerative and occur over time, with impingement of supraspinatus tendon between
the greater tuberosity and acromion.
ii. Signs and symptoms include:
-Significant reduction in AROM into abduction
-No reduction of PROM
-Drop arm test is positive
-Poor scapulothoracic and glenohumeral rhythm
b. Diagnostic tests utilized: arthrogram traditionally had been the gold standard test. MRI may be done,
but may not be as sensitive.
c. PT goals, outcomes, and interventions:
-Rehab is initiated, following a period of immobilization with surgical intervention

-PT intervention emphasizes return or normal strength/endurance/coordination of muscles, joint

mechanics, flexibility (AROM/PROM), and scapulothoracic and glenohumeral rhythm with overhead function.

2. Tendon injuries and repairs of the hand:

a. Flexor tendon repairs
i. First 3-4 weeks, distal extremity is immobilized with a protective splint, with wrist and digits
flexed. Rubber band traction is applied to maintain interphalangeal joints in 30-50 of passive
flexion.
ii. PT goals, outcomes and interventions:
1. Pt can perform resisted extension and passive flexion with constraints of splint. AROM to
tolerance is initiated at 4 weeks.
2. Goal is to manage all soft tissues through wound-healing phases by providing collagen
remodeling, which preserves free tendon gliding.
3. Early intervention consists of wound management, edema control, and passive exercises.
4. Active extension exercises are initiated first followed by flexion.
5. Resistive and functional exercises are introduced when full AROM is achieved.
b. Extensor tendon repairs
i. Distal repairs are immobilized such that the distal interphalangeal joints are in neutral for 6-8
weeks.
ii. PT goals, outcomes, and interventions:
1. AROM is initiated at 6 weeks, with PIP joints in neutral
2. Goal is to manage all soft tissues through wound-healing phases by providing collagen
remodeling, which preserves free tendon gliding
3. Early intervention consists of wound management, edema control, and passive exercises.
4. Active extension exercises are initiated first, followed by flexion.
5. Resistive and functional exercises are introduced when full AROM is achieved.
6. Proximal repairs are immobilized, with the wrist and digital joints in extension for 4 weeks.
7. PT goals, outcomes, and interventions: Early AROM/PROM in flexion with MCP joint in
extension. At 6 weeks, full AROM is initiated into flexion and extension.
3. Surgical repairs of lower extremity:
a. Total hip replacement/arthroplasty (THR):
This info may vary, depending on surgical procedure and/or MD preference/protocol. Must be
familiar with postoperative protocol for each patient relative to procedure and/or MD.
b. Cemented vs. non-cemented.

i. Cemented hips can tolerate full weight bearing immediately following surgery.
ii. Cement may crack with aging, causing a loosening of prosthesis. Noncemented technique is
more stressful on bones during the surgical procedure.
iii. Noncemented procedures are typically used with younger and/or more active individuals.
Cemented technique may be better for those who will benefit from immediate ability to weight
bear e.g. those with dementia or significant debilitation.
iv. Bed positioning with a wedge to prevent adduction
v. Pt should avoid the position of hip flexion >90 with adduction and IR.
vi. Partial weight bearing to tolerance is initiated on the second post-surgery day, using crutches or
a walker with typical surgical procedures.
vii. PT goals, outcomes, and interventions: PT focuses on bed mobility, transitional movements,
ambulation, and return to premorbid ADLs.
c. Open reduction internal fixation (ORIF) following femoral fx:
i. Pt will typically be non-weight bearing for 1-2 weeks, using crutches or a walker. Thereafter, the
pt will be partial weight bearing as tolerated.
ii. PT goals, outcomes, and interventions: Pt focus on bed mobility, transitional movements,
ambulation, and return to premorbid ADLs. Important to note that guidelines/precautions can
vary significantly.
d. Total knee replacement/arthroplasty (TKR):
i. TKR surgery is typically performed as a result of severe DJD of the knee joint, which has lead to
pain and impaired function.
ii. PT goals, outcomes, interventions: Goals of early rehab (1-3 weeks) include muscle reeducation,
soft tissue mobilization, lymphedema reduction, and initiation of PROM (CPM), AROM, and
reduction of postsurgical swelling.
iii. Goals of the second phase of rehab include regaining endurance, coordination, and strength of
the muscles surrounding the knee. Functional activities include progressive ambulation stair
climbing, as well as transitional training based on healing and the type of prosthesis used.
iv. Goals and outcomes of the last phase of rehab include returning the pt to premorbid ADLs.
Functional and endurance training and proprioceptive exercises introduced during this phase.
v. The weight bearing status of pts with a cemented prosthesis is at the level of the pts tolerance.
Pts with cementless prostheses are progressed according to the time frame for fx healing. Weight
bearing is 25% at 1-7 weeks, 50% by week 8, 75% by week 10, and 100% without an AD by week
12.

vi. Avoidance of forceful mobilization and PROM into flexion >90 is important, because of the
mechanical restraints of the prosthesis.
vii. Biomechanical faults caused by joint restrictions should be corrected with joint mobilizations to
the specific restrictions identified during the exam.
e. Ligamentous repairs of the knee
i. Six phases of rehab are followed with ACL and PCL reconstructive surgery.

Anterior cruciate ligament reconstruction:

-Immediately following surgery, a CPM unit is utilized, with PROM from 0-70 of flexion.
-Motion is increased to 0-120 by the 6th week.
-Reconstruction is usually protected with a hinged brace set at 20-70 of flexion initially.
-Pt is non-weight bearing for approx 1 week.
-Weight-bearing progresses as tolerated to full weight bearing
-Pt is weaned from brace between the 2nd and 4th weeks
Posterior cruciate ligament reconstruction:
-Generally similar to ACL repair, except is often initially in hinged brace at 0 during ambulation.
-6 phases of rehab for ACL/PCL are as follows: Preoperative, maximum protection, controlled motion,
moderate protection, minimum protection, and return to activity.
-Specific interventions:
-Soft tissue massage to quad/hams to reduce muscle guarding; joint oscillations to inhibit joint
pain and muscle guarding; correction of muscle imbalances and biomechanical faults; progress to
functional training based on pts occupation and recreation.
Lateral retinacular release:
-Typically performed as a result of patellofemoral pain syndrome (PFPS). Purpose of procedure is to restore normal
tracking of the patella during contraction of the quads muscle.
PT intervention:
1. Should emphasize closed kinetic chain exercises to strengthen quadriceps muscle and regain dynamic
balance of all structures (contractile and noncontractile) surrounding knee.
2. Normalize the flexibility of the hamstrings, triceps surae, and ITB will help restore mechanical alignment.

3. Mobilization of patella is important to maintain nutrition and decrease the likelihood of adhesions.
Meniscal arthoscopy:
1. Partial meniscectomy:
a. Partial weight bearing as tolerated when full knee extension is obtained
b. PT goals, outcomes, and interventions:
i. Initial goals focus on edema/effusion control
ii. AROM is urged after surgical day 1.
iii. Isotonic and isokinetic strengthening by day 3.
iv. Jogging on the ball of the foot or toes is recommended to decrease the loading of the knee joint.
2. Repairs
a. Pt will be non-weight bearing for 3-6 weeks
b. Rehab of the joint begins within 7-10 days of procedure.
c. PT goals, outcomes, interventions: Soft tissue/massage to quad/hams, joint oscillations, correction of
muscle imbalances, biomechanical faults, progression to functional training
3. Surgical repairs of spine:
a. Rehab varies according to the type of surgery performed.
b. A back protection program and early mobilization exercises should be initiated prior to surgery.
c. Pts should avoid prolonged sitting, heavy lifting, and long car trips for approx 3 months.
d. Repetitive bending with twisting should always be avoided.
e. With microdiscetomies, rehab time is decreased bc the fibers of the annulus fibrosus are not damaged.
f. With laminectomy/discectomy, early movement and activation of paraspinal musculature (especially
mulitfidus) is necessary.
g. Multilevel vertebra fusion:
i. Typically requires 6 weeks of trunk immobility with bracing
ii. Once brace is removed and movement is allowed, important to regain as much normal/functional
movement as possible, while restoring functional activation of muscles.
iii. With combined anterior/posterior surgical approach, bracing is seldom used.
h. With Harrington rod placement for idiopathic scoliosis, rehab goals focus on early mobilization in bed
and effective coughing.
i. The pt can begin ambulation between the 4 th and 7th postoperative days
j. The pt should avoid heavy lifting and excessive twisting and bending.
k. PT goals, outcomes, and interventions: Soft tissue/massage to paraspinal muscles; joint oscillations to
inhibit joint pain, correction of muscle imbalances, make sure that multifidus function is restored.

Interventions for Patients/clients with Acute Conditions

o Acute Phase
Immobilization with limited (1-2 days) bed rest. Use of braces, slings, corsets, cervical collars, assistive devices,
and taping
Control inflammatory response (RICE)
Physical agents: ice and electrical stimulation
Compression and elevation to reduce and prevent effusion and swelling.
NSAIDs
Rest/relaxation to reduce pain
Soft tissue/massage techniques
Assisted movement of injured tissue
Joint oscillations (grade 1-2) for pain relief
Therapeutic exercise
Dose of 40-60% of one rep max to stimulate regeneration of tissue and revascularization.
Exercise should be nontraumatic, meaning no pain and/or increased edema as a result of the exercise.
Educate Pt/client on joint protection strategies
o Subacute phase
Avoidance of continued irritation and repetitive trauma.
Modify activities at home/work/recreation
Modify use of equipment or type of equipment at home/work/recreation
Correct biomechanical faults, such as leg length discrepancy, abnormal foot biomechanics, abnormal throwing
motion.
Joint mobilization
Continued therapeutic exercises, including flexibility/endurance/coordination exercise.
Postural reeducation
Biomechanical education
o Functional restoration phase
Maintain or return to optimal level of Pt function
Normalize flexibility of joints and related soft tissues
Restore loading capacity of connective tissues to normal strength

 Functional strengthening exercise

Functional stabilization of the involved joint/region.
Interventions for Patients/Clients with a Chronic Condition
o Determine possible causative factors
Abnormal remodeling of injured tissues
Chronic low-grade inflammation due to repetitive stresses of tissues.
o Reduce stresses to tissues
Identify/eliminate magnitude of loading
Identify/eliminate direction of forces
Identify and eliminate any biomechanical barriers that are preventing haling
Pt education regarding protection of joints and associated soft tissues.
o Regain structural integrity
Improving flexibility
Postural reeducation
Increasing tissue capacity to tolerate loading
Functional strengthening, endurance, and coordination exercises.
o Resume optimal patient function and prevention of reoccurrence
Pt education regarding causative factors in dysfunction
Work conditioning
Specific Interventions:
o Soft tissue/myofascial techniques
Aid in reduction of metabolites for muscle, reactivating a muscle that has not been functioning secondary to
guarding and ischemia, revascularization of muscle, and also decreased guarding in a muscle
Autonomic: stimulation of skin and superficial fascia to facilitate a decrease in muscle tension.
Mechanical: movement of skin, fascia, and muscle causes histological and mechanical changes to occur in soft
tissue to produce improved mobility and function.
Goals: decrease pain, edema, and muscle spasm, increase metabolism and cutaneous temp, stretch tight muscles
and other soft tissues, improve circulation, strengthen weak muscles, and mobilize joint restrictions.

 Indications: Pt with soft tissue and joint restrictions that result in pain and limits in ADLs
Contraindications
Absolute- soft tissue breakdown, infection, cellulitis, inflammation, and or neoplasm.
Relative- hypermobility and sensitivity
Traditional massage techniques such as effleurage and petrissage
Functional Massage
Three techniques used to assist in reactivation of a debilitated muscle and/or to increase vascularity to a muscle.
o Soft tissue without motion
Traditional technique; however hands do not slide over skin; instead, they stay in contact with the skin while hands
and skin move together over the muscle.
Direction of force is parallel to muscle fibers, and total stroke time should be 5-7 seconds.
o Soft tissue with passive pumping
Place muscle in shortened position and with one hand place tension on muscle parallel to muscle fibers.
Other hand passively lengthens muscle and simultaneously gradually releases tension of hand in contact with muscle.
o Soft tissue with active pumping
Place muscle in lengthened position, and with one hand place tension on muscle, perpendicular to muscle fiber.
Other hand glides limb as Pt actively shortens muscle. As muscle shortens, gradually release tension of hand in
contact with muscle.

Transverse Friction Massage

o Used to initiate an acute inflammatory response for a tissue that is in metabolic stasis, such as a tendonosis.
o Involved tendon is briskly massaged in a transverse fashion
o Performed for 5-10 min and tends to be very uncomfortable for the pt

Movement approaches require the pt to actively participate in treatment.

Examples include:
o Feldenkrais
Facilitates development of normal movement patterns
The practitioner uses skillful, supportive, gentle hands to create a sense of safety, maintain supportive contact,
while introducing new movement possibilities in small, easily available increments.

o Muscle energy techniques

Include voluntary contraction in a precisely controlled direction, at varying levels of intensity, against an applied
counterforce from the clinician.
Purpose is to gain motion that is limited by restrictions of the neuromuscular system.
Modification of PNF technique

o PNF hold-relax-contract technique

Antagonist of the shortened muscle is contracted to achieve reciprocal inhibition and increased range
o Articulatory techniques
Joint oscillations
Inhibit pain and/or muscle guarding
Lubricate joint surfaces
Provide nutrition to the joint structure
Grades 3-4 are beneficial to stretch tight connective tissue

Five grades of joint play in neutral

Grade I oscillations are small amplitude at the beginning of the range of joint play.
Grade II oscillations are large amplitude at the midrange of joint play.
Grade III oscillations are large amplitude at the end range of joint play.
Grade IV oscillations are small amplitude at the end of joint play.
Grade V is a manipulation of high velocity and low amplitude to the anatomical endpoint of a joint.
Indications for use of oscillation grades, per Maitland
Grade I and II are used to improve joint lubrication/nutrition, as well as decrease pain and muscle guarding.
Grades III and IV are used to stretch tight muscles, capsules, and ligaments
Grade V is used to regain normal joint mechanics, as well as decrease pain and muscle guarding.
Contraindications

 Absolute: joint ankylosis, malignancy involving bone, disease that affects the integrity of ligaments, arterial
insufficiency, and active inflammatory and/or infective process.
Relative: arthrosis (DJD), metabolic bone disease, hypermobility, total joint replacement, pregnancy,
spondylolisthesis, use of steroids, and radicular symptoms.
Joint mobilization (nonthrust)
To stretch/lengthen/deform collagen and normalize the arthrokinematic glide of joint structures.
Grades of translatoric glide, as described by Kaltenborn:
o Grade I
Loosening translatoric glide
Movement is very small amplitude traction force
Used to relieve pain and/or decompress a joint during joint glides, performed within examination or intervention.
o Grade II
Tightening translatoric glide.
Movement takes up slack in tissues surrounding joint.
Used to alleviate pain, assess joint play, and/or reduce muscle guarding.
o Grade III
Stretching translatoric glide
Movement stretches tissue crossing joint
Used to assess end-feel, or to increase movement (stretch tissue)
Traction: manual, mechanical, and self or auto traction
Vertebral bodies separating
Distraction and gliding of facet joints
Tensing of the ligamentous structures of the spinal segments
Intervertebral foramen widening
Spinal muscle stretching
Contraindications
Absolute: joint ankylosis, malignancy involving bone, disease that affect the integrity of ligaments, arterial
insufficiency, and active inflammatory and/or infective process.

 Relative: arthrosis (DJD), metabolic bone disease, hypermobility, total joint replacement, pregnancy,
spondylolisthesis, use of steroids, and radicular symptoms.
Manipulation thrust
Inhibit pain and/or muscle guarding
Improve translatoric glide in cases of joint dysfunction due to restriction.
Health-care practitioners who commonly perform manipulative thrusts include physical therapist, osteopaths,
chiropractors, and medical doctors.
Types of manipulations
o Generalized
Fairly forceful, long lever techniques intended to include as many vertebral segments as possible.
More commonly performed by chiropractors
o Specific
Aimed at having an effect on either a specific segment or only a few vertebral segments.
Uses minimal force with short lever arms
Often include locking techniques based on biomechanics to ensure that a specific vertebral segment receives the
manipulative thrust.
More commonly performed by a PT.
o Mid-range
Vary gently, short lever arm technique
Barrier is created in mid-range by specific positioning of patient as well as creating tautness in surrounding soft
tissues.
More commonly performed by osteopathic practitioners.
Contraindications
Absolute: joint ankylosis, malignancy involving bone, disease that affect the integrity of ligaments, arterial
insufficiency, and active inflammatory and/or infective process.
Relative: arthrosis (DJD), metabolic bone disease, hypermobility, total joint replacement, pregnancy,
spondylolisthesis, use of steroids, and radicular symptoms.

 Common mistakes in performing a thrust manipulation

Not communicating clearly with the pt regarding the technique.
Taking too long to position the pt
Not performing the trial thrust prior to the actual thrust
Not allowing the person to bottom out with their breath prior to performing the thrust.
Taking up the slack as the Pt exhales and then letting off with pressure prior to the thrust
Velocity too slow/amplitude to great.

Suggested algorithm to perform a manipulation

Consider indications and contraindications
Explain the intensions and implications regarding manipulation to the Pt
Describe the actual technique to the Pt
Place the Pt into position and assess for Pt comfort
Perform a pre-thrust force into the rage to determine Pt comfort.
Ask Pt to inhale and then exhale. Take up the slack into the range as they exhale.
When they reach the end of exhalation perform the thrust.

o Neural tissue mobilization

Movement of neural structures to regain normal mobility.
Tension test for upper and lower extremities
Movement of soft tissues that may be restricting neural structures
Indications: used for pts who have some type of restriction in neural mobility, anywhere along the course of the
nerve.
Postural reeducation: to open up the intervertebral foramen and decrease tension to tissue.
Contraindications: extreme pain and/or increase in abnormal neurological signs
Determine whether managing irritated or nonirritated neurologic tissue:
1. Irritated tissue

a. Utilize grade II mobilizations (based on Maitland scale): should be nonpainful

2. Nonirritated tissue:

a. Utilize garde III mobilizations to engage the barrier but remain nonpainful.

Therapeutic exercise for ms conditions:

1. Therapeutic exercise is indicated to:
a. Decrease muscle guarding
b. Decrease pain
c. Increase vascularity of tissue
d. Promote regeneration and/or speed up recovery of connective tissues, such as cartilage, tendons,
ligaments, capsules, intervertebral discs
e. Mobilize restricted tissue to increase flexibility
f. Increase endurance of muscle
g. Increase coordination of muscle
h. Sensitize muscles to minimize joints going into excessive range, in cases of hypermobility
i. Develop dynamic stability and functional movement patterns, allowing for optimal function within the
environment
2. Home exercise program for pts with ms conditions:
a. Pts home program will consist of exercsies to reinforce clinical program
b. Necessary to perform enough repetitions for desired physiological effect on appropriate tissues, as well as
to develop coordination and endurance in order to promote dynamic stability within functional patterns.
3. Dry Needling
a. Also referred to intramusuclar manual therapy (IMT)
b. Utilized to break up trigger points in myofascial pain syndrome
c. A solid filiform needlel is inserted into the trigger point (within the muscle)
Manual Therapy Approaches in Rehab:
1. All approaches proved a philosophical basis, subjective evaluation, objective examination, a diagnosis, and
a plan of care.
2. Approaches can be divided into three categories:
a. Physician generated.
i. Mennell believed the joint is the dysfunctional unit.

ii. Osteopaths suggest that any component of the somatic system is responsible for dysfunction.
iii. Cyriax contends that dysfunction is due to interplay between contractile and noncontractile
tissues.
b. Physical Therapist Generated
i. Mckenzie feels that postural factors preciptiate discal dysfunction. Treatment emphasizes the
use of extension exercises.
ii. Maitland proposes that the subjective evaluation should be integrated with objective
measures to determine the dysfunctional area
iii. Kaltenborn believes that abnormal joint mobility and soft tissue changes account for
dysfunction
c. Chiropractic generated
i. Focus is to restore normal joint function through soft tissue and joint manipulation.
Chiropractics believe that restoration of normal biomechanical function affects other systems
of the body as well, thus improving the state of health in many ways.
Psychosocial Considerations:
1. Malingering (symptom magnification syndrome)
a. Defined as a behavioral response where displays of symptoms control the life of the patient, leading
to functional disability.
b. There may be psychological advantages to illness.
i. The pt may feel protected from the threatening world.
ii. Uncertainty or fear about the future.
iii. Social gain
iv. Reduces stressors
c. Therapist needs to recognize symptoms and respond to the pt
i. Tests to evaluate malingering back pain may include Hoover test, Burns test, and Waddells
signs.
ii. Hoover test involves the therapists evaluation of the amount of pressure the pts heels place
on the therapists hands when the pt is asked to raise one lower extremity while in a supine
position.
iii. Burns test requires the pt to kneel and bend over a chair to touch the floor.

iv. Waddells signs evaluate tenderness, simulation tests, distraction tests, regional disturbances,
and overreaction. Waddells scores can be predictive of functional outcome.
v. Functional capacity evaluations are used to evaluate psychosocial as well as physical
components of disability.
vi. Emphasize regaining functional outcomes, not pain reduction.
d. Secondary gain.
i. Usually some type of financial gain for staying ill.
ii. Workers compensation
iii. Larger settlement for injury claims
iv. Frequently seen in clinics that manage industrial injuries
v. May not want to return to work for various reasons associated with the work environment
(stress, disliking coworkers)
MS Imaging:
Tissue
Air
Fat
Bone Cortex
Bone Marrow

Radiograph
Black
Poorly
visualized
White
White

CT
Black
Black

TI MRI
Black
White

T2 MRI
Black
Gray

White
Gray

Black
White

Black
Gray

Neuromuscular Examination:
Blood Supply to the Brain:
Blood Supply to the Brain
Anterior cerebral artery (ACA): anterior frontal lobe;
medial surface of frontal & parietal lobes

Expected Possible Impairment

-Contralateral LE motor and sensory involvement
-Loss of bowel and bladder control
-Loss of behavioral inhibition
-Significant mental changes
-Neglect
-Aphasia
-Apraxia & agraphia
-Perservation
-Akinetic mutism with significant bilateral involvement

Middle Cerebral artery (MCA): most of outer cerebrum,

basal ganglia, posterior and anterior internal capsule,
putamen, pallidum, lentiform nucleus

Posterior cerebral artery (PCA): portion of midbrain,

subthalamic nucleus, basal nucleus, thalamus, inferior
temporal lobe, occipital and occipitoparietal cortices

Vertebral-basilar artery: lateral aspect of pons and

midbrain together with superior surface of cerebellum,
cerebellum, medulla, pons, midbrain

-Most common site of CVA

-Wernikes aphasia in dominant hemisphere
-Homonymous hemianopsia
-Apraxia
-Flat affect with right hemisphere damage
-Contralateral weakness and sensory loss of face and
upper extremity with lesser involvement in the lower
extremity
-Impaired spatial relations
-Anosognosia in non-dominant hemisphere
-Impaired body schema
-Contralateral pain & temp sensory loss
-Contralateral hemiplegia (central area), mild
hemiparesis
-Ataxia, athetosis or choreiform movement
-Quality of movement is impaired
-Thalamic pain syndrome
-Anomia
-Hemiballisums
-Visual agnosia
-Homonymous hemianopsia
-Memory impairment
-Alexia, dyslexia
-Cortical blindness form bilateral involvement
-Loss of consciousness
-Hemiplegia
-Comatose or vegative state
-Inability to speak
-Locked in syndrome
-Vertigo
-Nystagmus
-Dysphagia
-Dysarthria
-Syncope
-Ataxia

Spinal Cord tracts:

Ascending tracts-Sensory tracts ascending in the white matter of the spinal cord arise either from cells of spinal
ganglia or from intrinsic neurons within the gray matter that receive primary sensory input. Relay sensory feedback
to the cerebrum and cerebellum.
Descending tracts-Involved with voluntary motor function, muscle tone, reflexes and equilibrium, visceral
innervation, and modulation of ascending sensory signals.
Ascending Tracts
Fasciculus cuneatus (posterior or dorsal column):
sensory tract for trunk, neck, UE proprioception,
vibration, two-point discrimination, and graphesthesia.
Fasciculus gracilis (posterior or dorsal column):
sensory tract for trunk and LE proprioception, two-point
tract discrimination, vibration, and graphesthesia

Spinocerebellar tract (dorsal): sensory tract that

ascends to the cerebellum for ipsilateral subconscious
proprioception, tension in muscles, joint sense, and
posture of the trunk and LEs.
Spinocerebellar tract (ventral): sensory tract that
ascends to the cerebellum, some fibers crossing with
subsequent recrossing at the level of the pons for
ipsilateral subconscious proprioception, tension in
muscles, joint sense, and posture of the trunk, UEs, and
LEs.
Sino-olivary tract-ascends to the cerebellum and relays

Descending Tracts
Anterior corticospinal tract-pyramidal motor tract
responsible for ipsilateral voluntary, discrete, and skilled
movements
Lateral corticospinal tract-pyramidal motor tract
responsible for contralateral voluntary fine movement
Damage to the corticospinal tracts results in a positive
Babinksi sign, absent superficial abdominal reflexes and
cremasteric reflex, and the loss of fine motor or skilled
voluntary movement.
Reticulospinal tract: extrapyramidal motor tract
responsible for facilitation or inhibition of voluntary and
reflex activity through the influence on alpha and gamma
motor neurons.
Rubrospinal tract: extrapyramidal motor tract
responsible for motor input of gross posture tone,
facilitating activity of flexor muscles, and inhibiting the
activity of extensor muscles.
Tectospinal tract: extrapyramidal motor tract

info from cutaneous and proprioceptive organs

Spinoreticular tract: the afferent pathway for the
reticular formation that influences level of consciousness

responsible for contralateral postural muscle tone

associated with auditory/visual stimuli
Vestibulospinal tract: extrapyramidal motor tract
responsible for ipsilateral gross postural adjustments
subsequent to head movements; facilitating activity of
the extensor muscles and inhibiting activity of the flexor
muscles Damage to the extrapyramidal tracts results in
significant paralysis, hypertonsicity, exaggerated deep
tendon reflexes, and clasp-knife reaction.

Spinotectal tract-sensory tract providing afferent

information for spinovisual reflexes and assists with
movement of eyes and heads towards a stimulus
Anterior spinothalamic tract-sensory tract for light
touch and pressure
Lateral spinothalamic tract-sensory tract for pain and
temperature sensation
Cranial Nerves:
Nerve
I-Olfactory

Afferent (sensory)
function
Smell

II-Optic

Eye

III-Oculomotor

IV-Trochlear
V-Trigeminal

Skin of face, mucous

Efferent (motor)
function

Voluntary: Elevation of
eyelid, superior, medial,
and inferior recti, inferior
oblique muscle of eyeball.
Turns eye up, down & in
Autonomic: smooth muscle
of eyeball
Turns adducted eye down
Temporal & masseter

How to test
Identify familiar objects,
close off other nostril
Test visual fields (Snellen
eye chart), 20 ft away, test
peripheral vision
Up, down, and in (medial
gaze)
Pupillary size/shape,
reaction to light

Downward & lateral gaze

Corneal reflex, face

membranes of nose,
sinuses, mouth, anterior
tongue
VI-Abducens
VII-Facial

Taste: anterior tongue

VIII-Vestibulocochlear

Hearing & balance (ear)

IX-Glossophyaryngeal

Touch, pain: posterior

tongue, pharynx
Taste: posterior tongue
Touch,pain: pharynx,
larynx, bronchi
Taste: tongue, epiglottis

X-Vagus
XI-Spinal Accessory
XII-Hypoglossal

muscles (mastication)
Turns eye out (lateral
rectus muscle)
Facial expressions.
Autonomic: lacrimal,
submandibular, and
sublingual glands

Select muscle of pharynx;

parotid gland
Muscles of palate, pharynx,
and larynx Thoracic and
abdominal viscera
Sternocleidomastoid &
trapezius
Tongue movements

sensation, clench teeth;

push down on chin to
separate jaws
Lateral gaze
Close eyes tight, smile and
show teeth, whistle and
puff cheeks
Identify familiar tastes
Eye-head coordination,
vestibular ocular reflex,
auditory acuity. Webers
test: place tuning fork on
top of head. Rinnes testplace on mastoid process
Gag reflex, ability to
swallow, listen to voice
quality
Examine for difficulty in
swallowing, ability to say
ahhh
Resisted shoulder shrug
Tongue protrusion (if
injured, tongue deviates
toward injured side)

Upper Motor Neuron (UMN) VS. Lower Motor Neuron (LMN)

Location of Lesion:
Structures involved:

UMN Lesion
Central Nervous System
Cortex, brainstem, corticospinal
tracts, spinal cord

LMN Lesion
Peripheral nervous system
Anterior horn cell, spinal roots,
peripheral nerves, cranial nerves

Disorders:

CP, hydrocephalus, ALS, CVA, birth

injuries, MS, Huntingtons chorea,
TBI, Pseudobulbar palsy, brain
tumors

Tone:

Hypertonia; velocity dependent

Reflexes:

Increased: hyperreflexia, clonus, +

Babinski
Muscle spasms: flexor or extensor
Stroke: weakness or paralysis on one
side of the body
Disuse atrophy

Involuntary movements:
Strength:
Muscle Bulk:
Voluntary movements:

Impaired or absent: dyssynergic

patterns

Poliomyelitis, ALS, Guillain-Barre

syndrome, tumors involving the
spinal cord, trauma, progressive
muscular atrophy, infection, Bells
palsy, carpal tunnel syndrome,
muscular dystrophy, spinal muscular
atrophy
Hypotonia, flaccidity; not velocity
dependent
Decreased or absent, hyporeflexia
With denervation: fasciulations
Segmental or focal pattern
Neurogenic atrophy: rapid focal
severe wasting
Weak or absent if nerve interruped

Reflexes:
Superficial Reflex Testing:
Reflex
Abdominal Reflex

Spinal Level
T8-L1

Corneal blink reflex

Trigeminal and facial

nerves

Cremasteric reflex

L1-L2

Procedure
Stoke briskly & lightly with
a blunt object from each
quadrant of the abdomen
in a diagonal manner
towards the umbilicus
Ask the pt to look up and
away from you; stroke the
cornea using a piece of
cotton
Scratch the skin of the
upper medial thigh

Normal response
Contraction of the
abdominals and deviation
of the umbilicus in the
direction of the stimulus
Both eyes will blink with
contact to one eye
A brisk and brief elevation
of the testicle on the

Gag Reflex

Glossopharyngeal & vagus

nerves

Plantar reflex

L5-S1

The therapist lightly

stimulates each side of the
back of the throat and
notes the reaction
Stroke the lateral aspect of
the sole of the foot with the
blunt end of a reflex
hammer from theheel to
the ball of the foot and
medially to the base of the
great toe

ipsilateral side
A gag will occur post
stimulation; may be absent
in some percentage of the
normal population
Flexion of the toes
*Babinski reflex is the
abnormal response that
indicates CNS lesion

Reflex Grading Scale:

Reflex Grading
0=no response
1+=diminished response
2+=active normal response
3+=exaggerated resonse
4+=hyperactive; very brisk

Interpretation
Always abnormal
May or may not be normal
Normal
May or may not be normal
Always abnormal

Stroke: Ceberovascular accident-is a specific event that results in a lack of oxygen supply to a specific area of the
brain secondary to either ischemia or hemorrhage.
Types of Cerebrovascular Accidents:
Transient Ischemic Attack (TIA):

Completed Stroke:
Stroke in Evolution:

Is usually linked to an atherosclerotic thrombosis which

causes a temporary interruption of blood supply to an
area of the brain. Symptoms resolve typically between
24-48 hrs.
A CVA that presents with total neurological deficits at the
onset.
A CVA, usually caused by a thrombus that gradually
progresses. Total neurological deficits are not seen for

Ischemic Stroke:

Hemorrhage (10-15% of CVAs):

one to two days after onset.

Once there is a loss of perfusion to a portion of the brain
(within just seconds), there is a central area of
irreversible infarction surrounded by an area of potential
ischemia.
Embolus (20% of ischemic CVAs): associated with
cardiovascular disease, can be a solid liquid or gas and
originate in any part of the body. Occurs rapidly with no
warning, and presents with a headache.
Thrombus: atherosclerotic plaque develops in an artery
and occludes the artery causing an infarct. Symptoms
can appear in minutes or over several days. Usually
occurs during sleep or upon awakening after a MI or post
surgical procedure.
Abnormal bleeding in the brain due to a rupture in blood
supply. HTN is usually a precipitating factor causing
rupture of an aneurysm. Characteristics include:
headache, vomiting, high BP. Approx. 50% of deaths from
hemorrhagic stoke occur within the first 48 hours.

Characteristics of a CVA:
Left Hemisphere
Weakness, paralysis of the
right side
frustration
processing
Possible aphasia
(expressive, receptive,
global)
Possible dysphagia

Right Hemisphere
Weakness, paralysis of the
left side
attention span
Left hemianospia
awareness and judgment

Brainstem
Unstable vital signs

Cerebellum
balance

consciousness
ability to swallow
Weakness on both sides of
the body

Ataxia
coordination
Nausea

Memory deficits

Paralysis on both sides of

the body

Possible motor apraxia

(ideomotor and ideational)

Left inattention

ability for postural

adjustment
Nystagmus

discrimination between
left and r ight
Right hemianopsia

abstract reasoning

Emotional lability
Impulsive behaviors
spatial orientation
Left hemisphere (right hemiplegia): Slow, cautious, and insecure. Give frequent feedback and support.
Use appropriate communication: words, gestures, assess level of understanding. Dont underestimate
ability to learn.
Right Hemisphere (left hemiplegia): Quick, impulsive, poor judgment. Use verbal cues (demonstrations
or gestures may confuse pts). Give frequent feedback: focus on slowing down and controlling
movement. Focus on safety, avoid clutter. Do not overestimate ability to learn.
Synergy Patterns:
Upper Limb

Scapula
Shoulder
Elbow
Forearm
Wrist
Fingers
Thumb

Flexor synergy
Elevation & retraction
Abduction & ER
Flexion
Supination
Flexion
Flexion with adduction
Flexion and adduction

Extensory synergy
Depression & Protraction
IR & adduction
Extension
Pronation
Extension
Flexion with adduction
Adduction and flexion

Flexor synergy
Abduction and ER
Flexion
Dorsiflexion with supination
Extension

Extenor synergy
Extension, IR, and adduction
Extension
Plantar flexion with inversion
Flexion and adduction

Lower limb
Hip
Knee
Ankle
Toes
CVA tests and measures:

National Institue of Health (NIH) Stroke Scale:

Functional Independce Measure (FIM):
Stroke Impact Scale:
Fugl-Meyer Assessment of Physical Performance:

Assessment of an acute CVA relative to impairment

Provides a level of burden through assessment of
mobility and ADL management
Assessment of physical and social disability or level of
impairment secondary to CVA
Motor, sensory, and balance impairment; also assesses
pain and ROM

NM & nervous system Terminology

Agnoisa: the inability to interpret information.
Agraphesthesia: the inability to recognize symbols, letters, or numbers traced on the skin.
Agraphia: the inability to write due to a lesion within the brain and is typically lfound in
combination with aphasia.
Alexia: the inability to read or compreheand written language secondary to a lesion within in
the dominant lobe of the brain.
Anosognosia: the denial or unawareness of ones illness; often associated with unilateral
neglect.
Aphasia: the inability to communicate or comprehend due to damage to specific areas of the
brain.
Apraxia: the inability to perform purposeful learned movements or activities even though there
is no sensory or motor impairment that would hinder completion of the task.
Asterognosis: the inability to recognize objects by sense of touch.
Body schema: having an understanding of the body as a whole and the relationship of its parts
to the whole.
Constructional apraxia: the inability to reproduce geometric figures and designs. A person is
often unable to visually analyze how to perrom a task.
Decerebrate rigidity: a characteristic of a cortiospinal lesion at the level of the brainstem that
results in extension of the trunk and all extremities.
Decorticate rigidity: a characteristic of a cortiospinal lesion at the level of the diencephalon
where the trunk and lower extremities are positioned in extension and the upper extremities are
positioned in flexion.
Dilopia: double vision
Dysarthria: slurred and impaired speech
Dysphagia: inability to properly swallow

Dysprosody: impairment in the rhythm and inflection of speech.

Emotional lability: a characteristic of a right hemisphere infarct where there is an inability to
control emotions and outbursts of laughing or crying that are inconsistent with the situation.
Fluent aphasia (Wernikes aphasia/temporal): characteric of receptive aphasis where
speech produces functional output regarding articulation, but lacks content and is typically
dysprosodic using neologisic jargon.
Hemiparesis: condition of weakness on one side of the body
Hemiplegia: condition of paralysis on one side of the body
Homonymous hemianopsia: the loss of the right or left half of the visual field of vision in both
eyes.
Ideational apraxia: the inability to perform an initial motor plan and sequence tasks where the
proprioceptive input necessary for movement is impaired.
Ideomotor apraxia: a condition where a person plans a movement or task, but cannot
volitionally perform it. Automatic movement may occur, however a person cannot imose
additional movement on command.
Neologism: substitution within a word that is so severe that it makes the word unrecognizable.
Non-fluent aphasia (Brocas aphasia/frontal lobe): characteristic of expressive aphasia
where speech is non-functional, effortful, and contains paraphasias. Writing is also impaired.
Perservation: the state of repeatedly performing the same segment of a task or repeatedly
saying the same word/phrase without a purpose
Synergy: mass movement patterns that are primitive in nature and coupled with spasticty due
to brain damage
Unilateral neglect: the inability to interpret stimuli and events on the contralateral side of a
hemispheric lesion. Left-sided neglect is most common with a lesion to the right inferior parietal
or superior temporal lobes.

Spinal Cord Injuries:

Anterior Cord Syndrome:

An incomplete lesion that results from compression and

damage to the anterior part of the spinal cord. The MOI is
cervical flexion. There is a loss of motor function and
pain and temperature sense below the lesion due to

Brown-Sequards Syndome:

Cauda Equina Injuries:

Central Cord Syndome:

Poserior Cord Syndrome:

damange of the corticospinal and spinothalamic tracts.

Usually caused by a stab wound, which produces
hemisection of the spinal cord. There is paralysis and loss
of vibratory and postion sence on the ipsilateral side as
the lesion due to the damage of the corticospinal tract
and dorsal columns. There is a loss of pain and temp
sense on the contralateral side of the lesion from
damage to the lateral spinothalamic tract.
Occurs below the L1 spinal level where the long nerve
roots transcend. Can be complete, however they are
frequently incomplete due to the large number of nerve
roots in the area. A cauda equine injury is considerd a
peripheral nerve injury. Characterics include flaccidity,
arelexia, and impairment of bowel and bladder function.
Full recovery is not typical due to the distance needed for
axonal regeneration.
An imcomplte lesion that results from compression and
damage of the central portion of the spinal cord. The MOI
is usually cervical hyperextension that damages the
spinothalamic t tract, corticospinal tract, and dorsal
columns. The UEs present with greater involvement than
the LEs, and greater motoer deficts exist as compared to
sensory deficits.
A relatively rare syndrome that is caued by compression
of the posterior spinal artery and is characterized by a
loss of pain perception, proprioception, two-point
discrimination, and stereognosis. Motor function is
preserved.

Classification of Level of Injury:

Motor level: determined by the most caudal key muscles that have muscle strength of 3 or greater with the superior
segment tested as normal (5).
Sensory level: determined by the most caudal dermatome with a normal score of 2/2 for pinprick and light touch.

Terminology:
Myelotomy:
Neurectomy:
Neurogenic bladder:
Nonreflexive bladder:
Paradoxical breathing:

Paraplegia:
Spinal shock:
Tetraplegia:

A surgical procedure that severs certain tracts within the

spinal cord in order to decrease spastic and improve
function.
A surgical removal of a segment of nerve in order to
decrease spasticity and improve function.
The bladder empties reflexively for a pt with an injury
above the level of S2.
The bladder is flaccid as a result of a cauda equine or
conus medullaris lesion. Sacral reflex arc is damanged.
A form of abnormal breathing that is common in
tetraplegia where the abdomen rises and the chest is
pulled inward during inspiration. On expiration the
abdomen falls and the chest expands.
Used to describe injuries that occur at the level of the
thoracic, lumbar, or sacral spine.
A physiologic response that occurs between 30 and 60
minutes after trauma to the spinal cord and can last up
to several weeks.
Describes injuries that occur at the level of the cervical
spine.

Spinal Cord tests and measures:

ASIA Impairment Scale
A=
B=
C=

Complete: no sensory or motor function is preserved in sacral segments S4-S5.

Sensory Incomplete: Sensory but not motor function is preserved below the neurologic level and extends
through sacral segments S4-S5.
Motor Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the

D=
E=

neurologic level have a muscle grade less than 3.

Motor Incomplete: Motor function is preserved below the neurologic level, and most key muscles below have a
muscle grade greater than or equal to 3.
Normal: sensory and motor functions are normal.

Traumatic Brain Injury:

Types of brain injury:
Open Injury:
Closed
Injury:
Primary
Injury:
Secondary
Injury:

Direct penetration through the skull to the brain. Ex: gunshot wounds, knife, or shart objects, skull fx,
direct trauma.
Without penetration through the skull. Ex: Concussion, contusion, hematoma, hypoxia, drug overdose,
near drowning, acceleration/deceleration injuries
Initial injury to the brain sustained by impact. Ex: skull penetration, skull fx, and contusions. Coup
lesion: a direct lesion of the brain under the point of impact. Contracoup lesion: results on the
opposite side of the brain. Rebound effect of the brain after impact.
Brain damage that occurs as a response to the initial injry. Ex: increase pressure, hypoxia, ischemia

Levels of Consciousness:
Coma:
Stupor:
Obtundity:
Delirium:
Clouding of
consciousne
ss:
Consciousne
ss:

A state of unconsciousness and a level of unresponsiveness to all interal and external stimuli.
A state of general unresponsiveness with arousal occurring from repeated stiumuli.
A state of consciousness that is characterized by a state of sleep, reduced alertness to arousal, and
delayed responses to stimuli.
A state of consciousness that is characterized by disorientation, confusion, agitation, and loudness.
A state of consciousness that is characterized by quiet behavior, confusion, poor attention, and
delayed responses.
A state of alertness, awareness, orientation, and memory.

Traumatic Brain Injury Tests and Measures:

Ranchos Los Amigos Levels of Cogntive Functioning:

I.
II.

No response
Generalized Response

III.

Localized Response

IV.

Confused-agitated

V.

Confusedinappropriate

VI.

Confused-appropriate

VII.

Automatic-appropriate

VIII.

Purposefulappropriate

Pt appears to be in a deep sleep and is completely unresponsive to any stimuli.

Pt reacts inconsistently and non-purposefully to stimuli in a nonspecific manner.
Responses are limited and often the same regardless of stimulus presented.
Pt reacts specifically, but inconsistently to stimuli. Responses are directly related
to the type of stimulus presented. May follow simple commands such as closing
the eyes or squeezing the hand in an inconsistent, delayed manner.
Pt is in a heightned state of activity. Behavior is bizarre and non-purposeful
relative to the immediate behavior. Does not discriminate among persons or
objects, is unable to cooperate directly with treatment effors. Verbalizations
frequently are incoherent and/or inappropriate. Gross attention to environment is
very brief. Pt lacks short and long term recall.
Pt is able to respond to simple commands fairly consistently. However with
increased complexity of commands or lack of any external structure, responses
are non-purposeful, randome, or fragmented. Memory is severly impaired,
inappropriate use of objects may perform previously learned taks with structure
but is unable to learn new info.
Pt shows goal-directed behavior, but is dependent on external input or direction.
Follow simple directions consistently and shows carryover for relearned tasks such
as self-care. Responses may be incorrect due to memory problems, but they are
approparite to the situation. Past memories show more depth and detail than
recent memory.
Pt appears appropriate and oriented with the hospital and home setting. Goes
through daily routine automatically, but frequently robot-like. Pt shows minimal to
no confusion and has shallow recall of activities. Shows carryover for new learning,
but a decreased rate. With structure is able to initiate social or recreational
activityes, judgment remains impaired.
Pt is able to recall and integrate past and recent events and is aware of and
responsive to environment. Shows carryover for new learning and needs no
supervision once tasks are learned. May continue to show a decreased ability
relatively to premorbid abilities, abstract reasoning, tolerance for stress, and
judgment in emergencies or unusually circumstances.

Glasgow Coma Scale: Eye opening, Best motor response, Verbal response
Severe brain injury/coma: 8 or less

Moderate brain injury: 9-12

Mild brain injuries: 13-15

NM and Nervous System Patholody:

Pathology
Alzheimers
Disease

What is it
A progressive
neurodegenerative
disorder that results
in deterioration and
irreversible damange
within the cerebral
cortex.

Etiology
Unknown, however
hypothesized causes
unclude lower levels
of neurotransmitters,
higher levels of
aluminum within
brain tissue, genetic
inheritance,
autoimmune disease.
Risk of developing
increases with age,
higher incidence in
women.

Signs & Symptoms

Difficulty with new
learning and subtle
changes in memory
and concentration.
Progression includes
a loss of orientation,
word finding
difficulty, depression,
poor judgment,
rigidity, bradykinesia,
shuffling gait,
impaired ability to
perform self-care
skills. Later stages
include incontinence,
functional
dependence, and an
inability to speak.

Amyotrophic
Lateral Sclerois
(ALS)

A chronic
degenerative disease
that produces both
upper and lower
motor neuron

Unknown. Theories
include genetic
inheritance, virus,
metabolic
disturbances, and

Lower motor neuron

signs include
asymmetric muscle
weakness, cramping,
and atrophy within

Treatment
There is no curative
treatment for the
disease process.
Medications are
administered to
inhibit
acetylcholinesterase,
alleviate cognitive
symptoms, and
control behavioral
changes. PT: should
focus on maximizing
pts remaining
function and
providing family and
caregiver education.
Many pts require a
long term care
secondary to
personality changes,
aggressive behavior,
and end stage
complications.
Effective
management of ALS
is based on
supportive care and
symptomatic therapy.

impairments.
Produces weakness
and muscle atrophy.
The rapid
degeneration causes
denervation of
muscle fibers, mustly
atrophy, and
weakness.

toxicity of lead and

aluminum. Higher
incidence in men and
beings ages 40-70.

Bells Palsy

A temporary
unilateral facial
paralysis secondary
to trauma with
demyelination and/or
axonal degeneration
of the facial nerve.
This is a common
clinical condition with
the highest incidence
in individuals
between 15-45 years
of age.

Unclear, however
may be secondary to
viral infection,
specifically the
herpes
simplex/herpes
zoster virus.
Inflammation and
subsequenet
pressure injure the
nerve with varying
degress of damage.

Diabetic
Neuropathy

A complication and
direct effect of
diabetes. Nerve
ischemia results from
microvascular
disease combined
with the direct effects

Primary diagnosis is
result of DM.

the hands. Weakness

spreads in a distal to
proximal path. Upper
motor neuron
symptoms can
include spasticity,
clonus, + Babinski. A
pt with ALS will
exhibit fatigue, oral
motor impairment,
motor paralysis, and
eventual respiratory
paralysis.
Asymmetrical facial
appearanace with
drooopoing of the
eyelid and mouth,
potential for drooling,
dryness of the eye,
and inability to close
the eyelid due to
weakness.

Weakness and
sensory disturbances
occur distally in a
symmetrical pattern.
Initial symptoms
include tingling,
numbness or pain,

Pharmacological
intervention may
include riluzole.
Physical,
occupational, speech,
respiratory, and
nutritional therapies
may be warranted
with the focus on
quality of life and
caregiver training.
The sooner the
person is diagnosed
and treated, the
better the outcome.
Some pts have very
mild involvement and
their symptoms
typically resolve
within 2 weeks with
formal medical
intervention. PT may
be indicated for
stimulation of the
facial nerve, facial
massage, and
exercise.
Pts require strict
monitoring of blood
glucose levels to
prevent further nerve
pathology. PT is
typically indicated to
address the various

of hyperglycemia on
neurons resulting in
the impairment of
nerve function.

Epilepsy

Chronic condition
where there is
temporary
dysfunction of the
brain that results in
hypersynchronus
electrical discharge
of cortical neurons
and seizure activity
that is typically
unprovoked and
unpredictable. A
seizure is a transient
even that is a
symptom of
interrupted brain
functioning. A seizure
is the hallmark sign
of epilepsy, however,
one seizure does not
signal epilepsy.

Various classifications
of seizures, many
cases are idiopathic.
Other associated
conditions: genetic
influence, head
trauma, dementia,
CVA, cerebral palsy,
down syndrome, and
autism.

Guillain-Barre

Acute

Unknown, however, it

especially in the feet.

Additional symptoms
may include wasing
of muscles in the feet
or hands stocking
glove sensory
distribution
imparitmens,
orthostatic
hypotension,
weakness, urinary
impairments, and
significant pain.
Seizure symptoms
vary, depending on
type and extent. Loss
of awareness or
consciousness and
disturbances of
movement,
sensation, mood or
mental function may
occur.
-Stay calm & prevent
injury
-Remove all objects
that could cause
harm
-Do not restrain
-Avoid placing
anything in pts
mouth
-Call 911 if seizure
lasts longer than 5
minutes
Motor weakness in a

symptoms including
pain management,
foot care, and overall
fitness.

Antiepileptic
medication to
manage seizures. No
cure.

Typically requires

Syndrome

polyneuropathy, that
is a temporary
inflammation and
demyelination of the
peripheral nerves
myelin sheaths,
potentially resulting
in axonal
degeneration. The
autoantibodies of
GBS attack segments
of the myelin sheath
of the peripheral
nerves. Can occur at
any age, however
there is a peak in
frequency in young
adult population and
again in adults
between their 5th and
8th decades.

is hypothesized to be
an autoimmune
response to a
previous respiratory
infection, influenze,
immunization or
surgery. Viral
infections, EpsteinBarr syndrome,
cytomegalovirus,
bacterial infections,
surgery, and
vaccinations.

Huntingtons
Disease (chorea)

Is a neurological
disorder of the CNS
and is characterized
by degeneration and
atrophy of the basal
ganglia and cerebral
cortex within the
brain. The
neurotransmitters
become deficient and
are unable to
modulate movement.

Is genetically
transmitted as an
autosomal dominant
trait with the defect
linked to
chromosome 4 and to
the gene identified as
IT-15. The disease is
usually perpetuated
by a person that has
children prior to
diagnosis. The
average age for
developing

distal to proximal
progression, sensory
impairment, and
possible respiratory
paralysis. Will initially
present with distal
symmetrical motor
weakness, mild distal
sensory impairments,
and transient
paresthesias that
progress towards the
upper extremities
and head. Level of
disability peaks
within 2-4 weeks
after onset. Muscle
and respiratory
paralysis, inability to
speak or swallow
may also occur. Can
be life threatening.
HD is a movement
disorder that
included affective
dysfunction and
cognitive
impairment. The pt
may present with
involuntary choeric
movements, mild
alteration in
personality,
grimacing, protrusion
of the tongue, and
ataxia with

hospitalization for
treatment of
symptoms. Cardiac
monitoring and
mechanical
ventilation may be
required. PT may
include pulmonary
rehab, strengthening,
mobility training,
wheelchair and
orthotic prescription,
AD training.

Medical management
requires genetic,
psychological, and
social counceling for
the pt and family.
Pharmacological
mangt is initiated
once choreiform
movement impairs a
pts functional
capacity. PT should
maximize endurance,
strength, balance,
postural control, and

symptoms is between
35-55 years, however
can develop at any
age.
Multiple Sclerosis

Produces patches of
demyelination of the
myelin sheaths that
surround nerves
within the brain and
spinal cord. This
decreases the
efficiency of nerve
impulse transmission
and symptoms will
vary based on the
location and the
extent of
demyelination. There
is subsequent plaque
development and
eventual failure of
impulse transmission.

Genetics, viral
infections, and
environment all have
a role in the
development of MS.
MS can oocur at any
age with the highest
incidence between
20-35 years of age.

Myasthenia Gravis

Autoimmune disease
resulting in
neuromuscular
junction pathology.

Autoiummune
disease process that
also has an
association with an

choreoathetoid
movements. Late
stage HD includes
mental immobility,
and rigidity.
Vary based on the
type. Initial
symptoms include
visual problems,
paresthesias and
sensory changes,
clumsiness,
weakness, ataxia,
balance dysfunction,
and fatigue. The
clinical course usually
consists of periods of
exacerbations and
remissions, with the
degree of neurologic
dysfunction.

The cardinal signs

include extreme
fatiguability and
skeletal muscle

functional mobility.

Pharmacoligcal,
medical, and
therapeutic
interventions. The
goal is to lessen the
length of
exacerbations and
maximize the health
of the pt.
Pharmacological
intervention is
indicated along with
physical,
occupational, and
speech therapies
throughout the
disease process. PT
includes regulation of
activity level,
relaxation and energy
conservation
techniques,
normalization of tone,
balance and gait
training, core
stabilization, and AD
training.
Myasthenia gravic
crisis is a medical
emergency where
there is an

Parkinsons
Disease

There is a defect
specifically in the
transmisstion of
nerve impulses to the
muscles at the NM
junction. Antibodies
block or destroy the
receptors that are
needed for
acetylcholine uptake
and this prevents
muscle contraction.

enlarged thyms.
There is also an
associated with DM,
RA, lupus and other
immune disorders.
There are multiple
forms of gravis that
range from mild to
severe involvement.

weakness that can

fluctuate within
minutes or over an
extened period. The
ocular muscles are
typically affected first
and approx. half of
the pts experience
ptosis and diplopia,
Dysphagia,
dysarthria, and
cranial nerve
weakness are also
common.

Primary degenerative
disorder and is
characterized by a
decrease in
production of
dopamine
(neurotransmitter)
within the corpus
striatum of the basal
ganglia. The basal
ganglia stores the
majority of dopamine
and is responsible for
modulation and
control of voluntary
movement.

Unknown.
Contributing factors
that can produce
symptoms include
genetic defect,
toxicity from carbon
monoxide, excessive
copper, encephalitis,
and other
neurodegenerative
diseases such as HD
or Alzheimers. The
majority of pts are
between 50 and 79.

A resting tremor in
the hands
(sometimes called pill
rolling tremor), or
feet that increases
with stress and
disappears with
movement or sleep.
Early symptoms:
balance
disturbances,
difficuly rolling over
and rising from bed,
and impairment with
fine manipulataive
movements seen in
writing, bathing and
dressing. Progression
of the disease
includes hypokinesia.

exacerbation that
includes the
respiratory muscles
and requires a
ventilator. PT will
focus on obtaining a
respiratory baseline
and pulmonary
intervention as
needed. Energy
conservation and
strengthening using
isometric
contractions are
appropriate for most
pts.
Relies heavily on
pharmacolocial
intervention.
Dopamine
replacement therapy
is most effective in
reducing movement
disorders, rigidity and
tremor. PT should
include maximizing
endurance, strength,
and functional
mobility. Verbal
cueing and visual
feedback are also
effective tools to use
with this population.

Post-polio
Syndrome

A viral infection
resulting in
neuropathy that
includes focal and
asymmetrical motor
impairments. This
virus was all but
eradicated in the
1960s with the
development of a
vaccine. Post-polio is
a LMN pathology that
affects the anterior
horn cells of those
previously affected
with polio. Surviving
axons were originally
able to increase the

A previous diagnosis
of polio is essential to
diagnose PPS. Approx
25-50% of persons
with polio experience
PPS decades after
their initial recovery
(interval approx 25
years)

Sluggish movement,
difficulty with
initiating and
stopping movement,
festinating and
shuffling gait,
bradykinesia, poor
posture, cogwheel
and lead pipe rigidity
of skeletal muscles.
Pts may also
experience freezing
during ambulatin,
speech, blinking, and
movements of the
arms. Mask like
appearance with no
expression.
Commonly there is
slow and progressive
weakness, fatigue,
muscle atrophy, pain,
and swallowing
issues.

No pharmacological
intervention to alter
the progression of
PPS. Emphasis of
treatment surrounds
lifestyle modification
and symptomatic
intervention. PT
should emphasize
supervised exercise,
functional
independence,
adaptive equipment,
and education to
assit pts to maintain
as much
independence as
possible.

size of ther
innervation ratio to
assist denervated
muscle. PPS occurs
when the
compensated
reinnervation fails
and results in
ongoing muscle
denervation.
Peripheral nerve lesions: A lesion of the nerve can occur through many MOIs. Ex. Compression, fx, compartment
syndrome
Double crush
syndrome:
Mononeuropathy:
Neuroma:
Peripheral
neuropathy:
Polyneuropathy:
Wallerian
degeneration:

Existence of two separate lesions along the same nerve that create more severe symptoms
that in only one lesion existed.
An isolated nerve lesion, associated condtions include trauma and entrapment
Abnormal growth of nerve cells; associated conditions include vasculitis, AIDS, entrapment
Impairment or dysfunction of the peripheral nerves; associated conditions include diabetic
peripheral neuropathy, trauma, alcoholism
Diffuse nerve dysfunction that is symmetrical and typically secondary to pathology and not
trauma, associated conditions include GBS, peripheral neuropathy, use of neurotoxic drugs,
and HIV
Degeneration that occurs distally, specifically to the myelin sheath and axon.

Classification of Acute Nerve Injuries:

Neurapraxia:
(Class I)

-Mildest form of injury

-conduction block usually due to myelin dysfunction
-Axonal continuity preserved
-Nerve conduction is preserved
-Nerve fibers are not damaged
-Symptoms include pain, minimal muscle atrophy, numbness or greater loss of motor and
sensory function, diminished proprioception
-Recovery is rapid and complete and will occur within 4-6 weeks

Axonotmesis:
(Class II)

Neurotmesis:
(Class III)

-Pressure injuries are the most common

-A more severe grade of injury to a peripheral nerve
-Reversible injury to damaged fibers since they maintain an anatomical relationship to each
other
-Damage occurs to the axons with preservation of the endoneurium, epineurium, Schwann
cells, and supporting structures
-Distal Wallerian degeneration can occur
-The nerve can regenerate distal to the site of the lesion at rate of 1mm per day
-Recovery is spontaneous and varies from spotty to no recovery; surgery may be required for
repair
-Traction, compression, and crush injuries are most common
-The most severe grade of injury to a peripheral nerve
-Axon, myelin, connective tissue components are all damaged or transected
-Irreversible injury, no possibility of regeneration
-Flaccid paralysis and wasting of muscles occur, total loss of sensation to area supplied by the
nerve
-All motor and sensory loss distal to the lesion becomes permantely impaired
-No spontaneous recovery ; with surgical reattachment potential regenerating axons may
grow at 1 mm per day
-Complete transaction of the nerve trunk

Pediatrics & Development

Concepts of Development
Cephalic to
Caudal:
Gross to fine:
Mass to specific:
Proximal to distal:

A person develops head and UE control prior to trunk and LE control. There is a general skill
acquisition from the direction of head to toe.
A general trend for large muscle movement acquisition with progression to small muscle skill
acquisition.
A general trend for a person to acquire simple movements and progress towards complex
movements.
A concept that uses the midline of the body as the reference point. Trunk control (midline
stability) is acquired first with subsequent gain in distal control (extremities).

Infant Reflexes and Possible Effects if Reflex Persists Abnormally:

Reflex:
Asymmetrical Tonic Neck Reflex
(ATNR)

Normal:
Stimulus: Head position
Response: Arm & leg on face side
are extended, arm & leg on skull side
are flexed with convexity toward face
side
Normal age of response: Birth to 6
months

Symmetrical Tonic Neck Reflex

(STNR)

Stimulus: Head position, flexion or

extension
Response: When head is in flexion,
arms are flexed legs extended. When
head is in extension, arms are
extended, legs are flexed.
Normal age of response: 6-8
months
Stimulus: Position of labyrinth in
inner earreflected in head position
Response: in the supine position,
body and extremities are held in
extension; in the prone position,
body and extremities are held in
flexion
Normal age of response: Birth to 6
months
Stimulus: Touch to skin along spine
from shoulder to hip
Response: Lateral flexion of trunk to
side of stiumuls
Normal age of response: 30 weeks
of gestation to 2 months
Stimulus:Pressure in palm on ulnar

Tonic Labyrinthine Reflex (TLR)

Galant Reflex

Palmar grasp reflex

Interferes with:
-Feeding
-Visual tracking
-Midline use of hands
-Billateral hand use
-Rolling
-Development of crawling
-Can lead to skeletal deformities
(scoliosis, hip subluxation, hip
dislocation)
-Ability to prop on arms in prone
position
-Attaining and maintaining hands and
knees position
-Crawling reciprocally
-Sitting balance when looking around
-Use of hands when looking at object
in hands in sitting position
-Ability to initiate rolling
-Ability to prop on elbows with
extended hips when prone
-Ability to flex trunk and hips to come
to sitting position from supine
position
-Often causes full body extension,
which interferes with balance in
sitting or standing
-Development of sitting balance
-Can lead to scoliosis

-Ability to grasp and release objects

Plantar grasp reflex

Rooting reflex

Moro reflex

Startle reflex

Positive support reflex

Walking (stepping) reflex

side of hand
Response: Flexion of fingers causing
a strong grip
Normal age of response: Birth to 4
months
Stimulus: Pressure to base of toes
Response: Toe flexion
Normal age of response: 28 weeks
gestation to 9 months
Stimulus: Touch on cheek
Response: turning head to same
side with mouth open
Normal age of response: 28 weeks
gestation to 3 months
Stimulus: Head dropping into
extension suddenly for a few inches
Response: Arms abduct with fingers
open, then cross trunk into
adduction, cry
Normal age of response: 28 weeks
gestation to 5 months
Stimulus: Loud, sudden noise
Response: similar to Moro response,
but elbows remain flexed and hands
closed
Normal age of response: 28 weeks
gestation to 5 months
Stimulus: Weight placed on balls of
feet when upright
Response: Stiffening of legs and
trunk into extension
Normal age of response: 35 weeks
of gestation to 2 months
Stimulus: Supported upright
position with soles of feet on firm
surface

voluntarily
-Weight bearing on open hand for
propping, crawling, protective
responses
-Ability to stand with feet flat on
surface
-Balance reactions and weight
shifting in standing
-Oral-motor development
-Development of midline control of
head
-Optical righting, visual tracking, and
social interaction
-Balance reactions in sitting
-Protective responses in sitting
-Eye-hand coordination, visual
tracking

-Sitting balance
-Protective responses in sitting
-Eye-hand coordination
-Social interaction, attention
-Standing and walking
-Balance reactions and weight shift in
standing
-Can lead to contractures of ankles
into PF
-Standing and walking
-Balance reactions and weight
shifting in standing

Response: Reciprocal
flexion/extension of legs
Normal age of response: 38 weeks
of gestation to 2 months

-Development of smooth,
coordinated reciprocal movements of
lower extremities

Developmental Gross & Fine Motor Skills:

Age
Newborn to 1 month:

2-3 months

4-5 months

Gross motor skills

Prone: physiological flexion, lifts
head briefly, head to side
Supine: physiological flexion, rolls
partly to side
Sitting: head lag in pull to sit
Standing: Reflex standing and
walking
Prone: Lifts head 90 briefly, chest
up in prone position with some
weight through forearms, rolls prone
to supine
Supine: ATNR influence is strong,
legs kick reciprocally, prefers head to
side
Sitting: Head upright, but bopping,
variable head lag in pull to sitting
position, needs full support to sit
Standing: poor weight bearing, hips
in flexion, behind shoulders
Prone: Bears weight on extended
arms, pivots in prone to reach toys
Supine: Rolls from supine to side
position, plays with feet in mouth
Sitting: head steady in supported
sitting position, turns head in sitting
position, sits alone for brief periods
Standing: bears all weight through

Fine motor skills

-Regards objects in direct line of sight
-Follows moving onject to midline
-Hands fisted
-Arm movements jerky
-Movements may be purposeful or
random
-Can see farther distances
-Hands open more
-Visually follows through 180
-Grasp is reflexive
-Uses palmar grasp

-Grasps and releases toys

-Uses ulnar-palmar grasp

6-7 months

8-9 months

10-11 months

12-15 months

16-24 months

2 years

legs in supported standing

Prone: Rolls from supine to prone,
holds weight on one hand to reach
for toy
Supine: Lifts head
Sitting: Lifts head and helps when
pulled to sitting position, gets to
sitting position without assistance,
sits independently
Mobility: may crawl backward
Prone: gets into hands-knees
position
Supine: does not tolerate supine
position
Sitting: moves from sitting to prone
position, sits without hand support,
pivots
Standing: stands at furniture
Mobility: crawls forward, walks
along furniture (cruising)
Standing: stands without support
briefly, picks up object from floor
Mobility: walks with both hands
held, walks with one hand held, bear
walk
-Walks without support
-Fast walking
-Walks backward, sideways
-Bends to look between legs
-Creeps or hitches upstairs
-Squats in play
-kicks ball
-Throws ball
-Rides tricycle
-Walks backward

-Approaches objects with one hand

-Arm in neutral when approaching toy
-Radial-palmar grasp rakes with
fingers to pick up small objects
-Voluntary release to transfer onjects
between hands

-Develops active supination

-Uses inferior pincer grasp
-Extends wrist actively
-Points with index finger

-Fine pincer grasp developed

-Marks paper with crayon

-Builds tower

-Folds paper
-Strings beads
-Holds crayon with thumb and fingers
-Turns knob
-Opens and closes jar

-Walks on tiptoe
-Runs on toes
-Hops on one foot

-12-15 piece puzzle

NM and Nervous Systems Pediatric Pathology

Pathology
Cerebral Palsy (CP)

What is it
Is an umbrealla term
used to describe
movement disorders
due to brain damage
that are nonprogressive and are
acquired in utero,
during birth or
infancy. The brain
damage decreases
the brains abilility to
monitor and control
nerve and voluntary
muscle activity.

Etiology
CP can occur before
or during birth
secondary to a lack
of oxygen, maternal
infections, drug or
alcohol abuse,
placental
abnormalities,
toxemia, prolonged
labor, prematurity,
and Rh
imcompatibility. The
etiology of acquired
CP includes
meningitis, CVA,
seizures, and brain
injury.

Down Syndrome

Is a genetic

Includes incomplete

Signs & Symptoms

Spastic-indicating a
lesion in the motor
cortex of the
cerebrum; upper
motor neuron
damage
Athetoid-indicating
a lesion involving the
basal ganglia;
cerebellum and
cerebellar pathways
Distribution of
Involvement:
-Monoplegia-one
extremity
-Diplegia-bilateral LE
involvement,
however UE may be
affected
Hemiplegiaunilateral
involvement of the
upper and lower
exremties
Quadriplegiainvolvment of the
entire body
Mental retardation,

Treatment
Tx of CP is a life long
process. Intervention
includes ongoing
family and caregiver
education,
normalization fo tone,
stretching,
strengthening, motor
learning and
developmental
milestones,
positioning, weight
bearing activities,
and mobility skills.
Splinting, assistive
devices, and
specialized seating
may be indicated.
Surgical intervention
may be required for
orthopedic
management or
reduction of
spasticity.

Should emphasize

Duchenne Muscular
Dystrophy

Spina Bifida

abnormality
consisting of an extra
21 chromose, termed
trisomy 21.

cell division of the

21st pair of
chromosomes due to
nondisjunction,
translocation or
mosaic classficiation.
Advanced maternal
age increases the risk
of genetic imbalance.

exercise and fitness,

stability, maximizing
respiratory function,
and education for
caregivers. Surgical
intervention may be
indicated for cardiac
abnormaities.

The causative factor

is inheritance as an
X-linked recessive
trait. The childs
mother is a silent
carrier and only male
offspring will
manifest the disease.

hypotonia, joint
hypermobility,
flattened nasal
bridge, narrow
eyelids with
epicanthal folds,
small mouth, feeding
impairments, flat
feet, scoliosis,
congenital heart
disease, and visiual
and hearing loss.
Characteristics
usually manifest
between 2-5 years of
age. Progressive
weakness, disinterest
in running, falling,
toe walking,
excessive lordosis,
and
pseudohypertorphy
of muscle groups
(calves). Progressive
impairment with
ADLs and mobility
begins around age 5
and the ability to
ambulate slows.
*Gowers sign
Proximal weakness
first

Is a progressive
disorder caused by
the absence of the
gene required to
produce the musle
proteins dystrophin
and nebulin. Without
dystrophin and
nebulin, cell
membranes weaken,
myofibrils are
destored, and muscle
contractility is lost.
Fat and connective
tissue eventually
replace muscle, and
death usually occurs
from
cardiopulmonary
failure prior to age
25, usually in the
teenage years.
Is a developmental
abnormality due to

Causative factors
include: genetic

Motor loss below the

level of the defect,

PT emphasizes
significant family

Intervention focuses
on family/caregiver
education,
respiratory function,
submax exercise,
mobility skills,
splinting, orthotics,
and adaptive
equipment. Medical
management
includes the use of
immunosuppressants
, steroids, and
surgical intervention
for orthopedic
impairments.

insufficnet closure of
the neural tube by
the 28th day of
gestation.

predisposition,
environmental
influence, low levels
of maternal folic acid,
maternal
hyperthermia, and
certain classifications
of drugs.
Classifications of
spinal bifida include:
Spina bifida Occultaimpairment and nonfusion of the spinous
processes of a
vertebrae, however,
the spinal cord and
meninges remain
intact. No associated
disabilitiy. Spina
bifida cystic-presents
with a cyst like
protrusion through
the non-fused
vertebrae, which
results in
impairment.
2 types of Cystica:
1. Meningoceleherniation of
meninges and
CSF into a sac
that protrudes
through the
vertebral
defect.
2. 2.

sensory deficits,
hydrocephalus,
Arnold-Chiari Type II
malformation,
osteoporosis,
clubfoot, tethered
cord syndrome, latex
allergy, bowel and
bladder dysfunction,
and learning
disabilities.

teaching regarding
positioning, handling,
ROM, and therapeutic
exercises. Skin care,
strengthening, AD,
splinting, wheelchair
prescription.

Myelomeningo
cele-a severe
form with
herniation of
meninges,
CSF, and spinal
cord extending
through the
defect in the
vertebrae.
Cyst may or
may not be
covered by
skin.
Neuromuscular Pathologies:
Disease

Diagnosis

Alzheimer
s Disease

Is a
progressive
neurological
disorder that
results in
deterioration
& irreversible
damage
within the
cerebral
cortex and
subcortical
areas of the
brain. The
loss of

Contribut
ing
Factors
Hyopthesiz
ed causes
include
lower
levels of
neurotrans
mitterse,
higher
levels of
aluminum
within
brain
tissue,
genetic
inheritanc

Clinical
Presentati
on
Initially
noted by a
change in
higher
cortical
functions
characteriz
ed by
subtle
changes in
memory,
impaired
concentrati
on, and
difficulty

Lab/Imagi
ng

Management/
Outcome

Alzheimers
disease
presently
cannot be
confirmed
until a
postmorte
m biopsy
revels the
neurofibrill
ary tangles
and
amyloid
plaques.
MRI can be

Drug therapies
are usually
short term in
effect lasting
6-9 months. PT
should focus
on maximizing
the pts
remaining
function and
providing
family and
caregiver
education. The
therapist

neurons
results from
the
breakdown
of several
processes
that would
normally
sustain the
brain cells.

e,
autoimmu
ne
disease,
abnormal
processing
of the
substance
amyloid,
and virus.
The risk of
developing
with age
and a
higher
incidence
in women.

with new
learning.
During the
middle
stages, pt
will
develop
behavioral
and motor
problems
such as
aphasia,
apraxia,
perseverati
on,
agitation
and violent
or socially
unacceptab
le behavior
that can
include
wandering.
Eventually
all ability to
learn is lost
and longterm
memory
also
disappears.

used to
assess any
abnormaliti
es or signs
of atrophy
within the
brain that
is
associated
with
Alzheimers
disease or
to rule out
other
medical
conditions.

should attempt
to create an
emotional &
physical
environment
that provides
the pt with the
opportunity to
experience
success.
Safety with
functional
mobility and
gait training
may be
indicated in
the early
stages. Many
pts require a
long term care
facility due to
personality
changes,
aggressive
behavior, and
end-stage
complications.
This is a
chronic and
progressive
disorder and is
the 4th leading
cause of death
of adults. The
typical course
of the disease

Amyotroph
ic Lateral
Sclerosis
(ALS)

Is a chronic
degenerative
disease that
produces
both upper
and lower
motor
neuron
impairments.
Demyelinatio
n, axonal
swelling, &
atrophy
within the
cerebral
cortex,
premotor
areas,
sensory
cortex, and
temporal
cortex cause
the
symptoms of
ALS.

Exact
etiology
unknown,
theories of
causative
factors
that
include
genetic
inheritanc
e as an
autosomal
dominant
trait, a
slow
acting
virus,
metabolic
disturbanc
es, and
theories of
toxicity of
lead &
aluminum.
Familial
ALS occurs

Both upper
and lower
motor
neuron
involvemen
t. Lower
motor
neuron
signs
include
asymmetri
c muscle
weakness,
cramping,
and
atrophy
that are
usually
found
within the
hands.
Muscle
weakness
due to
denervatio
n

There are
multiple
tests used
to assist
with
diagnosing
ALS.
Electromyo
graphy
assesses
fibrillation
and muscle
fasciculatio
ns. Muscle
biopsy
verifies
LMN
involvemen
t rather
than
muscle
disease
and a
spinal tap
may reveal
a higher

averages
between 7-11
years. The
leading cause
of death of a pt
with
Alzheimers
disease is
infection or
dehydration.
Management is
based on
supportive
care and
symptomatic
therapy. PT
should focus
on quality of
life, low level
exercise, ROM,
mobility
training,
assistive/adapt
ive devices,
wheelchair
prescription,
bronchial
hygiene, and
energy
conservation
techniques.
ALS is usually
a rapidly
progressing
neurological
disease with

in 5-10%
of all
cases. Risk
for ALS is
higher in
men &
usually
occurs
between
40-70
years of
age.

eventually
causes
significant
fasiculation
s, atrophy,
and
wasting of
the
muscles.
The
weakness
spreads
throughout
the body
over the
course of
the disease
and
generally
follows a
distal to
proximal
path.
Upper
motor
neuron
symptoms
occur due
to the loss
of
inhibition
of the
muscle.
Incoordinat
ion of
movement,

protein
content in
some pts
with ALS.

an average
course of 2-5
years with 2030% surviving
longer than 5
years. Death
usually occurs
from
respiratory
failure.

Central
Cord

Is an
incomplete

Most
common

spasticity,
colnus, and
a positive
Babinski
reflex are
some of
the
indicators
of UMN
involvemen
t. Bulbar
involvemen
t is
characteriz
ed by
dysarthria,
dysphagia,
and
emotional
lability. A pt
will ALS will
exhibit
fatigue,
oral motor
impairment
,
fasciulation
s,
spasticity,
motor
paralysis, &
eventual
respiratory
paralysis.
CCS
presents

MRI is used
to assess

Rehab is
initiated once

Syndrome
(CCS)

SCI that
most often
results from
a cervical
hyperextensi
on injury.
Symptoms
are
secondary to
damage to
the central
aspect of the
spinal cord.
CCS usually
occurs from
a fall but can
occur from
other forms
of trauma
such as MVA.

MOI is a
hyperexte
nsion
injury of
the
cervical
spine.
Other
potential
contributin
g factors
in the
developme
nt of CCS
include
cervical
spondylosi
s,
narrowing
or
congenital
defect of
the spinal
canal,
tumor
rheumatoi
d arthritis
or
syringomy
elia. CCS
predomina
tely affects
the
population
over 50
and

with motor
loss that is
greater in
the UEs
than in the
LEs and is
most
severe
distally in
the UEs.
This
presentatio
n is due to
the
damage
that occurs
within the
central
location of
the spinal
cord.
Sensory
loss found
below the
level of the
lesion is
usually
limited, but
can be
variable.
Sacral
segments
are usually
unaffected.
Bowel &
bladder

spinal cord
impingeme
nt form
bone or
disk. CT
scan of the
spine will
assess
spinal canal
compromis
e and the
degree of
impingeme
nt. X-rays
can be
utilized to
assess
potential
fractures,
dislocations
, and
degree of
spondylotic
deterioratio
n.

the pt is
medically
stable. PT
intervention
should include
pt and
caregiver
education,
ROM,
strengthening,
endurance,
balance,
proximal
stabilization
ex, and
functional
mobility based
on current
function. If a pt
ambulates, a
platform
attachment
walker may be
initially
indicated since
hand function
is usually poor
for grasp.
Surgical
intervention is
rare. CCS is
the most
common
incomplete SCI
and accounts
for ~30% of

Cerebral
Palsy

Is an
umbrealla
term used to
describe a
group of nonprogressive
movement
disorders
that result
from brain
damage.
Most
common
cause of
permanent
disability in
children.

greater
incidence
in men.

functions
resolve in
55-85% of
pts with
CCS after 6
months.

Multifactor
ial &
sometimes
unknown.
Risk
factors are
categorize
d as
prenatal
(80%), or
perinatal
and
postnatal
(20%).
Factors
can
include
maternal
malnutrion
,
hypothyroi
dism,
infection,
diabetes,
and
chromoso

CP is a NM
disorder of
posture
and
controlled
movement.
A child may
present
with high
tone, low
tone, or
athetoid
movement.
CP is
classified
as
monoplegia
(one
involved
extremity),
hemiplegia
(unilateral
involvemen
t of the
upper and
lower

If CP is
suspected
through
clinical
findings,
including
seizures,
an
electroence
phalograph
y (EEG)
may be
performed.
X-ray of the
hp may
rule out hip
dislocation;
blood and
urine tests
can be
sued to
investigate
a metabolic
cause of
CP.
Observatio

overall
tetraplegia.
Statistics
indicated 77%
of pts with CCS
will ambulate.
Older pts do
not recover as
well as
younger ones.
Life long team
approach. PT
for CP often
uses
neurodevelop
mental
treatment and
sensory
integration
techniques.
Treatment
should include
normalization
of tone, family
education,
developmental
milestones,
positioning,
stretching,
strengthening,
balance,
mobility,
specialized
wheelchair
seating and
orthotic

me
abnormalit
ies.
Perinatal
factors
include
multiple or
premature
births,
breech
delivery,
low birth
weight,
prolapsed
cord. Post
natal
include
CVA, head
trauma,
infection
and brain
tumor. The
most
common
cause of
CP is
prenatal
cerebral
hypoxia.

Down
Syndrome
(DS)

(Trisomy 21)
occurs when
there is an

Some
theories
suggest

extremities
), and
quadriplegi
a (all
extremities
). General
characteris
tics include
motor
delays,
abnormal
muscle
tone, poor
postural
control,
reflex
abnormaliti
es, high
risk for hip
dislocation
s, and
perceptual
skills. Pt
may also
have
mental
retardation
(50-60%),
hearing
impairment
s,
constipatio
n.
DS is the
most
common

n usually
will
diagnose
CP
secondary
to the
observed
outward
characteris
tics.

prescription. If
a pt is going to
ambulate, this
will usually
occur by the
age of 8. CP is
a nonprogressive
but permanent
condition.
Prognosis for
mild to
moderate CP is
a near normal
lifespan. 50%
of children
with severe CP
die by the age
of 10.

During
pregnancy
a female

Team approach
that requires
life long

error in cell
division
either
through
nondisjunctio
n (95%),
translocation
(4%), or
mosaicism
(1%) and the
cell nucleus
results in 47
chromosome
s.

than an
increase in
maternal
age (and
age of the
oocyte)
may cause
predisposit
ion to
errors in
meiosis.
Environme
ntal
factors
such as
virus,
paternal
age,
medical
exposure,
reproducti
ve
medication
s, and
intrinsic
predisposit
ions have
been
associated
with DS.

cause of
MR. Pt will
present
with
hypotonia,
flattened
nasal
bridge,
almondshaped
eyes,
abnormally
shaped
ears.
Simian line
(palmar
crease),
epicanthal
folds,
enlargeme
nt of the
tongue,
congenital
heart
disease,
developme
ntal delay,
and a
variety of
MS
disorders.

can be
tested for
Alphafetoprotein,
human
chorionic
gonadotrop
in, and
unconjugat
ed
estrogen
levels (the
triple
screen).
Three
diagnostic
studies
include
chorionic
villsu
sampling,
amniocente
sis or
percutaneo
us
umbilical
blood
sampling.
Detection
of DS
occurs in
~60-70% in
the women
tested that
are
carrying a

intervention.
PT intervention
play a role in
developmental
delay,
hypotonia,
laxity of
ligaments, and
poor strength
are key areas
of tx.
Positioning and
handling are
key
components in
order to
maximize
proper
alignment and
to minimize
pathological
reflexes,
malalignment,
and instability.
Individual with
DS today have
a longer life
expectancy
secondary to
advances in
medical care,
however, it is
still less than
standard.
Approx 80%
reach the age

Duchenne
Muscular
Dystrophy
(DMD)

Is a
progressive
NM
degenerative
disorder than
manifests
symptoms
once fat and
connective
tissue being
to replace
muscle that
has been

Inheritanc
e as an Xlinked
recessive
trait. The
mother is
the silent
carrier of
this
disorder.
Since it is
a
recessive

Diagnosis
occurs
between 25 years of
age of only
males. The
first
symptoms
include
waddling
gait,
proximal
muscle

baby with
DS. After
birth a
chromosom
e analysis
called a
karyotype
can be
performed
to confirm
the
suspected
diagnosis.
Pt will have
AA
(atlantoaxi
al)
instability,
sensory,
hearing
and visual
impairment
s.
Electromyo
graphy is
used to
examine
the
electrical
activity
within the
muscles. A
muscle
biopsy can
be
performed

of 55.

Treatment
focuses on
maintaining
function of the
unaffected
musculature
for as long as
possible. PT is
initially
indicated to
assist a young
child with
progression

destroyed by
the disease
process. The
mutation of
the
dystrophin
gene causes
the
symptoms of
DMD.

trait, only
male
offspring
will
manifest
the
disorder
while
female
offspring
become
carriers.

weakness,
clumsiness,
toe
walking,
excessive
lordosis,
pseudohyp
ertrophy of
the calf
and other
muscle
groups,
and
difficulty
climbing
stairs. DMD
primarily
affects the
shoulder
girdle
musculatur
e, pects,
delts,
rectus
abdominis,
gluteals,
hamstrings
, and
calves. Pt
initially has
difficulty
getting off
the floor,
needing to
use the
Gowers

to
determine
the
absence of
dystrophin
and
evaluate
the muscle
fiber size.
DNA
analysis
and high
serum
creatinine
kinase
levels n the
blood also
assist with
confirming
the
diagnosis.

through the
developmental
milestones. PT
should focus
on maintaining
available
strength,
encouraging
mobility,
adapting to the
loss of
function. And
promoting
family
involvement in
a home
program. MMT
and ROM
should be
evaluated on a
consistent
basis to
determine the
pattern and
rate of
disability.
Orthotics, Ads,
and wheelchair
prescription
are areas that
will require
attention.
Respiratory
care will also
become a vital
part. DMD is a

Erbs Palsy

A term used
to denote an
upper
brachial
plexus injury
or palsy that
usually
results from
a difficult
birth. This
type of injury
is the most
common
palsy related
to the

One side
of the
babys
neck is
stretched
which
damages
the
nerves. If
the upper
nerves are
affected
the
condition
is termed

maneuver.
Approx 1/3
of pts have
some form
of learning
disability
secondary
to the
dystrophin
abnormaliti
es. There is
usually
rapid
progression
of this
disease
with the
inability to
ambulate
by 10-12
years.
There are 4
types of
brachial
plexus
injuries:
avulsion,
rupture,
neuroma,
and
neurapraxi
a, The
clinical
presentatio
n is a
flaccid

progressive
disorder and
progresses
rapidly. Death
occurs
primarily from
cardiopulmona
ry
complications.
Death usually
takes place by
the time a pt is
a teenager or
less frequently
into their 20s.

An x-ray or
MRI may be
performed
to see if
there is any
damage to
the bones
and joints
of the neck
and
shoulder.
The
physician
may also
use an EMG

PT is
recommened
for a pt with
Erbs palsy
with focuses
on increasing
active &
passive
movement and
promoting use
to the weak UE
for functional
activities. If a
pt has
spontaneous

brachial
plexus. It
primarly
affects the
muscles of
the shoulder
and elbow.
The muscles
affected are
those
supplied by
cervical roots
C5 & C6;
axillary,
lateral
pectoral,
upper and
lower
subscapular,
suprascapula
r, and partial
paralysis of
the long
thoracic and
musculocuta
neous
nerves. The
result is loss
of rotator
cuff, deltoid,
brachialis,
coracobrachi
als, and
biceps.

Erbs
palsy. One
theory
suggests
that
congenital
chicken
pox or
amniotic
bands may
also
produce
this
condition.
When it
occurs in
adults, the
cause
typically is
an injury
that has
caused
stretching,
tearing, or
other
trauma to
the upper
brachial
plexus
network.
The
chance of
an infant
having a
brachial
plexus

paralysis
that is
nicknamed
the
Waiters
tip
deformity
characteriz
ed by a
loss of
shoulder
function,
loss of
elbow
flexion,
forearm
pronation,
and the
hand
positioned
in a pinch
grip
manner.

or nerve
conduction
studies to
see if any
nerve
signals are
present.

recovery of
active
movements
within 3-4
months, the
caregivers are
given a home
program. If
conservative tx
fails, surgery is
indicated.
Surgery will
not restore
normal
function. After
surgery, the
infant will wear
a splint for ~34 weeks.
Caregiver
education is
very important
regarding
positioning and
handling to
avoid further
traction.
Approx. 9 out
of 10 infants
with brachial
plexus palsy
can recover
with
conservative
treatment.
Since nerves

palsy is
equally
distributed
according
to gender,
gestational
age, and
race.

GuillainBarre
Syndrome
(GBS)

Or acute
polyneuropat
hy is a
temporary
inflammation
and
demyelinato
n of the
peripheral
nerves
myelin
sheaths,
potentially
resulting in
axonal
degeneration
. GBS results
in motor
weakness
and in a
distal to
proximal
progression,
sensory

Unknown,
however it
is
hypothesiz
ed to be
an
autoimmu
ne
response
to a
previous
respiratory
infection,
influenza,
immunizati
on, or
surgery.
Viral
infections,
cytomegal
ovirus,
bacterial
infections,
surgery

Can occur
at any age,
there is a
peak in
frequency
in the
young
adult
population
and again
in adults
that are
between
their 5th
and 8th
decades.
Incidence
is slightly
greater in
males than
females
and in
Caucasians
than

GBS can be
diagnosed
through a
cerebrospin
al fluid
sample
that
contains
high
protein
levels and
little to no
lymphocyte
s.
Electromyo
graphy will
result in
abnormal
and slowed
nerve
conduction.

grow at a rate
of 1 inch per
month, it may
take several
months or
even years for
nerves
repaired at the
cervical spine
to reach the
muscles of the
hand.
May require
hospitalization
for treatment
of symptoms.
A
tracheostomy
may be
performed for
ventilation. PT
should be
initiated upon
admission to
the hospital
with focus on
PROM,
positioning,
and light
exercise.
During the
acute stage a
therapist must
limit over
exertion and
fatigue to

impairment,
and possible
respiratory
paralysis.

and
vaccinatio
ns have
been
associated
with the
developme
nt of GBS.

African
Americans.
Pt will
initially
present
with distal
symmetric
al
weakness
and will
experience
sensory
impairment
s&
transient
paresthesia
s. The
weakness
will
progress
towards
the upper
extremities
and head.
The level of
disability
usually
peaks
within 2 to
4 weeks
after onset.
Muscle &
respiratory
paralysis,
absence of
DTRs. GBS

avoid
exacerbation
of symptoms.
As the pt
progresses,
intervention
may include
orthotic,
wheelchair or
AD
prescription,
family
teaching, gait
training. The
pool may be
indicated to
initiate
movement
without the
effects of
gravity. PT may
assist with
recovery, but it
cant alter the
course of the
disease. PT
may be
required on an
ongoing basis
to assist w
recover that
can last from
3-12 months.
Recover is slow
and can last up
to 2 years after

can be life
threatening
if there is
respiratory
involvemen
t.

Huntington
s Disease
(HD)

AKA
Huntingtons
Chorea, is a
neurological
disorder of
the CNS and
is
characterize
d by
degerneratio
n & atrophy
of the basal
ganglia
(specifically
the striatum)
and cerebral
cortex within
the brain.

HD is
genetically
transmitte
d as an
autosomal
dominant
trait with
the defect
linked to
chromoso
me four
and to the
gene
identified
as IT-15.
The
disease is
usually
perpetuate
d by a
person
that has
children

The
average
age for
developing
symptoms
ranges
between
35 & 55.
HD is a
disease
that
produces a
movement
disorder,
affective
dysfunction
, and
cognitive
impairment
. Pt will
initially
present
with

MRI or CT
scan may
indicate
atrophy or
abnormaliti
es within
the
cerebral
cortex as
well as the
basal
ganglia.
PET may be
used to
augment
other
testing and
obtain info
regarding
blood flow,
oxygen
uptake, and
metabolism

onset.
Although most
pts experience
full recovery,
statistics
indicated that
20% have
remaining
neurologic
deficits and 35% die from
respiratory
complications.
PT should
maximize
endurance,
strength,
balance,
postural
control, and
functional
mobility. Pt
education
should include
prone lying,
stretching,
prevention of
deformity and
contracture,
and safety with
mobility. As the
disease
progresses the
degree of
dementia will
influence

prior to
the normal
onset of
symptoms
& without
knowledge
that
he/she
possesses
the
defective
gene.
Genetic
testing is
able to
identify
the
defective
gene for
HD prior to
the onset
of
symptoms.

involuntary
choreic
movement
s and a
mild
alteration
in
personality.
Unintention
al facial
expression
s such as a
grimace,
protrusion
of the
tongue,
and
elevation
of the
eyebrows
are
common.
As the
disease
progresses
gait will
become
ataxic and
a pt
experience
s
choreoathe
toid
movement
of the
extremities

of the
brain. A
DNA
marker
sutyd may
be
administere
d to
determine
if the
autosomal
dominant
trait is
present for
HD.

treatment and
goals. HD is a
chronic
progressive
genetic
disorder that is
fatal within 1520 years after
clinical
manifestation.
Late stages of
the disease
result in total
physical and
mental
incapacitation.
The pt usually
requires an
extended care
facility due to
the burden of
care &
physical,
cognitive, and
emotional
dysfunction.

Multiple
Sclerosis

MS produces
patches of
demyelinatio
n that
decreases
the efficiency
of nerve
impulse
transmission.

Genetics,
viral
infections,
and
environme
nt all have
a role in
the
developme

and trunk.
Speech
disturbanc
es &
mental
deterioratio
n are
common.
Late stage
HD is
characteriz
ed by a
in IQ,
dementia,
depression,
dysphagia,
incontinenc
e, inability
to
ambulate
or transfer,
and
progression
from
choreiform
movement
s to rigidity.
Differs by
geographic
area, sex,
and race.
MS can be
classified
as
relapsingremitting

There is not
a single
testing
procedure
to diagnose
MS early in
the
disease.
MRI may

The goal of
medical
treatment is to
lessen the
length of
exacerbations
and maximize
the health of
the pt. PT

Symptoms
vary based
on the
location &
extent of
demyelinatio
n

nt of MS. It
is
theorized
that a slow
acting
virus
initiates
the
autoimmu
ne
response
in
individuals
that have
environme
ntal and
genetic
factors of
the
disease.
The
incidence
of MS is
higher in
Caucasian
s between
20 & 35
years and
is nearly
twice as
common in
women as
in men.
There is
also a
higher

(85%),
secondary
progressive
, primary
progressive
, or
progressive
relapsing.
Initial
symptoms
include
visual
problems,
paresthesia
s, and
sensory
changes,
clumsiness,
weakness,
ataxia,
balance
dysfunction
, and
fatigue.

assist with
observation
and
establishin
ga
baseline for
lesions,
evoked
potentials
may
demonstrat
e slowed
nerve
conduction,
and
cerebrospin
al fluid can
be
analyzed
for an
elevated
concentrati
on of
gamma
globulin
and protein
levels.

includes
regulation of
activity level,
relaxation and
energy
conservation
techniques,
normalization
of tone,
balance
activities, gait
training, core
stabilization, &
adaptive/assist
ive device
training. Pt and
caregiver
education
regarding
safety, energy
conservation,
patterns of
fatigue, and
the use of AD
is vital to the
quality of life.
Exercise in the
morning when
the pt is rested
and to avoid
fatigue.
Factors that
influence
exacerbations
include heat,
stress,

incidence
of MS in
temperate
climates.

Parkinson

This

Contributin

The risk for

There are

infection,
trauma, and
pregnancy.
Most pts live
with MS for
many years
and die from
secondary
complications
such as disuse
atrophy,
pressure sores,
contractures,
fractures, renal
infection, and
pneumonia. If
left untreated
50% of pts will
require a w/c
within 15 years
post diagnosis.
Overall
mortality rate
and long-term
outcome
correlates to
age at
diagnosis,
number of
attacks &
exacerbations,
frequency &
duration of
remissions &
type of MS
The medical

s Disease

syndrome
occurs as a
secondary
effect or
disorder from
another
disease
process.
Parkinsons
disease is a
primary
degenerative
disorder and
is a
characterize
d by a
decrease in
production of
dopamine
(neurotrans
mitter)
within the
corpus
striatum
portion of
the basal
ganglia. The
degeneration
bof the
dopaminergi
c pathways
creates an
imbalance
between
dopamine
and

g factors
that can
produce
symptoms
of
Parkinson
s include
genetic
defect,
toxicity
from
carbon
monoxide,
excessive
manganes
e or
copper,
carbon
disulfide,
vascular
impairmen
t of the
striatum,
encephaliti
s, and
other
neurodege
nerative
diseases
such as
Huntington
s disease
or
Alzheimer
s disease.

developing
increases
with age,
1:100 are
affected
over the
age of 75.
Majority of
pts are
between
50-79
years.
Initially pts
will notice
a resting
tremor in
the hands
(pill rolling)
or feet that
increases
with stress
and
disappears
with
movement
or sleep.
Early in the
disease
process a
pt may
attribute
symptoms
to old
age such
as balance
disturbanc

no
laboratory
or imaging
studies that
initially
diagnose
Parkinsons
. CT scan or
MRI may be
used to
rule out
other
neurodege
nerative
disease
and obtain
a baseline
for future
comparison
.

management
of Parkinsons
disease relies
heavily on
pharmacologic
al intervention.
Dopamine
replacement
therapy
(Levadopa,
Siinemet,
Madopar) is
the most
effective
treatment in
reducing
symptoms. PT
should include
maximizing
endurance,
strength, and
functional
mobility. Verbal
cueing and
oral/visual
feedback are
effective tools
to use with this
population. PT
is recommened
on an
intermittent
basis.
Parkisons
disease does
not

acetylcholie.
This
produces the
symptoms of
Parkinsonss.

es,
difficulty
rolling over
and rising
from bed,
and
impairment
with fine
manipulati
ve
movement
s seen in
writing,
bathing, &
dressing. A
pts
symptoms
slowly
progress
and often
include
hypokinesi
a, sluggish
movement,
difficulty
with
initiating
(akinesia)
and
stopping
movement.
Festinating
and
shuffling
gait,
bradykinesi

significantly
alter a pts
lifespan if the
pt is diagnosed
with a
generalized
form between
50-60 years.
As the disease
progresses,
however, there
will be an
exacerbation
of all
symptoms and
significant loss
of mobility. The
inactivity &
Deconditioning
allows for
complications
and eventual
death.

Spina
BifidaMyelomeni
ngocele

Incomplete
fusion of the
posterior
vertebral
arch with
both
meninges
and spinal
cord
protruding
outside the
neural arch.
Characterize
d by a sac or
cyst that
protrudes
outside the
spine.

The
incidence
varies by
socioecono
mic status,
geographic
area, and
ethnic
backgroun
d. The
overall
incidence
is
declining
due to
improved
prenatal
care.
Prenatal
care
including
recommen
ded

a, poor
posture,
dysphagia,
and
cogwheel
or lead
pipe
rigidity of
skeletal
muscles.Ma
sk like with
no facial
expression.
Impairment
s
associated
include
motor and
sensory
loss below
the
vertebral
defect,
hydrocepha
lus, ArnoldChiari type
II
malformati
on,
clubfoot,
scoliosis,
bowel &
bladder
dysfunction
, and
learning

Prior to
birth a fetal
ultrasound
may
identify the
myelomeni
ngocele
defect in
the spine.
Prenatal
testing of
alphafetopr
otein
(AFP)in the
blood will
show and
elevation in
levels that
indicate a
probably
neural tube
defect at
approx.

Immediate
surgical
intervention to
repair and
close the
defect and for
placement of
shunt to
alleviate
hydrocephalus.
PT is initiated
immediately
and focuses on
family
education
regarding
positioning,
handling
techniques,
ROM, and
therapeutic
play. Long term
PT attempts to

amounts
of folic
acid,
especially
in the first
6 weeks of
pregnancy,
appears to
be the
most
effective
way to
prevent
neural
tube
defects.

disabilities.
The higher
the lesion
the worse
the
prognosis
is for
survival. In
90% of the
cases a
shunt is
required for
hydrocepha
lus. Approx
2/3 of
children
with
myelomeni
ngocele
and
shunted
hydrocepha
lus have
normal
intelligence
and the
other third
demonstrat
e only mild
retardation.
Regardless
of
intelligence
, children
exhibit
difficulties

week 16 of
gestation.
At birth an
obvious sac
will be
present
over the
spinal
defect.

maximize
functional
capacity, skin
care, strength,
blance, and
mobility, w/c
prescription,
orthotics. A pt
with
myelomeningo
cle has a near
normal life
expectancy as
long as the pt
receives
consistent and
thorough
health care.
Functional
outcome of the
pt depends on
the level of
injury, the
amount of
associated
impairments,
and the
caregiver
support that is
provided.

Spinal
Cord Injury

Complete
C7
Tetraplegia

After injury,
C7 is the
most distal
segment of
the spinal
cord that
both the
motor and
sensory
components
remain
intact.

Motor
Vehicle
Accidents,
violence &
falls are
the top
causes.
Higher
ratio of
injury in
men (80%)
and
Caucasian
s. The
highest
incidence
of occurs
between
15-30
years of
age.

with
perceptual
abilities,
attention,
problem
solving,
and
memory.
Spinal
shock
which is
the total
depression
of all
nervous
system
function
below the
level of the
lesion
occurs
immediatel
y following
injury and
may last
for days.
Include
flaccid
paralysis
and loss of
all reflexes
&
sensation.
Surgical
interventio
n may be

X-rays of
the cervical
spine
observe the
positioning
and
damage of
the
involved
vertebrae.
The results
of imaging
determine
subsequent
medical
interventio
n including
stabilizatio
n of the
spine.

The acute
phase begins
at injury and
includes
medically
stabilizing the
pt. Inpatient
rehab
(typically 6-8
weeks) should
initially focus
on ROM,
positioning in
bed, and
cough,
clearance of
secretions,
bronchial
drainage, and
incentive
spirometry.
Compensatory
techniques,
strengthening,
muscle
substitution,
and the use of
momentum

required
after injury
in order to
stabilize
the spinal
cord
through
decompres
sion and
fusion at
the site of
injury. A
Halo device
is
commonly
used with
cervical
injuries to
stabilize
the spine.
As sock
subsides, a
pt will
experience
an in
muscle
tone below
the level. A
pt with C7
tetraplegia
will also
present
with
impaired
cough and
ability to

and the headhips

relationship
should be
utilized during
all activities.
Ongoing
intervention
should include
mat skills, selfROM, transfer
skills, and
community
reintegration.
Typical
outcomes at
this level
include
independence
with feeding,
grooming, and
dressing, selfROM,
independent
manual
wheelchair
mobility,
independent
transfers, and
independent
driving with an
adapted
automobile.
Independent
living with
adaptive

clear
secretions,
altered
breathing
pattern and
poor
endurance.

Spinal
Cord Injury

Complete
L3
Paraplegia

A pt sustains
primary
damage to
the spinal
cord and
surrounding
tissues at the
L3 level
through the
disruption of
the
membrane,
displacement
or
compression
of the spinal
cord, &
subsequent
hemorrhage

Motor
Vehicle
Accidents,
violence &
falls are
the top
causes.
Higher
ratio of
injury in
men (80%)
and
Caucasian
s. The
highest
incidence
of occurs
between
15-30

Pts
specifically
with a
complete
lesion at
the L3 level
typically
have a
least
partial
innervation
of the
gracilis,
iliopsoas,
quadratus
lumborum,
rectus
femoris,
and

The
evaluation
of a pt with
an acute
lumbar
spine
fracture
should
include
routine lab
tests, such
as CBC,
and
electrolytes
. X-rays, CT
scan, and
MRI allows
for bony
and

equipment is
possible. The
triceps,
extensor
pollicis longs
and brevis,
extrinsic finger
extensors, and
flexor carpi
radialis will
remain the
lowest
innervated
muscles. Life
expectancy
over 45 years
of age.
Stabilization of
the pts airway
in order to
secure
adequate
oxygenation.
All pts with
spinal cord
injury should
immediately
receive
intravenous
methylprednis
olone since it
has proven to
control the
amount of
secondary
damage and

and vascular
damage.
After a
complete
injury at this
level, L3 is
the most
distal
segment of
the spinal
cord that
both the
motor and
sensory
components
remain
intact.

years of
age.

Sartorius.
Pts have
full use of
their UEs
and have
hip flexion,
adduction,
and knee
extension.

ligamentou
s injury
diagnosis.

improve the
neurological
outcome. The
pt may be
placed in a
thoracolumbar
orthosis (TLSO)
with restriction
of activities or
undergo
stabilization
surgery
followed by the
use of a TLSO.
Orthotic
prescription
(KAFOs or
AFOs) is
recommended
once the pt
has gained
strength to
assist with
ambulation
using crutches.
A pt with L3
SCI will usually
participate in
4-8 weeks of
inpatient rehab
immediately
after injury and
stabilization.
The pt should
be able to
function

Thoracic
Outlet
Syndrome

Is a term
used to
describe a
group of
disorders
that presents
with
symptoms
secondary to
neurovascula
r
compression
of fibers of
the brachial
plexus. This
usually
occurs
between the
points of the
interscalene
triangle and

Results
from
compressi
on and
damage
the
brachial
plexus
nerve
trunks,
subclavian
vascular
supply,
and/or the
axillary
artery.
Contributin
g factors
in the
developme
nt of TOS

Will
present
with
symptoms
based on
nerve
and/or
vascular
compressio
n. Typical
symptoms
include
diffuse pain
in the arm
most often
at night,
paresthesia
s in the
fingers and
through the
upper

independently
from a w/c
level and
ambulation
level. Outcome
is based on the
degree of
injury, the pts
mental
capacity,
outside
support,
emotional
stability, and
co-morbidities.
X-ray will
Initially
confirm the management
presence of takes a
a cervical
conservative
rib or other approach, it
bony
that fails its
abnormality followed by
. Nerve
surgical
conduction intervention.
velocity
PT require
testing may intervention to
be valuable assist with
if a
modification of
neuropathy posture,
exists.
breathing
Otherwise,
patterns,
diagnosis
positioning in
relies solely bed and at the
on a
work site, and
through
gentle
history of a stretching.

the inferior
border of the
axilla.
Compression
of the nerves
and blood
supply can
occur as they
pass over
the first rib.

include the
presence
of a
cervical
rib, an
abnormal
first rib,
postural
deviations
or
changes,
body
compositio
n, chronic
hyperabdu
ction of
the arm,
hypertroph
y or
spasms of
the
scalene
muscles,
degenerati
ve
disorders,
and an
elongated
cervical
transverse
process.

extremities
, weakness
& muscle
wasting,
poor
posture,
edema,
and
discoloratio
n. If the
upper
plexus is
involved,
pain will be
reported in
the neck
and may
radiate to
the face
and follow
the lateral
aspect of
the forearm
into the
hand. If the
lower
plexus is
involved,
pain is
reported in
the back of
the neck
and
shoulder,
which will
radiate

pts
symptoms,
provocative
testing,
and
physical
exam.
Adsons,
wright,
roos,
sallen,
Halstead
maneuver,
hyperabduc
tion.

Should focus
on pain magnt,
strengthening
(trap, levator,
and
rhomboids)
joint mobs,
body
mechanics,
flexibility. If a
pt has positive
result from PT
there will not
be any long
term
impairments,
however if
they persist for
3 to 4 months,
surgery may
be warranted.
PT should
allow pts to
return to
previous
activity within
4-8 weeks.

Traumatic
Brain
Injury (TBI)

Injury where
the brain
makes
contact with
the skull
secondary to
a sudden
violent
acceleration
or
deceleration
impact. Can
also occur
secondary to
anoxia as
with cardiac
arrest or
near
drowning.

Falls and
motor
vehicle
accidents
are the
leading
causes.
High risk
groups
include
ages 0-4,
15-19, and
greater
than 65.
Males are
at a
greater
risk.

over the
ulnar
distribution
of the
hand.
Altered
consciousn
ess (coma,
obtundity,
delirium),
cognitive
and
behavioral
deficits,
changes in
personality,
motor
impairment
s,
alterations
in tone,
speech and
swallowing
issues.

CT scan or
MRI should
be
performed
immediatel
y in order
to rule out
hemorrhag
e,
infarction,
and
swelling. Xrays taken
of the
cervical
spine can
be used to
rule out fx
and
potential
for
subluxation
. An EEG,
PET, and
cerebral
blood flow
mapping
may also
be utilized
for
diagnosis

Medical mangt
initiated at the
site of injury or
in the
emergency
room for life
preserving
measures.
Once stable,
PT rehab in
initiated and
treatment
includes PROM
for a comatose
pt or
pathfinding
and high-level
balance for a
pt with mild
injury. Mobility
tranining,
behavior
modification,
serial casting,
compensatory
strategies,
vestibular
rehab, task
specific
activities, w/c
seating.

and
baseline
data.

Outcome is
based on the
degree of
primary and
secondary
damage. Many
pts experience
long term
deficits that
dont allow
them to return
to their preinjury lifestyle.

NM Medications:
Drug

Action

Indications

Side effects

Antiepilept
ic Agents

Reduce or
eliminate
seizure activity
within the
brain. These
agents attempt
to inhibit the
firing of certain
cerebral
neurons
through various

Seizure
activity
(partial,
generalized
, and
unclassified
seizures)

Ataxia, skin
issues,
behavioral
changes, GI
distress,
headache,
blurred
vision,
weight gain

Implicati
ons for
PT
Therapist
s must
have
adequate
knowled
ge of
establish
ed
protocols
for
respondi

Examples
Seconal
(secobarbital),
Klonopin
(clonazepam),
Depakote
(valproic
acid), Dilantin
(phenytoin),
Tegretol
(carbamazepi
ne0, Celontin

effects on the
CNS. Chemical
classifications
include
barbiturates,
benzodiazepine
s, carboxylic
acids,
hydantoins,
iminostilbenes,
succinimides,
and second
generation
drugs.

Antispastic
ity Agents

Promote
relaxation in a
spastic muscle.
Spasticity is an
exaggerated
stretch reflex of
the muscle that
can occur after
injury to the
CNS. Spasticity
is not a primary

Increased
tone,
spasticity,
SCI, CVA,
MS

Drowsiness
, confusion,
headache,
dizziness,
generalized
muscle
weakness,
hepatotoxic
ity
potential
with

ng to a
seizure
as well
as
potential
side
effects of
antiepile
ptic
medicati
ons. Pts
with
epilepsy
may
show
greater
sensitivit
y to
environm
ental
surroundi
ngs such
as light
or noise
level.
Therapist
s must
balance
the need
to
decrease
spastic
muscles
with the
loss of
function

(methsuximid
e), Neurontin
(gabapentin)

Lioresal
(baclofen),
Valium
(diazepam),
Dantrium
(dantrolene),
Zanaflex
(tizanidine)

condition, but a
secondary
effect from CNS
damage.
Agents bind
selectively
within the CNS
or within the
skeletal muscle
cells to reduce
spasticity.

Dantrium,
tolerance,
dependenc
e

that a pt
may
experien
ce with
the
reduction
of
hyperton
icity.
Once
spasticity
is
reduced,
therapist
s should
focus on
therapeu
tic
handling
techniqu
es,
facilitatio
n, and
strength
ening to
promote
overall
mobility.
Sedation
may also
alter the
schedulin
g of
therapy
to allow
for

Cholinergic
Agents

Cholinergic
direct stimulant
agents mimic
acetylcholine
and bind
directly to the
cholinergic
receptor to
activate &
create a
response at the
cellular level.
Indirect acting
cholinergic
stimulants
increase
cholinergic
synapse
activity through
the inhibition of
acetylcholinest
erase (which
normally
destroys
acetylcholine).
The increase of
acetylcholine at
the synapse
increases
cholinergic
synaptic
transmission.

Glaucoma,
dementia
due to
Alzheimers
disease,
postoperati
ve in GI
motility,
myasthenia
gravis,
reversal of
anticholiner
gic toxicity

GI distress,
impaired
visual
accommod
ation,
bronchocon
striction,
bradycardia
, flushing,
other
parasympa
thetic
effects

maximal
participat
ion.
Pts may
experien
ce a in
HR and
dizziness
.
Therapist
would be
aware of
character
isics of
both
sympath
etic and
parasym
pathetic
systems
and
notify
the
physician
if pt
begins to
exhibit
unexpect
ed side
effects.
Pts with
Alzheime
rs
disease
and
myasthe

Direct:
Duvoid
(bethanechol)
, Pilocar
(pilocarpine)
Indirect:
Aricept
(donepezil),
Tensilon
(endrophoniu
m),
Prostigmin
(neostigmine)
, Cognex
(tacrine)

Dopamine
Replaceme
nt Agents

Assist to relieve
the symptoms
of Parkinsons
disease
secondary to
the in
endogenous
dopamine.
These agents
are able to
cross the bloodbrain barrier
through active
transport and
transform to
dopamine
within the
brain.

Parkinsons
disease,
Parkinsonis
m

Arrhythmia
s
(levadopa),
GI distress,
orthostatic
hypotensio
n,
dyskinesias
, mood and
behavioral
changes,
tolerance

nia
gravis
may be
better
able to
participat
e in
therapeu
tic
activities
when
taking
cholinerg
ic
agents.
Therapist
s & pts
attain
maximal
benefit
from
schedulin
g
therapy
one hour
after
administr
ation of
levadopa
.
Therapist
must
understa
nd the
debilitati
ng

Sinemet or
Madopar
(levadopa),
Symmetrel
(amantadine)

effects of
drug
holidays
and
should
monitor
the pts
BP
frequentl
y due to
the
potential
for
orthostat
ic
hypotens
ion.
Muscle
Relaxant
Agents

Promote
Muscle
relaxation in
spasm
muscles that
typically
present with
spasm that is a
continuous,
tonic
contraction.
Spasms
typically occur
secondary to a
MS or
peripheral
nerve injury
rather than CNS
injury.

Sedation,
drowsiness,
dizziness,
nausea,
vomiting,
headache,
tolerance,
dependenc
e

Therapist
s must
be aware
of the
potential
side
effects,
however,
maximiz
e the
potential
for
relaxatio
n
through
therapeu
tic
techniqu

Valium
(diazepam),
Flexeril
(cyclobenzapr
ine), Paraflex
(chlorzoxazon
e)

es and
the use
of
modalitie
s during
treatmen
t.
Preventio
n of
reinjury
through
stretchin
g,
posture
retrainin
g, and
educatio
n should
assist
the pt to
achieve
desired
outcome
s.

Neuromuscular Rehab:
Grading Spasticity: Modified Ashworth Scale
Grad
e
0
1

Description
No increase in muscle
tone
Slight increase in muscle

1+

3
4

tone, minimal resistance

at the end of ROM
Slight increase in muscle
tone, minimal resistance
through less than half of
the ROM
More marked increase in
muscle tone, through
most of ROM, but
affected part easily
moved
Considerable increase in
muscle tone, passive
movement difficult
Affected part rigid in
flexion or extension

Balance:
Somatosensory Input:
Somatosensory receptors are located in the joints, muscles, ligaments, and skin to provide proprioceptive
information regarding length, tension, pressure, pain, and joint position. Proprioceptive and tactile input from the
ankles, knees, hips, and neck provide balance information to the brain.
Challenging the somatosensory system: examination of pressure and vibration; observation of a pt when
changing the surface they are standing on. Examples would be slopes, uneven surfaces, standing on foam.
Visual Input:
Visual receptors for perceptual acuity regarding verticality, motion of objects and self, environmental orientation,
postural sway, and movements of the head/neck. Children rely heavily on this system for maintenance of balance.
Challenging the visual system: examination of quiet standing with eyes open, observing balance strategies to
maintain center of gravity with and without visual input. Assessment of potential visual field cuts, hemianopsia,
pursuits, saccades, double vision, gaze control, and acuity is necessary.

Vestibular Input:
The vestibular input provides the CNS with feedback regarding the position and movement of the head with relation
to gravity. The labyrinth consists of three semicircular canals filled with endolymph and two otolith organs.
Semicircular canals respond to the movement of fluid with head motion. Otoliths measure the effects of gravity and
movement with regard to acceleration/deceleration.
Challenging the vestibular system: examination of balance with movement of the head; testing such as Dixhallpike maneuver, bithermal caloric testing, assessment for nystagmus, head thrust sign; testing of the
vestibulocular reflex.
Balance Reflexes:
Vestibuloocular reflex
(VOR)
Vestibulospinal reflex
(VSR)

VOR allows for head/eye movement coordination. This

reflex supports gaze stabilization through eye movement
that counters movements of the head. This maintains a
stable image on the retina during movement.
VSR attempts to stabilize the body and control
movement. The reflex assists with stability while the
head is moving as well has coordination of the trunk
during upright postures.

Automatic Postural Strategies: Are automatic motor responses that are used to maintain the center of gravity
over the base of support. These responses always react or respond to a particular stimulus.
Ankle strategy:

Hip strategy:

Suspensory

The ankle strategy is the first strategy to be elicited by a small

range and slow velocity perturbation when the feet are on the
ground. Muscle groups contract in a distal to proximal fashion to
control postural sway from the ankle joint.
The hip strategy is elicited by a greater force, challenge or
perturbation through the pelvis and hips. The hips will move (in
the opposite direction from the head) in order to maintain
balance. Muscle groups contract in a proximal to distal fashion in
order to counteract the loss of balance.
The suspensory strategy is used to lower the center of gravity

strategy:

Stepping
strategy:

during standing or ambulation in order to better control the center

of gravity. Examples of this include knee flexion, crouching or
squatting. This strategy is often used when both mobility and
stability are required during a task (such as surfing)
Is elicited through unexpected challenges or perturbations during
static standing or when the perturbation produces such a
movement that the center of gravity is beyond the base of
support. The lower extremities step and/or upper extremities
reach to regain a new base of support.

Vertigo is used to describe a sense of movement and rotation of oneself or the surrounding environment. It typically
is a sensation of spinning, but can also present as liner motion or falling. Vertigo may have a peripheral or central
origin.
Characteristics of Central Vs. Peripheral Vertigo:
Peripheral
Episodic and
short duration
Autonomic
symptoms
present
Precipitating
factor

Central
Autonomic
symptoms less
severe
Loss of
consciousness can
occur
Neurological
symptoms present
including:
-diplopia
-hemianopsia
-weakness
-numbness

-ataxia
-dysarthria
Pallor, sweating
Nausea and
vomiting
Auditory fullness
(fullness within
the ears)
Tinnitus
Etiology of Central Vs. Peripheral Vertigo
Peripheral
Benign
paroxysmal
positional
vertigo (BPPV)
Menieres
disease
Infection
Trauma/tumor
Metabolic
disorders (DM)
Acute alcohol
intoxication

Central
Meningitis

Migraine headache
Complications of
neurologic origin
post ear infections
Trauma/tumor
Cerebellar
degeneration
disorders
(alcoholism)
Multiple Sclerosis

Benign paroxysmal positional vertigo (BPPV): this condition is comprised of repeated episodes of vertigo that
occur subsequent to changes in head position. BPPV only lasts a few seconds and is typically first noted while in a
recumbent position since it most commonly affects the posterior semicircular canal. The etiology is usually otoconia

(canalith) that loosens and travels into the posterior semicircular canal, causing vertigo. Nystagmus is present and
can be noted when assessing a patient using the Dix-Hallpink test. Pts with BPPV typically find it self-limiting and can
be successfully treated with canalith repositioning maneuvers which are passive movements used to remove the
otoconia from the canals, thus remediating the vertigo.
Dix-Hallpike test: This maneuver is a vertiginous position test used in assessment and treatment. This test
stimulates the posterior semicircular canal and attempts to determine if otoconia exist within the canal. If the pt
experiences nystagmus and vertigo, the test is performed to determine if a pt presents with BPPV or a central lesion.
Procedure:
The initial positioning for the Dix-hallpike test where the pt starts in sitting with the legs extended on the table and
head rotated 45 to one side.
The pt is rapidly moved to a supine position with the head (still in 45 rotation) extended 30 beyond horizontal off
the end of the table.
The therapist continues to hold the pts head in this position for 20-30 seconds observing the potential for
nystagmus. If nystagums exists, the direction of the eyes and appearance of the nystagmus can determine inner ear
versus CNS lesion.
Balance Tests and Measures:
Berg Balance Scale: this is a tool designed to assess a pts risk for falling. There are 14 tasks, each scored on an
ordinal scale from 0-4. These tasks include static activities, transitional movements, and dynamic activities in sitting
and standing positions. The maximum score is a 56 with a score less than 45 indicating an risk for falling. This tool
can be used as one time examination for as an ongoing tool to monitor a pt who may be at risk for falls.
Fregley-Graybiel Ataxia Test Battery: A tool that consists of 8 test conditions used in the battery with each leg
measured on 2 accounts, the time spent in each test position and the number of steps that a pt takes without falling.
5 trials of each condition are performed. The test conditions include:
-stand on beam with eyes open
-Stand on beam with eyes closed
-walk on beam with eyes open
-sharpened Romberg (heel-toe static positioning)
-standing with eyes open
-standing with eyes closed

-standing on one leg with eyes closed

-walking on the floor with eyes closed
The therapist scores each condition on a pass/fail basis with normative data for comparison. This tool is best suited
for pts with high level motor skills since each condition is challenging. Therapists use this tool to assess and treat
balance dysfunction, however, pt performance does not assist the therapist to diagnose the cause of balance
dysfunction.
Fugl-Meyer Sensorimotor Assessment of Balance performance Battery: this tool is designed as a subset of
the Fugl-Meyer Physical Performance Battery and is designed to assess balance specifically for pts with hemiplegia.
Each of the 7 items assessed is scored from 0-2, specific to each item with the maximum score being 14. Even
though 14 is the best score that a person can receive, the pt still may not have normal balance.
Functional Reach Test: a single task screening tool used to assess standing balance and risk of falling. A person
is required to stand upright with a static base of support. A yardstick is positioned to measure the forward distance
that a pt can reach without moving the feet. Three trials are performed and averaged together.
The following are age-related standard measurements for functional reach:
20-40 years: 14.5-17 inches
41-69 years: 13.5-15 inches
70-87 years: 10.5-13.5 inches
A pt that falls below the age appropriate range for functional reach has an increased risk for falling. The outcome
measure demonstrates high test-retest correlation and intrarater reliability
Romberg Test: this is an assessment tool of balance and ataxia that initially positions the pt in unsupported
standing, feet together, upper extremities folded, looking at a fixed point straight ahead with eyes open. With the
eyes open, 3 sensory systems (visual, vestibular, somatosensory) provide input to the cerebellum to maintain
standing stability. If there is a mild lesion in the vestibular or somatosensory systems, the pt will typically
compensate through the visual sense.
Next the pt maintains the same standing posture, but closes the eyes. A pt receives a grade of normal if they are
able to maintain the position for 30 seconds. An abnormal response occurs with the inability to maintain balance
when standing erect with the feet together and the eyes closed. Pts may exhibit excessive sway or begin to fall.
When the visual input is removed, instability will be present if there is a larger somatosensory or vestibular deficit

producing the instability. If a pt demonstrates ataxia and has a positive Romberg test, this indicates sensory ataxia
and not cerebellar ataxia.
There is also a sharpened Romberg test where the pts balance is further assessed by performing in the same
manner but with a heel-to-toe stance, typically with the non-dominant foot in front. The pt would first be tested with
eyes open and then with the eyes closed. This modification increases the challenge to the vestibular and
somatosensory systems.
Timed Get Up and Go Test: this is a functional performance screening tool used to assess a persons level of
mobility and balance. The person initially sits in a supported chair with a firm surface, transfers to a standing
position, and walks approximately 10 feet. The pt must then turn around without external support, walk back
towards the chair, and return to a sitting position. The pt is scored based on amount of postural sway, excessive
movements, reaching for support, side-stepping or other signs of loss of balance. The 5 point ordinal rating scale
designates a score of 1 as normal and a score of 5 as severely abnormal. In an attempt to increase overall reliability
the use of time was implemented. Pts who are independent can complete the multi-task process in 10 seconds or
less. Pts that require over 20 seconds to complete the process are at the limit for functional independence and may
be at an increased risk for falling. Pts that require 30 seconds are at high risk for a fall.
Tinetti Performance Oriented Mobility Assessment: a tool used to screen pts and identify if there is an
increased risk for falling. The first section assesses balance through sit to stand and stand to sit from an armless
chair, immediate standing balance with eyes open and closed, tolerating a slight push in the standing position, and
turning 360. A pt is scored form 0-2 in most categories with a maximum score of 16. The second section assess gait
at normal spend and at a rapid, but safe speed. Items scored in this section include initiation of gait, step length,
and height, step asymmetry and continuity, path, stance during gait, and trunk motion. A pt is scored 0-2 for each
with a maximum score of 12. The tool has combined maximum total of 28 with the risk of falling increasing as the
total score decreases. A total score less than 19 indicates a high risk for a fall.
Vestibular Rehab:
Vestibular rehab is a therapeutic intervention that can be highly successful for pts with vestibular or central balance
system disorders. Exercise protocols for vestibular retraining utilize compensation, adaption, and plasticity to
increase the brains sensitivity, restore symmetry, improve vestibulocular control, and subsequently increase motor
control and movement.
Goals for vestibular
Rehab:

-Improve balance
-Improve trunk stability
- strength and ROM in
order to improve ms
balance responses and
strategies
-the rate and risk of
falls
-Minimize dizziness
Vestibuloocular Retraining Therapeutic Guidelines:
-Vestibuloocular reflex (VOR) and vestibulospinal
reflex (VSR) stimulation exercises
-Ocular motor exercises
-Balance exercises
-Gait exercises
-combination exercises (obstacle courses, functioning
in a public place)
-Habituation training exercises (use only with
appropriate pts)
-Individualize each program based on the pts specific
impairments (rehab vs. compensation training)
-Use of practice, feedback, and repetition are vital for
skill refinement
-Use of gravity, varying surface conditions, visual
conditions, and environmental cues should be
included in therapeutic planning
-The center of gravity must be controlled at each
stage of treatment
-Strategy (hip, ankle, stepping, suspense) training
should be implemented during treatment so that
strategies become automatic responses
-Force plate systems, electromyographic
biofeedback, optokinetic visual stimulation, and
videography are all technical systems that can

provide feedback to motor learning during vestibular

rehab
-Foam, mirrors, rocker boards, BAPS boards, Swiss
balls, foam rollers, tramplines, and wedges are lower
tech treatment tools that are successfully used to
vestibular rehab
CVA Tests and Measures:
There are various tests and measures to assess the different impairments secondary to CVA. Pts are administered
specific tests based on clinical diagnosis and pt presentation.
National Institute of Health (NIH) stroke scale: assessment of an acute CVA relative to impairment
Functional Independence Measure (FIM): provides a level of burden through assessment of mobility and ADL
management
Stroke Impact Scale: assessment of physical and social disability or level of impairment secondary to CVA
Fugl-Meyer Assessment of Physical Performance: motor, sensory, and balance impairment; also assesses pain and
ROM
Neurological Rehabilitation:
Neuro rehab may incorporate a variety of treatments based on the pts pathology, problem list, and deficits. There
are many forms of neurological rehab based on each constructs beliefs regarding motor control and motor learning.
A therapist must use therapeutic techniques that meet the individual pts therapeutic objectives and goals. The
following are various theories of neurological rehab based on each theorys interpretation of motor control and
motor learning.

Motor Control: is the study of the nature of movement; or the ability to regulate or direct essential movement.
Historically, control was thought to arise from reflex or hierarchical models where the cortex was perceived as the
highest functioning component of the system and spinal level reflexes were the lowest functioning components. New
models of motor control challenge these theories and believe that there is a greater distribution of control and that
the cortex is not solely at the top of the hierarchy.

Theories in general should provide a framework to interpret the issue or behavior, guide clinical action and
treatment, provide new ideas, and utilize working hypotheses for examination and intervention. There are multiple
theories of motor control that each embrace abstract ideas regarding the actual control of movement and are based
on a specifc interpretation of how the brain functions and interacts with other body systems. Some of the motor
control theories include the Reflex theory, Hierarchical theory, Motor programming theory, Task-oriented theory, and
ecological theory.
Motor Learning:
Motor learning is the study of the acquisition or modification of movement. Motor learning differentiates learning
versus performance, provides guidelines for appropriate use of feedback, prioritizes the impact of practice as it
relates to skill and movement, and also focuses on the transfer of learning across tasks and environments of
practice. Two of the initial theories of motor learning include:
Adams closed loop theory: The first attempt at the creation of a comprehensive motor learning theory with
the premise of sensory feedback as an ongoing process for the nervous system to compare current movement with
stored information on memory of past movement; high emphasis on the concept of practice.
Schmidts schema theory: this theory was created in response to the limitations of the closed loop theory. Its
main construct relies on open loop control processes and a motor program concept; promotes clinical value to
feedback and importance of variation with practice.

Three Stage Model of Motor Learning:

Cognitive Stage: This is the initial stage of learning where there is a high concentration of conscious processing of
information. The person will acquire information regarding the goal of the activity and being to problem solve as to
how to attain the goal. A controlled environment is ideal for learning during this stage and participation is a must for
the person to progress.
Characterized by:
-large amount of errors
-inconsistent attempts
-repetition of effort allows for improvement in strategies
-inconsistent performance
-high degree of cognitive work: listening, observing, and processing feedback

Associative Stage: This is the intermediate stage of learning where a person is able to more independently
distinguish correct versus incorrect performance. The person is linking the feedback that has been received with the
movement that has been performed and the ultimate goal. A controlled environment is helpful but at this stage, the
person can progress to a less structured or more open environment. Avoid excessive external feedback as the
person should have improved internal or proprioceptive feedback for the task at hand.
Characterized by:
-decreased errors with new skill performance
-decreased need for concentration and cognition regarding the activity
-skill refinement
-increased coordination of movement
-large amount of practice yields refinement of the motor program surrounding the activity
Autonomous Stage: this is the final stage of learning or skilled learning where a person improves the efficiency of
the activity without a great need for cognitive control. The person can also perform the task with interference from a
variable environment.
Characterized by:
-automatic response
-mainly error-free regardless of environment
-distraction does not impact the activity
-the person can simultaneously perform more than one task if needed
-extrinsic feedback should be very limited or should not be provided
-internal feedback or self-assessment should be dominant
Feedback: is imperative for the progression of motor learning. A pt will rely on both intrinsic and extrinsic feedback
as it relates to movement. Feedback allows for correction and adaptation within the environment. Current research
supports reducing the extrinsic feedback (fading of feedback) in order to ultimately enhance learning.
Intrinsic
(inherent
feedback):

Represents all feedback that

comes to the person through
sensory systems as a result of
the movement including visual,
vestibular, proprioceptive, and
somatosensory inputs.

Extrinsic
(augmented)
feedback:

Knowledge of
results:

Knowledge of
performance:

Represents the information

that can be provided while a
task or movement is in
progress or subsequent to the
movement. This is typically in
the form of verbal feedback or
manual contacts.
Is an important form of
extrinsic feedback and includes
terminal feedback regarding
the outcome of a movement
that has been performed in
relation to the movements
goals.
Is extrinsic feedback that
relates to the actual movement
pattern that someone used to
achieve their goal of
movement.

Practice: refers to repeated performance of an activity in order to learn or perfect a skill. Physical practice allows
for direct physical experience and kinesthetic stimulation to assist with acquisition of the skill. Mental practice is the
cognitive rehearsal of a task or experience without any physical movement.

Massed
practice:
Distributed
practice:
Constant
practice:
Variable
practice:
Random

The practice time in a trial is greater than

the amount of rest between trials
The amount of rest time between trials is
equal to or is greater than the amount of
practice time for each trial
Practice of a given task under a uniform
condition
Practice of a given task under differing
conditions
Varying practice amongst different tasks

practice:
Blocked
practice:
Whole
training:
Part training:

Consistent practice of a single task

Practice of an entire task
Practice of an individual component or
selected components of a task

Key terminology:
Closed system
model:

Compensation:
Habituation:
Learning:
Non-associative:
Associative:
Procedural:

Declarative:
Motor learning:

This is characterized by transfer of information that

incorporates multiple feedback loops and larger distribution of
control. In this model, the nervous system is seen as an active
participant with the ability to enable the initiation of
movement as opposed to solely reacting to stimuli.
The ability to utilize alternate motor and sensory strategies due
to an impairment that limits the normal completion of a task.
The decrease in response that will occur as a result of
consistent exposure to non-painful stimuli.
The process of acquiring knowledge about the world that leads
to a relatively permanent change in a persons capability to
perform a skilled action.
A single repeated stimulus (habituation, sensitization)
Gaining understanding of the relationship between two stimuli,
causal relationships or stimulus and consequence (classical,
operant conditioning)
Learning tasks that can be performed without attention or
concentration to the task; a task is learned by forming
movement habits (developing a habit through repetitive
practice)
Requires attention, awareness, and reflection in order to attain
knowledge that can be consciously recalled (internal practice)
The ability to perform a movement as a result of internal
processes that interact with the environment and produce a
consistent strategy to generate the correct movement. It is the

Motor program:

Open system
model:
Performance:

Plasticity:
Postural control:
Recovery:
Sensitization:
Strategy:

acquisition of, or modification of movement.

A concept of a central motor pattern that can be activated by
sensory stimuli or central processes. Motor programs are seen
as containing the rules for creating spatial and temporal
patterns of motor activity needed to carry out a given motor
task.
This is characterized by a single transfer of information without
any feedback loop (reflexive hierarchial theory). In this theory,
the nervous system is seen as awaiting stimuli in order to react.
A temporary change in motor behavior seen during a particular
session of practice that is a result of many variables, however,
only one variable is focusing on the act of learning.
Performance is not an absolute measure of learning since there
are multiple variables that potentially affect performance.
The ability to modify or change at the synapse level either
temporarily or permanently in order to perform a particular
function.
The ability of the motor and sensory systems to stabilize
position and control movement.
The ability to utilize previous strategies to return to the same
level of functioning.
The increase in response that will occur as a result of a noxious
stimuli.
A plan used to produce a specific result or outcome that will
influence the structure or system.

Carr & Shepherd: Motor Relearning Approach:

An approach developed by Janet Carr and Roberta Sheperd in the 1970s that targets normal movement and how it
is relearned after neurological insult. Carr and Shepherds construct is that factors that are involved with learning are
also involved with relearning and should include:
Identification of a goal
inhibition of any unnecessary activity that does not relate to normal movement
the ability to adjust during activity to the effects of gravity and balance

proper body alignment

proper motivation
incorporate internal or mental practice as well as external or physical practice
feedback
knowledge of results
A significant construct of this approach is centered around a therapists observation of the pt during examination in
order to identify the variations in normal movement. Through critical assessment, the therapist is able to identify
components of movement that are missing or abnormal and the corresponding interventions. Treatment relies on
techniques inherent to this approach as well as other various approaches to neurological rehab. Intrinsic feedback
through sensory, visual, proprioceptive or tactile channels as well as external feedback through an observer is
necessary for the pt to influence their progress towards their goals.

Key terminology:
Closed motor skill: a skill that is performed under a stable and unchanging environment
Knowledge of results: providing the pt with external feedback regarding a pts performance of a task. This can
include observations as well as objective data and can be positive or negative in nature with the goal of influencing
the learner.
Open motor skill: a skill that is performed under a consistently changing environment
Transfer of learning: An action cannot be separated from the environment that is performed in. A pt must be able
to transfer the skill or motor task into different environments.
Bobath: Neuromuscular Development Treatment (NDT):
An approach developed by Karl and Berta Bobath based on the hierarchical model of neurophysiologic function.
Abnormal postural reflex activity and abnormal muscle tone are caused by the loss of central nervous system control
at the brainstem and spinal cord levels. The concept recognizes that interference of normal function within the brain
caused by central nervous system dysfunction leads to a slowing down or cessation of motor development and the
inhibition of righting reactions, equilibrium reactions, and automatic movements. The pt should learn to control
movement through activities that promote normal movement patterns that integrate function.
New assumptions that have been incorporated into NDT resulting from current motor control research include:

Postural control can be learned and modified through experience

Postural control uses both feedback and feed-forward mechanisms for execution of tasks
Postural control is initiated from a pts base of support
Postural control is required for skill development
Postural control develops by assuming progressive positions in which there is an increase in the distance between
the center of gravity and base of support; the base of support should also decrease
Key Terminology:
Facilitation: a technique utilized to elicit voluntary muscular contraction
Inhibition: a technique utilized to decrease excessive tone or movement
Key points of control: specific handling of designated areas of the body (shoulder, pelvis, hand, and foot) will
influence and facilitate posture, alignment, and control
Placing: the act of moving an extremity into a position that the pt must hold against gravity
Reflex inhibiting posture: Designated static positions that Bobath found to inhibit abnormal tone influences and
reflexes.
Brunnstrom: Movement therapy in Hemiplegia
Movement therapy in hemiplegia developed by Singe Brunnstrom is based on the hierarchical model by Hughlings
Jackson. This approach created and defined the term synergy and initially encouraged the use of synergy patterns
during rehab. The belief was to immediately practice synergy patterns and subsequently develop combinations of
movement patterns outside of the synergy. Synergies are considered primitive patterns that occur at the spinal cord
level as a result of the hierarchial organization of the central nervous system. Reinforcing synergy patterns is rarely
utilized now as research has indicated that reinforced synergy patterns are very difficult to change. Brunnstrom
developed the seven stages of recovery, which are used for evaluation and documentation of pt progress.
Key Terminology:
-Associated reaction: an involuntary and automatic movement of a body part as a result of an intentional active or
resistive movement in another body part
-Homolateral synkinesis: a flexion pattern of the involved upper extremity facilitates flexion of the involved lower
extremity.
-Limb synergies: a group of muscles that produce a predictable pattern of movement in flexion or extension
patterns.
-Raimistes phenomenon: the involved LE will abduct with applied resistance to the uninvolved LE in the same
direction

-Souques phenomenon: Raising the involved UE above 100 with elbow extension will produce extension and
abduction of the fingers
Seven Stages of Recovery:
Stage 1:
Stage 2:
Stage 3:
Stage 4:

Stage 5:
Stage 6:
Stage 7:

No volitional movement
initiated
The appearance of basic limb
synergies. The beginning of
spasticity.
The synergies are performed
voluntarily; spasticity increases
Spasticity beings to decrease.
Movement patterns are not
dictated solely by limb
synergies.
A further decrease in spasticity
is noted with independence
form limb synergy patterns.
Isolated joint movements are
performed with coordination
Normal motor function is
restored.

Kabat, Knott, and Voss: Proprioceptive Neuromuscular Facilitation (PNF)

PNF was introduced in the early 1950s using the hierarchial model as its framework. The original goal of treatment
was to establish gross motor patterns within the central nervous system. This approach is based on the premise that
stronger parts of the body are utilized to stimulate and strengthen the weaker parts. Normal movement and posture
is based on a balance between control of antagonist and agonist muscle groups. Development will follow the normal
sequence through a component of motor learning. This theory places great emphasis on manual contacts and
correct handling. Short and concise verbal commands are used along with resistance throughout the full movement
pattern. The PNF approach utilizes methods that promote or hasten the response of the NM mechanism through
stimulation of the proprioceptors. Movement patterns follow diagonals or spirals that each possess a flexion,
extension, and rotary component and are directed toward or away from midline.

Key Terminology:
-Chopping: a combination of bilateral UE asymmetrical patterns performed as a closed chain activity
-Developmental sequence: a progression of motor skill acquisition. The stages of motor control include mobility,
stability, controlled mobility, and skill.
-Mass movement patterns: the hip, knee, and ankle move into flexion or extension simultaneously
-Overflow: muscle activation of an involved extremity due to intense action of an involved muscle or group of
muscles
Upper Extremity:
D1 Flexion: flexion/adduction/external rotation; verbal cues:close your hand, turn, and pull your arm across your
face. (grabbing earring)
D1 Extension: extension/abduction/internal rotation; verbal cues: open your hand, turn, and push your arm down
and out. (throwing earring away)
D2 Flexion: flexion/abduction/external rotation; verbal cues: open your hand, turn and lift your arm up and out.
(sword drawn)
D2 Extension: extension/adduction/internal rotation; verbal cues: close your hand, turn, and pull your arm down
and across your body. (put sword in holder)
Lower Extremity:
D1 Flexion: flexion/adduction/external rotation; verbal cues: bring your foot up, turn, and pull your leg up and
across your body (frog sit)
D1 Extension: extension/abduction/internal rotation; verbal cues: push your foot down, turn, and push your leg
down and out.
D2 Flexion: flexion/abduction/internal rotation; verbal cues: lift your foot up, turn, and lift your leg up and out.
D2 Extension: extension/adduction/external rotation; verbal cues: push your foot down, turn, and pull your leg
down and in.

Levels of Motor Control:

Mobility:
Stability:

The ability to initiate movement through

a functional range of motion
The ability to maintain a position or
posture through co- contraction and

Controlled
mobility:

Skill:

tonic holding around a joint.

Unsupported sitting with midline control
is an example of stability.
The ability to move within a weight
bearing position or rotate around a long
axis. Activities in prone on elbows or
weight shifting in quadruped are
examples of controlled mobility.
The ability to consistently perform
functional tasks and manipulate the
environment with normal postural reflex
mechanisms and balance reactions. Skill
activities include ADLs and community
locomotion.

PNF Therapeutic Exercise Descriptions:

Agonistic
Reversals (AR)

Alternating
Isometrics (AI)

Contract-Relax
(CR)

Controlled mobility, skill: An

isotonic concentric contraction
performed against resistance followed
by alternating concentric and eccentric
contractions with resistance. AR
requires use in a slow and sequential
manner, and may be used in
increments throughout the range to
attain maximum control.
Stability: Isometric contractions are
performed alternating from muscles on
one side of the joint to the other side
without rest. AI emphasizes endurance
or strengthening.
Mobility: a technique used to increase
ROM. As the extremity reaches the
point of limitation, the pt performs a
maximal contraction of the
antagonistic muscle group. The

Hold-relax (HR)

Hold-Relax Active
Movement
(HRAM)

Joint Distraction

therapist resists movement for 8-10

seconds with relaxation to follow. The
technique is repeated until no further
gains in ROM are noted during the
session.
Mobility: an isometric contraction
used to increase ROM. The contraction
is facilitated for all muscle groups at
the limiting point in the ROM.
Relaxation occurs and the extremity
moves through the newly acquired
range to the next point of limitation
until no further increases in ROM occur.
The technique is often used for pts that
present with pain.
Mobility: a technique to improve
initiation of movement to muscle
groups tested at 1/5 or less. An
isometric contraction is preformed
once the extremity is passively placed
into a shortened range within the
pattern. Overflow and facilitation may
be used to assist with the contraction.
Upon relaxation, the extremity is
immediately moved into a lengthened
position of the pattern with a quick
stretch. The pt is asked to return the
extremity to the shortened position
through an isotonic contraction.
Mobility: a proprioceptive component
used to increase ROM around a joint.
Consistent manual traction is provided
slowly and usually in combination with
mobilization techniques. It can also be
used in combination with a quick
stretch to initiate movement.

Normal Timing
(NT)

Repeated
contractions (RC)

Resisted
Progression (RP)

Rhythmic
Initiation (RI)

Rhythmical
Rotation (RR)

Skill: a technique used to improve

coordination of all components of a
task. NT is performed in a distal to
proximal sequence. Proximal
components are restricted until the
distal components are activated and
initiate movement. Repetition of the
pattern produces a coordinated
movement of all components.
Mobility: a technique used to initiate
movement and sustain a contraction
through the ROM. RC is used to initiate
a movement pattern, throughout a
weak movement pattern or at point of
weakness within a movement pattern.
The therapist provides a quick stretch
followed by isometric or isotonic
contractions.
Skill: a technique used to emphasize
coordination of proximal components
during gait. Resistance is applied to an
area such as the pelvis, hips, or
extremity during the gait cycle in order
to enhance coordination, strength or
endurance.
Mobility: a technique used to assist in
initiating movement when hypertonia
exists. Movement progresses from
passive let me move you to active
assistive help me move you, to
slightly resistive move against the
resistance. Movements must be slow
and rhythmical to reduce the
hypertonia and allow for full ROM.
Mobility: a passive technique used to
decrease hypertonia by slowly rotating

Rhythmic
Stabilization (RS)

Slow Reversal
(SR)

Slow Reversal
Hold (SRH)

Timing for
Emphasis (TE)

an extremity around the longitudinal

axis. Relaxation of the extremity will
increase ROM.
Mobility, stability: a technique used
to increase ROM and coordinate
isometric contractions. The technique
requires isometric contractions of all
muscles around a joint against
progressive resistance. The pt should
relax and move into the newly acquired
range and repeat the technique. If
stability is the goal, RS should be
applied as a progression from AI in
order to stabilize all muscle groups
simultaneously around the specific
body part.
Stability, controlled mobility, skill:
A technique of slow and resisted
concentric contractions of agonists and
antagonists around a joint without rest
between reversals. This technique is
used to improve control of movement
and posture.
Stability, controlled mobility, skill:
Using slow reversal with the addition
of an isometric contraction that is
performed at the end of each
movement in order to gain stability.
Skill: used to strengthen the weak
component of a motor pattern. Isotonic
and isometric contractions produce
overflow to weak muscles.

Rood:
This theory is based on Sherrington and the reflex stimulus model. Rood believed that all motor output was the
result of both past and present sensory input. Treatment is based on sensorimotor learning. It takes into account the

autonomic nervous system and emotional factors as well as motor ability. Rood used a developmental sequence,
which was seen as key patterns in the enhancement of motor control. A goal of this approach is to obtain
homeostasis in motor output and to activate muscles to perform a task independent of a stimulus. Exercise is seen
as a treatment technique only if the response is correct and if it provides sensory feedback that enhances the motor
learning of that response. Once a response is obtained during treatment, the stimulus should be withdrawn. Rood
introduced the use of sensory stimulation to facilitate or inhibit responses such as icing, and brushing in order to
elicit desired reflex motor responses.
Sensory Stimulation techniques:
Facilitation
-Approximation
-Joint
compression
-Icing
-Light touch
-Quick stretch
-Resistance
-Tapping
-Traction

Inhibition
-Deep pressure
-Prolonged stretch
-Warmth
-Prolonged cold

Key Terminology:
Heavy work: a method used to develop stability by performing an activity (work) against gravity or resistance.
Heavy work focuses on the strengthening of postural muscles.
Light work: a method used to develop controlled movement and skilled function by performing an activity (work)
without resistance. Light work focuses on the extremities.
Key patterns: a developmental sequence designed by Rood that directs pts mobility recover from synergy patterns
through controlled motion.

Integumentary Examination:
Foundational Science: Integ is the bodys largest organ. The avascular epidermis is the most superficial layer of
skin. The dermis, known as the true skin, is well vascularized, and is characterized as elastic, flexible, and tough.

Key functions: Protection, sensation, thermoregulation, excretion of sweat, vitamin D synthesis

Phases of Normal wound Healing: Normal wound healing occurs as damaged tissues move through distinct yet
overlapping phases of repair. In chronic wounds, this progression is either interrupted or delayed causing the wound
to become stuck in a particular phase of healing.
Inflammatory Phase (1-10 days)

Proliferative Phase (3-21 days)

Maturation Phase (7 days - 2 years)

Inflammation is the immune systems

initial response to a wound. Temporary
repair mechanisms rapidly re-establish
hemostasis through platelet activation
and the clotting cascade. Debris and
necrotic tissue are removed and bacteria
are killed by mast cells, neutrophhils,
and leukocytes. Processes occurring in
the inflammatory phase establish a clean
wound bed which signals tissue
restoration and permanent repair
processes to begin. Re-epithelialization
typically begins within 24 hours at the
wound borders, though visible signs are
usually not observed earlier than 3 days
after injury.
The formation of new tissue signals the
beginning of the proliferative phase.
Capillary buds and granulation tissue
begin to fill the wound bed creating a
support structure for the migration of
epithelial cells. Keratinocytes,
endothelial cells, and fibroblasts are
active and the collagen matrix is formed.
Skin integrity is restored in the
proliferative phase with wound closure
occurring through epithelialization and
wound contraction.
The maturation, or remodeling phase is
initiated when granulation tissue and

epithelial differentiation being to appear

in the wound bed. As the maturation
phase progresses, mechanisms of fiber
reorganization and contraction shrink
and thin the scar. An immature scar will
appear red, raised, and rigid while a
mature scar will appear pale, flat, and
pliable. Scar tissue is remodeled and
strengthened though the processes of
collagen lysis and synthesis. Newly
repaired tissues have approximately 15%
of pre-injury tensile integrity and should
be protected to prevent re-injury. Over
time, tensile integrity may increase as
much as 80% of the pre-injury strength.
Hypertrophic scarring, especially in
relation to burn injuries, can significantly
impact maturation phase progression. A
burn without hypertrophic scarring will
typically mature within 4-8 weeks; burns
with hypertrophic scarring, however,
may require up to two years to reach
maturity.
Wound Types:
Acute wounds
Abrasion
Avulsion
Incisional
wound

Is a wound caused by a combination of friction and shear forces,

typically over a rough surface, resulting in the scraping away of the
skins superficial layers.
A soft tissue avulsion, sometimes referred to as degloving, is a serious
wound resulting from tension that causes skin to come detached from
underlying structures.
Is most often associated with surgery and is created intentionally by
means of a sharp object such as a scalpel or scissors.

Laceration

Penetratin
g
Puncture

Skin tear

Is a wound or irregular tear of tissues often associated with trauma.

Lacerations can result from shear, tension, or high force compression
with the resultant wound characteristics dependent on the mechanism
of injury.
Can result from various mechanisms of injury and is described as a
wound that enters the interior of an organ or cavity.
Is made by a sharp pointed object as it penetrates the skin and
underlying tissues. Typically, there is relatively little tissue damage
beyond the wound tract, however, the risks of contamination and
infection can be significant.
Often results from trauma to fragile skin such as bumping into an
object, adhesive removal, shear or friction forces. The severity of a skin
tear can range from a flap like tear, that may or may not remain viable,
to full-thickness tissues loss.

Ulcers:
Type
Arterial Insufficiency
Ulcers

Description
Wounds resulting from
arterial insufficiency occur
secondary to inadequate
circulation of oxygenated
blood (ischemia) often due
to complicating factors
such as atherosclerosis.

Venous Insufficiency
Ulcers

Wounds resulting from

venous insufficiency occur
secondary to impaired
functioning of the venous
system resulting in
inadequate circulation and
eventual tissue damage
and ulceration.

Recommendations
-Rest, limb protection, risk
reduction education,
inspect legs and feet daily,
avoid unnecessary leg
elevation, avoid using
heating pads or soaking
feet in hot water, wear
appropriately sized shoes
with clean, seamless socks
-Limb protection, risk
reduction education,
inspect legs & feet daily,
compression to control
edema, elevate legs above
the heart when resting or
sleeping, attempt active
exercise including

Neuropathic Ulcers

Are a secondary
complication usually
associated with a
combination of ischemia
and neurophathy.
Neuropathic ulcers are
often associated with
diabetes mellitus,
however, any form of
peripheral neuropathy
poses an increased risk of
wound development
Also referred to as
decubitus ulcers, result
from sustained or
prolonged pressure on
tissue at levels greater
than that of capillary
pressure. Skin covering
bony prominences is
particulary susceptible to
localized ischemia and
tissue necrosis due to
pressure. Pressure injury
risk assessment tools
(Braden Scale, Norton
Scale)

Pressure Ulcers

frequent ROM, wear

appropriately sized shoes
with clean, seamless socks
-Limb protection, risk
reduction education,
inspect legs and feet daily,
inspect footwear for debris
prior to donning, wear
appropriately sized offloading footwear with
clean, cushioned,
seamless socks

-Repositioning every 2
hours in bed,
management of excess
moisture, off-loading with
pressure relieving devices,
inspect skin daily for signs
of pressure damage, limit
shear and friction forces
over fragile skin

Characteristics of LE Ulcers:
Location

Arterial Ulcers
Lower one third of

Venous Ulcers
Proximal to the

Neuropathic Ulcers
Areas of the foot

leg, toes, web

spaces, dorsal foot,
lateral malleolus

medial malleolus

Appearance

Smooth edges, well

defined, lack of
granulation tissue,
tend to be deep

Irregular shape,
shallow

Exudate
Pain

Minimal
Severe

Moderate/heavy
Mild to moderate

Pedal pulses

Diminished or
absent

Normal

Edema
Skin Temp
Tissue changes

Normal
Decreased
Thin and shiny,
hair loss, yellow
nails

Increased
Normal
Flaking, dry skin,
brownish
discoloration

Miscellaneous

Leg elevation
increases pain

Leg elevation
lessens pain

susceptible to
pressure or shear
forces during
WBing
Well-defined oval
or circle, callused
rim; cracked
periwound tissue;
little to no wound
bed necrosis with
good granulation
Low/moderate
None, however
dysesthesia may
be reported
Diminished or
absent, unreliable
ankle-brachial
index with diabetes
Normal
Decreased
Dry, inelastic, shiny
skin, decreased or
absent sweat and
oil production
Loss of protective
sensation

Wound Assessment
Wound Classification by depth of injury:
*Wounds that are not categorized as pressure or neuropathic ulcers (skin tears, surgical wounds, venous statisis
ulcers) are classified based on the depth of tissue loss.
Superficial wound:

Causes trauma to the skin with the epidermis remaining intact,

Partial-thickness
wound:

Full-thickness
wound:
Subcutaneous
wound:

such as with a non-blistering sunburn. A superficial wound will

typically heal as part of the inflammatory process.
Extends through the epidermis and possibly into, but not
through the dermis. Examples include abrasions, blisters, and
skin tears. A partial thickness wound will typically heal by reepithelialization or epidermal resurfacing depending on the
depth of injury.
Extends through the dermis into deeper structures such as
subcutaneous fat. Wounds deeper than 4 mm are typically
considered full thickness and heal by secondary intention.
Subcutaneous wounds extend through integumentary tissues
and involve deeper structures such as subcutaneous fat,
muscle, tendon or bone. Subcutaneous wounds typically
require healing by secondary intention.

Primary intention: Most common in acute wounds with minimal tissue loss. Smooth clean edges are reapproximated
and closed with sutures, staples, or adhesives. Typically have minimal scarring, and heal quickly in uncomplicated
progression. Examples: surgical incision, laceration, puncture, and superficial & partial thickness wounds.
Secondary Intention: Permits wounds to close on their own without superficial closure. Wounds with characteristics
such as significant tissue loss or necrosis, irregular on nonviable wound margins that cant be reapproximated,
infection or debris contamination. Require ongoing wound care and have larger scars. Examples: neuropathic,
arterial, venous or pressure ulcers, most full thickness wounds, and chronically inflamed wounds.
Tertiary Intention: AKA delayed primary intention. Wounds at risk for developing complications such as sepsis or
dehiscence, may be temporarily left open. Once risk factors have been alleviated, the wound is closed by the usually
primary intention methods.

Wagner Ulcer Grade Classification Scale

Grad
e
0

Description
No open lesion, but may possess pre-ulcerative lesions; healed ulcers;
presence of bony deformity

1
2
3
4
5

Superficial ulcer not involving subcutaneous tissue

Deep ulcer with penetration through the subcutaneous tissue, potentially
exposing bone, tendon, ligament or joint capsule
Deep ulcer with osteitis, abscess or osteomyelitis
Gangrene of digit
Gangrene of foot requiring disarticulation

Pressure Ulcer Staging

*A pressure ulcer describes a localized injury to the skin and/or underlying tissue usually over a bony prominence, as
a result of pressure or pressure in combination with shear/friction forces.
Stage I

StageII

Stage III

Stage IV

Intact skin with non-blanchable redness of a localized area usually over a

bony prominence. Darkly pigmented skin may not have visible blanching,
but instead present as local coloration differing from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as compared to
adjacent tissue. Stage 1 may be difficult to detect in individuals with dark
skin tones.
Partial-thickness tissue loss of the dermis presenting as a shallow open
ulcer with red or pink wound bed. May present as an intact or ruptured
serum filled blister or presents as a shiny or dry shallow ulcer without
slough or bruising. This stage should not be used to describe skin tears,
tape burns, perineal dermatitis, maceration or excoriation.
Full-thickness tissue loss. Subcutaneous fat may be visible but tone,
tendon or muscle are not exposed. Slough may be present, but does not
obscure the depth of tissue loss. May include undermining and tunneling.
Bone and tendon are not visible or directly palpable. The depth of a stage
III pressure ulcer varies by anatomical location. For example, a stage III
ulcer on the bridge of the nose, ear, occiput, and malleolus, where there is
not significant subcutaneous tissue, can be quite shallow. In contract, areas
with significant adipose tissue can develop extremely deep stage III
pressure ulcers.
Full-thickness tissue loss with exposed bone, tendon or muscle that is
visible or directly palpable. Slough or eschar may be present on some parts
of the wound bed. Undermining and tunneling may be present. Stage IV

Suspecte
d Deep
tissue
injury

Unstagea
ble

ulcers can extend into muscle and supporting structures (fascia, tendon,
joint capsule) making osteomyelitis possible.
Purple or maroon localized areas of intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure/and or shear forces. The
area may be preceded by tissue that is painful, firm, mushy, boggy,
warmer or cooler compared to adjacent tissue. Deep tissue injury may be
difficult to detect in individuals with dark skin tones. The evolution may
include a thin blister over a dark wound bed. The wound may further
evolve and become covered by thin eschar. Evolution may be rapid,
exposing additional layers of tissue even with optimal treatment.
Full-thickness tissue loss in which the base of the ulcer is covered by
slough (yellow, gray, green, or brown) and or eschar (tan, brown, or black)
in the wound bed. Until enough slough and/or eschar is removed to expose
the base of the wound, the true depth, and therefore stage, cannot be
determined. Stable (dry, adherent, intact without erythema or fluctuating
appearance) eschar on the heels serve as the bodys natural (biological)
cover and should not be removed.

Exudate Classification:
Serous
Sanguineous

Serosanguine
ous
Seropurulent

Presents with a clear, light color and a thin, watery consistency. Serous
exudates is considered to be normal in a healthy healing wound and is
observed during the inflammatory and proliferative phases of healing.
Presents with a red color and a thin, watery consistency. The red
appearance of sanguineous exudates is due to the presence of blood
which may become brown if allowed to dehydrate. Sanguineous exudates
may be indicative of new blood vessel growth or the disruption of blood
vessels.
Presents with a light red or pink color and a thin, watery consistency.
Serosanguineous exudates is considered to be normal in a healthy healing
wound and is typically observed during the inflammatory and proliferative
phases of healing.
Presents as cloudy or opaque, with a yellow or tan color and a thin, watery
consistency. Seropurulent exudates may be an early warning sign of an
impending infection and is always considred an abnormal finding.

Purulent

Presents with a yellow or green color and a thick, viscous consistency.

Purulent exudates is generally an indicator of wound infection and is
always considered an abnormal finding.

Necrotic Tissue Types:

*Necrotic tissue is dead tissue resulting from the localized physiological and enzymatic changes associated with cell
death. Necrotic tissue is often documented and named by the specific type observed, and may also be referred to as
devitalized or nonviable tissue.
Eschar
Gangrene

Hyperkerat
osis
Slough

Described as dark or leathery, black/brown, dehydrated tissue that tends to

be firmly adhered to the wound bed.
Refers to death and decay of tissue resulting from an interruption of blood
flow to an area of the body. Some types of gangrene are also characterized
by the presence of bacterial infection. Gangrene most commonly affects the
extremities, but can also occur in muscles and internal organs.
Also referred to a callus, is typically white/gray in color and can vary in
texture from firm to soggy depending on the moisture level in surrounding
tissue.
Described as moist, stringy or mucinous, white/yellow tissue that tends to
be loosely attached in clumps to the wound bed.

Red-Yellow-Black System
Red

Color

Wound Description
Pink granulation tissue

Yellow

Most, yellow slough

Black

Black, thick eschar firmly

attached

Wound Terminology:

Goals
Protect wound, maintain
moist environment
Remove exudates and
debris; absorb drainage
Debride necrotic tissue

Contusion
Dehiscence
Dermis
Desiccated
Desquamatio
n
Ecchymosis

Epidermis
Erythema
Friable
Hematoma
Hypergranula
tion
Hyperpigment
ation
Hypertrophic
scar

An injury, usually caused by a blow, that does not disrupt skin integrity.
The injury is characterized by pain, edema, and discoloration which
appears as a result of blood seepage under the surface of the skin.
The separation, rupture or splitting of a wound closed by primary
intention. This disruption of previously approximated surfaces may be
superficial or involve all layers of tissue.
The vascular layer of skin located below the epidermis containing hair
follicles, sebaceous glands, sweat glands, lymphatic and blood vessels,
and nerve endings.
The drying out or dehydration of wound. Desiccation often results from
poor dressing selection that does not control the evaporation of wound
bed moisture.
The peeling or shedding of the outer layers of the epidermis.
Desquamation normally occurs in small scales, although certain injuries
and conditions, and medications may cause peeling in larger scales or
sheets and extend to deeper layers of skin.
The discoloration occurring below intact skin resulting from trauma to
underlying blood vessels and blood seeping into tissues. The
discoloration is typically blue-black, changing in time to a greenish brown
or yellow color. An area where ecchymosis is present is commonly
referred to as a bruise.
The superficial, avascular epithelial layer of the skin that includes flat,
scale-like squamous cells, round basal cells, and melanocytes which
produce melanin and give skin its color.
A diffuse redness of the skin often resulting from capillary dilation and
congestion or inflammation.
Tissue that readily tears, fragments or bleeds when gently palpated or
manipulated.
A localized swelling or mass of clotted blood confined to a tissue, organ
or space usually caused by a break in a blood vessel.
Increased thickness of the granular layer of the epidermis that exceeds
the surface height of the skin.
An excess of pigment in a tissue that causes it to appear darker than
surrounding tissues.
An abnormal scar resulting from excessive collagen formation during
healing. A hypertrophic scar is typically raised, red, and firm with

Keloid

Maceration
Normotrophic
scar
Turgor
Ulcer

disorganized collagen fibers.

An abnormal scar formation that is out of proportion to the scarring
required for normal tissue repair and is comprised of irregularly disturbed
collagen bands. A keloid scar typically exceeds the boundaries of the
original wound appearing red, thick, raised, and firm.
The skin softening and degeneration that results from prolonged
exposure to water and other fluids.
Characterized by the organized formation of collagen fibers that align in a
parallel fashion.
The relative speed with which the skin resumes its normal appearance
after being lightly pinched. Turgor is an indicator of skin elasticity and
hydration and normally occurs more slowly in older adults.
An open sore or lesion of the skin accompanied by sloughing of inflamed
necrotic tissue.

Types of Burns:
Thermal burns
Electrical burns

Chemical burns

Radiation burns

Caused by conduction or convection. Ex: hot liquid, fire or steam

Caused by the passage of electrical current through the body.
Typically there is an entrance and an exit wound. Complications
can include cardiac arrhythmias, respiratory arrest, renal failure,
neurological damage, and fractures. Ex. Lightning
Occurs when certain chemical compounds come in contact with
the body. The reaction will continue until the chemical is diluted at
the site of contact. Sulfuric acid, lye, hydrochloric acid, and
gasoline are examples.
Occurs most commonly with exposure to external beam radiation
therapy. DNA is altered in exposed tissues and ischemic injury
may be irreversible. Complications may include severe blistering
and desquamation, non-healing wounds, tissue fibrosis,
permanent discoloration, and new malignancies.

Zones of Injury:
Zone of

The area of the burn that received the most severe injury with

coagulation
Zone of stasis
Zone of
hyperemia

irreversible cell damage.

The area of less severe injury that possesses reversible damage
and surrounds the zone of coagulation.
The area surrounding the zone of stasis that presents with
inflammation, but will fully recover without any intervention or
permanent damage.

Burn Classification:
Superficial
Burn
Superficial
PartialThickness Burn
Deep PartialThickness Burn

Full thickness
burn
Subdermal
Burn

Involves only the outer epidermis, Area may be red with slight
edema. Healing occurs without peeling or evidence of scarring in
2-5 days.
Involves the epidermis and the upper portion of the dermis. The
involved area may be extremely painful and exhibit blisters.
Healing occurs with minimal to no scarring in 5-21 days.
Involves complete destruction of the epidermis and the majority of
the dermis. The involved area may appear to be discolored with
broken blisters and edema. Damage to nerve endings may result in
only moderate levels of pain. Hypertrophic or keloid scarring may
occur. In the absence of infection, healing will occur in 21-35 days.
Involves complete destruction of the epidermis and dermis along
with partial damage to the subcutaneous fat layer. Healing varies
within weeks, with or without grafting, and/or months to heal.
Involves the complete destruction of the epidermis, dermis, and
subcutaneous tissue. Subdermal burns may involve muscle and
bone and as a result, often require multiple surgical interventions
and extensive healing time.

Rule of Nines:
Head and neck
Anterior trunk
Posterior trunk
Bilateral
anterior arm,

9%
18%
18%
9%

forearm &
hand
Bilateral
posterior arm,
forearm, &
hand
Genital region
Bilateral
anterior leg
and foot
Bilateral
posterior leg
and foot

9%

1%
18%
18%

Integumentary Pathology:
Pathology

What is it

Etiology

Cellulitis

Is a fast
spreading
inflammation
that occurs as
a result of a
bacterial
infection of the
skin and
connective
tissues. It can
develop
anywhere
under the skin,
but will

Caused by a
particular
bacterial
infections
including strep
or staph.
Predisposing
factors to
cellulitis include
an increased
age,
immunosuppres
sion, trauma,
the presence of

Signs &
Symptoms
Localized
redness that
may spread
quickly, skin
that is warm or
hot to touch,
local abscess
of ulceration,
tenderness to
palpation,
chills, fever,
and malise

Treatment
Should be
immediately
referred to a
physician for
further
assessment.
Cellulitis
requires
pharmacologic
al intervention
using systemic
antibiotics.
Differential
diagnosis

Contact
dermatitis

Eczema

typically affect
the
extremities.

wounds or
venous
insufficiency.

Is a superficial
irritation of the
skin resulting
from localized
irritation
(poison ivy,
latex, soap,
jewelry,
sensitivity).
This condition
can be acute
or chroic based
on exposure to
the
precipitating
agent. Contact
dermatitis is a
very common
skin disease
that can occur
at any age.
AKA
dermatitis. Is
used to

Occurs with
exposure to
mechanical,
chemical,
environmental
or biological
agents. Nickel,
rubber, latex
and topical
antibiotics are
common agents.

Intense
itching,
burning and
red skin in
areas
corresponding
to the location
of the
irritation.

Is based on the
particular form
of the disorder.

Red or browngray, itchy,

lichenified skin

should attempt
to rule out DVT
and contact
dermatitis. PT
may be
warranted for
wound care.
Cellulitis can
lead to sepsis
or gangrene if
not properly
treated.
Focus should
be on
identifying and
removing the
source of
irritation.
Topical steroid
application is
commonly
employed.

Pharmacologic
al
interventions

Gangrene
(Dry)

Gangrene
(wet)

describe a
group of
disorders that
cause chronic
skin
inflammation
typically due
to an immune
system
abnormality,
allergic
reaction or
external
irritant.
When there is
a loss of
vascular
supply
resulting in
local tissue
death. Fingers,
toes, and limbs
are most
affected.
Typically
develops
slowly and
results in autoamputation.
If there is an
associated
bacterial
infection in the
affected tissue.
Swelling
resulting from

Infants and
children are at a
high risk for
eczema but may
outgrow it.

plaques that
may be
exacerbated
by some
topical agents
such as soaps
and lotions.
Oozing and
crusting of the
patchy occurs
in younger
population.

are variable
from topical to
oral. Cold
compresses
and other
modalities may
assist with
reducting the
itching.
Extreme temps
should be
avoided.

Occurs most
commonly in
blood vessel
disease, such as
DM or
atherosclerosis.
It develops when
blood flow to an
affected area is
impaired,
typically as a
result of poor
circulation.

Dark brown or
black
nonviable
tissue that
eventually
becomes a
hardened
mass. Pt will
complain of
cold or numb
skin and they
may present
with pain.

Serious
medical
condition and
requires
immediate
medical
intervention.
Tx includes
pharmacolocial
intervention,
surgery, and
hyperbaric
oxygen
therapy.

Can develop
after a severe
burn, frostbite or
injury and
requires
immediate
treatment since

Swelling and
pain at the site
of infection,
change in skin
color from red
to brown to
black, blisters

Serious
medical
condition and
requires
immediate
intervention.
Surgical

Onychomycosi
s

Plaque
psoriasis

the bacterial
infection
causes a
sudden
stoppage of
blood flow.
Refers to a
fungal
infection that
primarily
affects the
toenails &
nailbeds.

Autoimmune
disease of the
skin and is
most common
of the 5 types
of psoriasis. T
cells trigger
inflammation
within the skin
and produce
an accelerated

it tends to
spread very
quickly and can
be fatal.

that produce
pus, fever, and
general
malaise

Acquiring a
fungal infection
is a common
occurrence. Risk
factors include
manicures and
pedicures with
unsterile
utensils,
possessing nail
injuries or
deformities,
excess skin
moisture,
wearing closed
toe shoes, and
an impaired
immune
response.
Genetic
predisposition to
plaque psoriasis.
Other factors
may trigger
psoriasis, such
as injury to the
skin, insufficient
or excess
sunlight, stress,
excessive

Yellow or
brown nail
discoloration;
hyperkeratosis
and
hypertrophy of
the nail
causing it to
partially
detach from
the nailbed.

Red raised
blotches that
typically
present in a
bilateral
fashion (over
both knees or
elbows). Tend
to itch and
flake.

debridement
and
intravenous
antibiotic
treatment are
typical.
Manual
debridement of
the nail and
topical
antifungal
medications
are primary.

Control
symptoms and
prevent
secondary
infection.
Lifelong
condition that
can be
effectively
managed and
controlled

Tinea pedis

rate of skin cell

growth. The
skin cells
accumulate in
raised red
patches on the
surface of the
skin.
Athletes foot.
Is a superficial
fungal
infection which
causes
epidermal
thickening and
a scaly skin
appearance.
This fungus is
opportunistic
and will rapidly
multiply in a
warm and
most
environment
(between the
toes)

alcohol, HIV
infection,
smoking, and
certain
medications.

Wearing closed
toed shoes that
dont allow
airflow,
prolonged
periods of
moisture or
wetness,
excessive
sweating, and
possessing small
nail or skin
abrasions. This
infection is
contagious
through direct
contact.

through the
various stages
and
exacerbations.

Itching,
redness,
peeling skin
between the
toes, pain,
odor, and in
more severe
cases breaks in
skin continuity

Pharmacologic
al
management
includes
topical or oral
antibiotics
depending on
the severity of
symptoms.
May persist or
recur and more
long-term
management
may be
required.
Prevention
includes drying
of the feet
when bathing
or swimming,
wearing
sandals around
public pools or
showers,
changing socks
frequently,
proper
hygiene, and

avoiding shoe
wear that
creates a moist
environment.
Integumentary Pathologies:
Patholo
gy

Diagnosi
s

FullThickne
ss Burn

This
severe
burn
causes
immediat
e cellular
and tissue
death and
subseque
nt
vascular
destructio
n.
Indicates
complete
destructio
n of the
epidermis
, dermis,
hair
follicle,
and nerve
endings,
within the
dermis;

Contribut
ing
Factor
75% of
burns are
a direct
result from
the pts
actions.
Higher risk
for burns
in children
between 1
& 5 years
as well as
individuals
over 70.
Burns are
currently
the third
leading
cause of
accidental
death in
all age
categories
with males
having a

Clinical
Presentatio
n
Characterized
by a variable
appearance
of deep red,
black or white
coloring.
Eschar form
from necrotic
cells and
creates a dry
and hard
layer that
requires
debridement.
Edema is
present at the
site of injury
and in
surrounding
tissues. Hairs
within this
region of the
burn are
easily pulled
from the

Lab/Imagi
ng

Management/Ou
tcome

Blood work
should
include a
complete
blood
count,
electrolyte
s, blood
urea
nitrogen,
creatinine,
bilirubin,
and arterial
blood
gases. This
will
indicate
baseline
data,
systemic
changes,
level of
shock, and
metabolic
complicatio

Initial
management
includes medically
stabilizing the pt.
This emergent
phase lasts 48-72
hours and
concludes with
regaining capillary
permeability and
hemodynamic
stability. An
autograft
procedure is
usually required
for full-thickness
burns. The rehab
phase is a long
term commitment
that includes all
aspects of
functional recover.
PT begins
immediately
following skin

and also
affects
the
subcutan
eous fat
layer and
underlyin
g
muscles,
resulting
in red
blood cell
destructio
n.

higher
overall
frequency
of injury.

follicle due to
the
destruction.
An area of
full-thickness
burn does not
have
sensation or
pain due to
destruction of
free nerve
endings,
however
there may be
pain from
adjacent
areas that
experience
partialthickness
burns. During
the initial
stages the pt
will
experience
thermoregula
tion
impairment,
SOB,
electrolyte
disturbances,
poor urine
output, and
variation in
level of
consciousnes

ns.
Bronchosco
py &
pulmonary
function
tests may
be
indicated
to assess
airway
damage
and
pulmonary
insufficienc
y.

grafting and
includes wound
care, pulmonary
exercises,
positioning,
splinting, and
immobilization for
the first 3-5 days.
Early ambulation
and mobility
activities should
be incorporated as
soon as possible in
order to decrease
complications.
Continued PT
should involve
edema control,
monitoring of any
elastic garments,
massage,
stretching,
hydrotherapy,
ROM,
debridement,
relaxation
techniques,
progressive
exercise,
ambulation, and
functional mobility
training. The
mortality rate has
decreased over
the last 2 decades
due to

s.

Pressure
Ulcer

Ischemia
to the
site,
subseque
nt cell
death,
and tissue
necrosis.
A
definition
of
unrelieve
d

Can occur
at any
time
secondary
to
unrelieved
pressure,
but there
are certain
population
s and risk
factors
that are

A pt will
usually
develop a
pressure
ulcer over a
bony
prominence
with common
sites
including the
greater
trochanter,
ischium,

A diagnosis
is made
from visual
inspection,
however,
blood
studies
such CBC,
electrolyte,
and protein
levels, as
well as
tests for

improvement in
burn care.
Mortality rates are
highest for
children under 4
and adults over
65. Overall
prognosis is
dependent on
factors such as
cardiac pathology,
alcoholism, PVD,
and obesity.
Garments may be
worn up to 2 years
after injury.
Without significant
complications a pt
should achieve
independence
within a few
months post
injury.
Pt and caregiver
education for the
prevention of
subsequent
pressure ulcers is
very important
and should include
skin inspection,
positioning, and
pressure relief
techniques. Seat
cushions,
multipodus boots

pressure
is >32mm
Hg of
pressure
to an area
for more
than 2
hours.

associated
with its
developme
nt.
Immobility
is a
leading
factor and
seen in pts
with SCI,
paralysis,
hemiplegia
, impaired
cognition,
poor
nutrition,
altered
sensation,
incontinen
ce,
decreased
lean body
mass, and
infection.

sacrum, and
heel. A stage
I is classified
as an area of
nonblanchabl
e erythema of
intact skin.
State II is
classified as a
partial
thickness
wound
involving the
epidermis,
dermis, or
both. Does
not extend
through the
entire dermis.
Stage III is
classified as
an ulcer that
extended into
subcutaneous
tissue, but
not through
fascia. Stage
IV is classified
as an ulcer
that extends
through the
fascia and
deeper. It is a
full-thickness
wound that
may damage

baceremia
or sepsis
may be
indicated.
Urinalysis
and stool
samples
may be
indicated
to
determine
contributin
g factors in
the
developme
nt of the
ulcer.
Coagulatio
n studies
and tissue
sampling
may also
be
indicated.
The Braden
Scale,
Gosnell
Scale, or
Norton
Scale along
with
baseline
measurem
ent of size
and depth
of the

or specialized
mattresses is also
an important
aspect of care of
ulcers. Dressing
for the ulcer may
include
nonocclusive or
occlusive types.
Nonocclusive
include dry to dry,
wet to wet, wet to
dry or composite
dressings.
Occlusive
dressings include
semipermeable
films,
hydrocollooids,
hydrogels,
semipermeable
foams, and
alginates. A
general exercise
program should be
provided daily. Pts
should avoid the
use of hot water
and the use of
massage
surrounding the
site. Therapist
should promote
proper positioning
techniques (such
as positioning of

muscles,
bones,
ligaments
and/or
tendons.

ulcer.

the bed at less

than 45 angle) in
order to decrease
friction and shear.
Approx 60,000 pts
die annually due
to secondary
complications
from ulcers.
However, many
people that
develop a
pressure ulcer
completely
recover with no
residual
impairments.

Types of Dressings:
Dressings may be defined as either primary or secondary. A primary dressing is one that comes into direct contact
with a wound. A number of primary dressings include a self-adhesive backing and not require a secondary dressing.
Secondary dressings are placed directly over the primary dressing to provide additional protection, absorption,
occlusion, and/or to secure the primary dressing in place.
Type
Hydrocolloids:
Consist of gelforming polymers
(carboxymethylcell
ulose, gelatin,
pectin) backed by a
strong film or foam
adhesive. The
dressing does not

Indications
Hydrocolloids are
useful for partial
and full-thickness
wounds. The
dressings can be
used effectively
with granular or
necrotic wounds.

Advantages
-Provides a moist
environment for
wound healing
-Enables autolytic
debridement
-Offers protection
from microbial
contamination
-Provides moderate

Disadvantages
-May traumatize
surrounding intact
skin upon removal
-May tend to roll in
areas of excessive
friction
-Cannot be used on
infected wounds

attach to the wound

itself but instead
anchors to the
intact surrounding
skin. The dressings
absorb exudates by
swelling into a gellike mass and vary
in permeability,
thickness, and
transparency.
Hydrogels: Consist
of varying amounts
of water and gelforming materials
such as glycerin.
The dressings are
typically available
in both sheet and
amorphous forms.

Foam Dressings:
Are comprised of a
hydrophilic
polyurethane base
that contacts the
wound surface and
a hydrophobic outer
layer. The dressings
allow exudates to

absorption
-Does not require a
secondary dressing
-Provides a
waterproof surface

Hydrogels are
moisture retentive
and commonly
used on superficial
and partialthickness wounds
(abrasions, blisters,
pressure ulcers)
that have minimal
drainage.

Foam dressings are

used to provide
protection and
absorption over
partial and fullthickness wounds
with varying levels
of exudates. They
can also be used as

-Provides a moist
environment for
wound healing
-Enables autolytic
debridement
-May reduce
pressure and
diminish pain
-Can be used as a
coupling agent for
ultrasound
-Minimally adheres
to wound
-Some products
have absorptive
properties
-Provide a moist
environment for
wound healing
-Available in
adhesive and nonadhesive forms
-Provides
prophylactic
protection and

-Potential for
dressing to
dehydrate
-Cannon be used
on wounds with
significant drainage
-Typically requires a
secondary dressing

-May tend to roll in

areas of excessive
friction
-Adhesive form
may traumatize
periwound area
upon removal
-Lack of
transparency

be absorbed into
the foam through
the hydrophilic
layer. The dressings
are most commonly
available in sheets
or pads with
varying degrees of
thickness.
Semipermeable
foam dressings are
produced in
adhesive and nonadhesive forms.
Non-adhesive forms
require a secondary
dressing.
Transparent Film:
Film dressings are
thin membranes
made from
transparent
polyurethane with
water-resistant
adhesives. The
dressings are
permeable to vapor
and oxygen, but are
largely
impermeable to
bacteria and water.
They are highly
elastic, conform to
a variety of body
contours, and allow
easy visual

secondary
dressings over
amorphous
hydrogels.

cushioning
-Encourages
autolytic
debridement
-Provides moderate
absorption

makes inspection
of wound difficult

Film dressings are

useful for
superficial or
partial-thickness
wounds with
minimal drainage
(scalds, abrasion,
lacerations)

-Provides a moist
environment for
wound healing
-Enables autolytic
debridement
-Allows
visualization of the
wound
-Resistant to
shearing and
frictional forces
-Cost effective over
time

-Excessive
exudates
accumulation can
result in periwound
maceration
-Adhesive may
traumatize
periwound area
upon removal
-Cannot be used on
infected wounds

inspection of the
wound since they
are transparent.
Gauze:
Manufactured from
yarn or thread and
are the most readily
available dressing
used in inpatient
environments.
Gauze dressings
come in many
shapes and sizes
(sheets, squares,
rolls, packing
strips).
Impregnated gauze
is a variation of
woven gauze in
which various
materials such as
petroalatum, zinc or
anitmicrobials have
been added).
Alginates: Are
derived from a
seaweed
extraction,
specifically, the
calcium salt
component of
alginic acid.
Alginates are highly
absorptive, but are
also highly
permeable and

Gauze dressings
are commonly used
on infected or noninfected wounds of
any size. The
dressings can be
used for wet-towet, wet-to-moist
or wet-to-dry
debridement.

-Readily available
and cost effective
short-term
dressings
-Can be used alone
or in combination
with other
dressings and
topical agents
-Can modify
number of layers to
accommodate for
changing wound
status
-Can be used on
infected or noninfected wounds

-Has a tendency to
adhere to the
wound bed
traumatizing viable
tissue on removal
-Highly permeable
-Requires frequent
dressing changes
-Prolonged use
decreases cost
effectiveness
-Increased infection
rate compared to
occlusive dressings

Alginates are
typically used on
partial or fullthickness draining
wounds such as
pressure or venous
insufficiency ulcers.
Alginates are often
used on infected
wounds due to the
likelihood of
excessive

-High absorptive
capacity
-Enables autolytic
debridement
-Offers protection
from microbial
contamination
-Can be used on
infected or noninfected wounds
-Non-adhering to
wound

-May require
frequent dressing
changes based on
level of exudates
-Requires a
secondary dressing
-Cannot be used on
wounds with an
exposed tendon,
joint capsule or
bone

non-occlusive. As a
result, they require
a secondary
dressing. Alginate
dressings act as a
hemostat and
create hydrophilic
gel through the
interaction of
calcium ions in the
dressing and
sodium ions in the
wound exudate.

drainage.

Dressings from
Most Occlusive to
Non-Occlusive
Hydrocolloids
Hydrogels
Semipermeable
foam
Semipermeable film
Impregnated gauze

Dressings from
Most to Least
Moisture
Retentive
Alginates
Semipermeable
foams
Hydrocolloids
Hydrogels
Semipermeable
films

Alginates
Traditional gauze
Topical Agents Used in Burn Care:

Topical Agent
Silver Sulfadiazine

Silver Nitrate

Povidone-iodine

Mafenide Acetate

Advantages
-Can be used with or
without dressings
-Painless
-Can be applied to wound
directly
-Broad-spectrum
-Effective against yeast
-Broad-spectrum
-Non-allergenic
-Dressing application is
painless

-Broad-spectrum
-Penetrates burn eschar
-May be used with or
without occlusive
dressings
-Broad-spectrum
-Penetrates burn eschar
-May bused with or
without occlusive
dressings

Gentamicin

-Broad-spectrum
-May be covered or left
open to air

Nitrofurazone

-Bacteriocidal
-Broad-Spectrum

Disadvantages
-Does not penetrate into
eschar

-Poor penetration
-Discolors, making
assessment difficult
-Can cause severe
electrolyte imbalances
-Removal of dressings is
painful
-Not effective against
pseudomonas
-May impair thyroid
function
-Painful application
-May cause metabolic
acidosis
-May compromise
respiratory function
-May inhibit
epithelizlization
-Painful application
-Has caused resistant
strains
-Ototoxic
-Nephrotoxic
-May lead to overgrowth of
fungus and pseudomonas
-Painful application

Selective Debridement- involves the removal of only nonviable tissue.

 Sharp Debridement- requires the use of a scalpel, scissors, and/or forceps to selectively remove devitalized tissue,
foreign material or debris from a wound. Sharp debridement is most often used for wounds with large amounts of
thick, adherent, necrotic tissue; however, it may be used in the presence of cellulitis or sepsis.
Enzymatic Debridement- refers to the topical application of an enzymatic preparation to necrotic tissue. Enzymatic
debridement can be used on infected and non-infected wounds with necrotic tissue. Enzymatic debridement can be
slow to establish a clean wound bed and should be discontinued once devitalized tissue is removed to avoid damage
to adjacent healthy tissue.
Autolytic Debridement- refers to the use of the bodys own mechanisms to remove nonviable tissue. Common
methods of autolytic debridement include the use of transparent films, hydrocolloids, hydrogels, and alginates.
Autolytic debridement develops a moist wound environment that rehydrates necrotic tissue and eschar, facilitating
enzymatic digestion of the nonviable tissue.
Non-selective Debridement- involves the removal of viable and nonviable tissue.
Wet-to-dry Dressings- refers to the application of moistened gauze dressing over an area of necrotic tissue. The
dressing is allowed to dry completely and is later removed, along with any necrotic tissue that has adhered to the
gauze. Wet to dry dressing are most commonly used on moderate amounts of exudate and necrotic tissue. This type
of debridement should be used sparingly on wounds containing both necrotic and viable tissue since granulation
tissue will be traumatized during the process.
Wound irrigation- Removes necrotic tissue from the wound bed using pressurized fluid. Pulsatile levage is an
example of wound irrigation that uses a pressurized stream of irrigation solution. This type of debridement is most
desirable for wounds that are infected or have loose debris.
Hydrotherapy- is most commonly employed using a whirlpool tank with agitation directed toward a wound requiring
debridement. This process softens and loosens adherent necrotic tissue. PT must be aware of potential hydrotherapy
side effects such as maceration of viable tissue, edema from dependent lower extremity positioning, and systemic
effects such as hypotension.

Skin Care Products

Therapeutic Moisturizers- Lotions are largely water-based and best used to replace skin moisture that has been
lost either to the air or as a result of frequent hand washing. Creams are thicker water-based substances with higher
concentrations of solids and oils than lotions.

Moisture Barriers- (e.g., ointment) Moisture barriers are designed to adhere to the skin and repel excess moisture
from protected areas. They are frequently used to protect surrounding skin from a heavily draining wound or
perineal tissue from exposure to incontinence.

Liquid Skin Portectants- (e.g., skin sealant) Liquid skin protectant is applied to skin and when dry it creates a thin
plastic film protecting the skin from adhesive-related tissue damage. This thin barrier also offers some degree of
moisture protection.

Skin Cleansers- skin cleansers are liquid agents typically intended for use on the skin of patients at risk of
breakdown. Ingredients often have pH-balancing component that is especially beneficial for perineal cleansing in
patients who are incontinent.

Wound Cleansers- Wound cleansers vary from simple saline solutions to more complex compositions with
cytotoxicity. Many wound cleansers have the potential to cause inflammation; however, this quality is product
dependent. Wound cleansers are not typically designed to remove necrotic tissue, but rather associated wound
substances such as foreign materials, exudate and dried blood.
Integumentary Interventions:
Selective debridement: removal of only the nonviable tissues from a wound.
Sharp
Debridement:

Enzymatic
Debridement:

Requires the use of a scalpel, scissors, and/or

forceps to selectively remove devitalized tissue,
foreign material or debris from a wound. Sharp
debridement is most often used for wounds with
large amounts of thick, adherent, necrotic tissue,
however, it may also be used in the presence of
cellulitis or sepsis. Sharp debridement is the most
expedient form of removing necrotic tissue. PTs
are permitted to perform sharp, selective
debridement as a procedural intervention.
Refers to the topical application of an enzymatic
preparation to necrotic tissue. Enzymatic
debridement can be used on infected and noninfected wounds with necrotic tissue. This type of
debridement may be used for wounds that have
not responded to autolytic debridement or in

Autolytic
Debridement:

conjunction with other debridement techniques.

Enzymatic can be slow to establish a clean wound
bed and should be discontinued once devitalized
tissue is removed to avoid damage to adjacent
healthy tissue.
Refers to the use of the bodys own mechanism to
remove nonviable tissue. Common methods
include the use of transparent films, hydrocolloids,
hydrogels, and alginates. Autolytic debridement
establishes a moist wound environment that
rehydrates necrotic tissue and eschar, facilitating
enzymatic digestion of the nonviable tissue. This
type of debridement can be used with any amount
of necrotic tissue, however, requires a longer
healing period and should be not be performed on
infected wounds.

Non-selective Debridement (mechanical): involves the removal of both viable and nonviable tissue from a wound.
Wet-to-dry
dressings

Wound Irrigation

Refer to the application of a moistened gauze

dressing over an area of necrotic tissue. The
dressing is allowed to dry completely and is later
removed, along with any necrotic tissue that has
adhered to the gauze. Wet to dry dressings are
most often used to debride wounds with moderate
amounts of exudates and necrotic tissue. This type
of debridement should be used sparingly on
wounds containing both necrotic and viable tissue
since granulation tissue will be traumatized in the
process. Removal of dry dressings from
granulation may cause bleeding and be extremely
painful.
Removes necrotic tissue from the wound bed
using pressurized fluid. Pulsatle lavage is an
example of wound irrigation that uses a
pressurized stream of irrigation solution. This type

Hydrotherapy

of debridement is most desirable for wounds that

are infected or have loose debris. Many devices
permit variable pressure settings and provide
suction for the removal of exudates and debris.
Is most commonly employed using a whirlpool
tank with agitation directed toward a wound
requiring debridement. This process softens and
loosens adherent necrotic tissue. PTs must be
aware of potential hydrotherapy side effects such
as maceration of viable tissue, edema from
dependent LE positioning and systemic effects
such as hypotension.

Modalities & Physical Agents:

Modality

Indications

Negative
Pressure
Wound
Therapy
(NPWT): also
referred to as
vacuumassisted
closure (V.A.C)
is a noninvasive
wound care
modality used
to facilitate
healing and
manage
drainage. A
sterile foam
dressing is

Chronic or
acute wounds
which cannot
be closed by
primary
intention such
as dehisced
surgical
incisions, fullthickness
wounds,
partialthickness
burns, heavily
draining
granular
wounds, flaps,
grafts, and
most ulcer

Contraindicat
ions
Malignancy
within the
wound,
insufficient
vascularity to
sustain wound
healing, large
amounts of
necrotic tissue
with eschar
present,
untreated
osteomyelitis,
fistulas to
organs or body
cavities,
exposed
arteries or
veins, and

Advantages
-Provides
management
of wound
drainage
-Maintains a
moist wound
environment
-Decreases
interstitial
edema
-Decreasees
bacterial
colonization
-Increases
capillary blood
flow
-Increases
granular tissue
formation

Disadvantage
s
-Requires
special
supplies and
training
-Treatment can
be painful
-Not
reimbursed in
acute or longterm care
settings

placed in the
wound and
sealed with an
airtight
secondary
dressing which
attaches via
tubing to a
vacuum pump
with a
reservoir
container.
Treatment
protocols vary
depending on
wound
characteriscis.

types.

uncontrolled
pain

-Enhances
epithelial cell
migration

Hyperbaric
Oxygen:
refers to the
inhalation of
100% oxygen
delivered at
pressures
greater than
one
atmosphere.
Hyperbaric
oxygen
treatment is
delivered in a
closed
chamber

Osteomyelitis,
diabetic
wounds, crush
injuries,
compartment
syndromes,
necrotizing soft
tissue
infections,
thermal burns,
radiation
necrosis, and
compromised
flaps and
grafts.

Terminal
illness,
untreated
pneumothorax,
active
malignancy,
pregnancy,
seizure
disorder,
emphysema,
and use of
certain
chemotherapy
agents

-Antibiotic
effects
-Stimulation of
fibroblast
production and
collagen
synthesis
-Stimulation of
growth factor
release and
epithelializatio
n

-Specialized
equipment is
not widely
available
-Cannot be
used with
active
malignancy

typically at
pressures 2-3x
that of the
atmosphere,
effectively
reducing
edema and
hyperoxygenat
ing tissues.
Growth
Factors: used
in wound
healing and
are derived
from naturally
occurring
protein factors.
These
substances
facilitate
healing by
stimulating the
activity of
specific cell
types
(neutrophils,
endothelial
cells,
fibroblasts).
Currently, only
a limited
number of
growth factors
have been
approved by
the FDA for

Neuropathic
ulcers
extending into
or through
subcutaneous
tissue with
adequate
circulation to
sustain wound
healing.

Wounds closed
by primary
intention, pts
with known
hypersensitivit
y to any
component of
the product or
a history of
neoplasm at
the application
site.

-Adjunct to
promote
wound healing
environment
-Increases
growth rate of
new tissue
-Promotes cell
division

-Costly
-Poor
reimbursement
-Additional
research is
needed
-Secondary
dressing
required
-Requires
refrigeration
-Limited
number of
products

topical wound
healing
applications.
Burns:
Pathophysiology:
1. Burn Injury: results from thermal, chemical, electrical, or radioactive agents
2. Burn wound, consists of 3 zones:
a. Zone of coagulation: cells are irreversibly injured, cell death occurs
b. Zone of stasis: cells are injured; may die without specialized treatment, usually within 24-48 hours
c. Zone of hyperemia: minimal cell injury; cells should recover
3. Degree of burn: Burns are classified by severity, layers of skin damage
Rule of 9s:
-Head and neck: 9%
-Anterior trunk: 18%
-Posterior trunk: 18%
-Arms: 9% each
-Legs: 18% each
-Perimeum: 1%
Classification by percentage of body area burned:
1. Critical: 10% of body with third degree burns and 30% or more with second degree burns; complications
common (respiratory involvement, smoke inhalation)
2. Moderate: less than 10% with third-degree burns and 15% to 30% with second degree burns.
3. Minor: less than 2% with third degree burns and 15% with second degree burns.
Complications of burn injury:
1. Infection: leading cause of death; gangrene may develop
2. Shock
3. Pulmonary complications: Smoke inhalation of hot smoke results in pulmonary edema and airway obstruction;
suspect with burns of the face, singed nose hairs; pneumonia
4. Metabolic complications
5. Cardiac and circulatory complications
6. Integumentary scars

Burn Management:
1. Emergency care: Immersion in cold water. If less than half the body is burned and injury is immediate; cold
compresses may also be sued. Cover burns with sterile bandage or clean cloth; no ointments or creams.
2. Medical management
a. Asepsis and wound care:
b. Removal of charred clothing
c. Wound cleansing
d. T
e. Topical medications reapplied one to 3 times daily (Ointments: bacitracin, polymyxin B, and Neomycin);
Silver sulfadiazine: common topical agent, avoid at term pregnancy, on infants less than 2 months, and
those with sulfa drug allergies.
f. Dressings: prevents bacterial contamination, prevents fluid loss, and protects the wound. May
additionally limit ROM. Dressings include: silver-impregnated, and gauze dressing
g. Estabiilsh and maintain airway, adequate oxygenation, and respiratory function
h. Monitor: arterial blood gases, serum electrolyte levels, urinary output, vital signs
i. GI function: provide nutritional support
j. Pain relief: morphine sulfate
k. Prevention and control of infection: tetanus prophylaxis, antibiotics, standard precatution
l. Fluid replacement therapy: prevention and control of shock. Post shock fluid and blood replacement
m. Surgery: Grafts closure of the wound
i. Allograft (homograft)-use of other human skin; cadaver skin; temporary grafts for large burns,
used until autograft is available
ii. Xenograft (heterograft)-use of skin from other species (pig skin) a temporary graft
iii. Biosynthetic grafts: combination of collagen and synthetics
iv. Cultured skin: laboratory grown form pts own skin
v. Autograft: use of pts own skin
vi. Split-thickness graft: contains epidermis and upper layers of dermis from donor site
vii. Full-thickness graft: contains epidermis and dermis from donor site
Rehab: Prevent or reduce the complications of immobilization.
1. Exercises to promote deep breathing and chest expansion; ambulation to prevent pneumonia
2. Positioning and splinting to prevent or correct deformities.
a. Anterior neck: common deformity is flexion; stress hyperextension; position with firm (plastic)
cervical orthosis

b. Shoulder: common deformity is adduction and internal rotation; stress abduction, flexion, and
external rotation; position with an axillary splint (airplane splint).
c. Elbow: common deformity is flexion and pronation in extension with posterior arm splint.
d. Hand: common deformity is a claw hand (intrinsic minus position); stress extension (15), MP flexion
(70), PIP, and DIP extension, thumb abduction (intrinsic plus position) with resting hand splint.
e. Hip: common deformity is flexion and adduction; stress hip extension and abduction; position in
extension, abduction, neutral rotation.
f. Knee: common deformity is flexion; stress extension; position in extension with posterior knee splint.
g. Ankle: common deformity is plantar flexion; stress dorsiflexion; position with foot-ankle in neutral
with splint or plastic ankle-foot orthosis.
3. Edema control: elevation of extremities, active ROM.
4. Active and passive exercise to promote full ROM.
a. Combine with dressing changes, hydrotherapy; medication doses
b. Post grafting: discontinue exercise for 3-5 days to allow grafts to heal
c. Massage to help reduce scar formation; eg deep friction massage
d. Resistive and strengthening exercises to correct loss of muscle mass and strength.
e. Increase activity tolerance and cardiovascular endurance (ambulation)
f. Promote independence in ADLs, all functional mobility skills
g. Elastic supports to help control edema; pressure garments to help prevent hypertrophic scarring or
keloid formation
h. Management of chronic pain.
5. Provide emotional support

1. Edema management:
a. Leg elevation and exercise (ankle pumps)
b. Compression therapy; to facilitate movement of excess fluid from lower extremity
c. Compression wraps: elastic or tubular bandages
d. Paste bandages; Unna boot is a pliable, nonstretchable dressing impregnanted with ainc or calamine
and gelatin
e. Compression stockings, e.g. Jobst
f. Compression pump therapy
2. Electrical Stimulation for wound healing:
a. Used to improve circulation, facilitate debridement, and enhance tissue repair
b. Continuous waveform application with direct current

c. High-voltage pulsed current

d. Pulsed biphasic current
3. Nutritional considerations:
a. Delayed wound healing associated with malnutrition and poor hydration
b. Albumin: normal is 3.5-5.5 mg/dl; less than 3.5=malnutrition
c. BMI <21 with weight loss increased risk for pressure ulcer
d. Provide adequate hydration
e. Individuals with wounds require approximately 3 or more liters of water a day
f. Pts on air-fluidized beds require greater hydration (40-60 ml/Kg a day)
g. Provide adequate nutrition: frequent high calorie/high-protein meals; energy intake (25-35
kcal/kg/bodyweight) and protein 1.5-2.5 gm/kg body weight)
h. Patients with trauma stress and burns require higher intakes.
4. Injury prevention or reduction
a. Daily, comprehensive skin inspection, paying particular attention to bony prominences (sacrum, coccys,
trochanter, ischial tuberosities, medial and lateral malleolus)
b. Therapeutic positioning to relieve pressure and allow tissue reperfusion.
i. In bed: turning or repositioning every 2 hours during acute and rehab phases
ii. In wheelchair: wheelchair pushups every 15 minutes
c. Use techniques to ensure skin protection, avoid friction, shear, or abrasion injury
i. Lifting, not dragging
ii. Use of turning and draw sheets; trapeze, manual, or electric lifts
iii. Use of corn starch, lubricants, pad protectors, thin film dressings, or hydrocolloid dressings over
friction risk sites.
iv. Use of transfer boards for sliding wheelchair transfers
d. Pressure-relieving devices (PRDs):
i. Reduce tissue interface pressures
ii. Static devices: use if pt can assume a variety of positions, examples: foam, air, or gel mattress
overlays; whater-filled mattresses; pillows or foam wedges, protective padding (heel relief boots)
iii. Dynamic devices: use if pt cannot assume a variety of positions; examples: alternating pressure
air mattresses, fluidized air or high-air-loss bed.
iv. Seating supports: use for chair-bound or wheelchair bound pts; examples: cushions made out of
foam, gel, air, or some combination
e. Avoid restrictive clothing; e.g. with rough textures, hard fasteners, and studs. Avoid tight-fitting shoes,
socks, splints, and orthoses.
f. Avoid maceration injury

i. Prevent moisture accumulation and temperature elevation where skin contacts support surface.
ii. Incontinence management strategies: use of absorbent pads, brief or panty pad, scheduled
toileting, and prompted voiding, ointments, creams, and skin barriers prophylactically in perineal
and perianal areas.
g. Pt and caregiver education:
i. Mechanisms of pressure ulcer development
ii. Daily skin inspection and hygiene
iii. Avoidance of prolonged positions
iv. Repositioning, weight shifts, lifts
v. Safety awareness during self-care
vi. Safety awareness with use of devices and equipment
vii. Importance of ongoing activity/exercise program

Metabolic and Endocrine Systems:

The metabolic system governs the chemical and physical changes that take place within the body enabling it to
grow and function. Metabolism involves breakdown of the bodys complex organic compounds in order to generate
energy for all bodily processes. It also generates energy for the synthesis of complex substances that form tissues
and organs. During metabolism, organic compounds are broken down by a process called catabolism, while
anabolism is the process that combines simple molecules for tissue growth. Many metabolic processes are
facilitated by enzymes. The overall speed at which an organism carries out its metabolic processes is termed its
metabolic rate (or when the organism is at rest, its basal metabolic rate).

Metabolic System Pathology:

Metabolic disorders are classified by the particular building block that is affected. An enzyme deficiency leads to
accumulation of the substrate and a subsequent deficiency in the intended enzymes product. There are many
different disorders that can occur genetically and these are grouped according to the substrate that has been
affected (carbohydrates, amino acids). Inherited metabolic disorders can be diagnosed in utero via aminocentesis or
chorionic villus sampling. Many inherited metabolic disorders will produce symptoms in a newborn including

lethargy, apnea, poor feeding, tachypnea, vomiting, hypoglycemia, urine changes, and seizures. Symptoms that are
immediately apparent indicate a more dangerous disorder.
Pathology

What is it

Phenylketonuri
a (amino
acid/organic
acid metabolic
disorder

Phenylketonuri
a (PKU) is a
syndrome that
consist of
mental
retardation as
well as
behavioral and
cognitive
issues
secondary to
an elevation of
serum
phenylalanine.
There is a
deficiency in
the enzyme
phenylalanine
hydroxylase.
Normally,
excessive
phenlalanine is
converted to
tyrosine by
phenylalanine
hydroxylase.
When this
process does
not occur and
there is an
excess of

Etiology
This is an
autosomal
recessive
inherited trait
and is most
common in
Caucasian
populations

Signs &
Symptoms
Symptoms will
typically
present within
a few months
of birth as the
phenylalanine
accumulates. If
left untreated,
severe mental
retardation will
occur. These
children may
also
experience
gait
disturbances,
hyperactivity,
psychoses,
abnormal body
order, and
display
features that
are lighter in
coloring when
compared to
other family
memberse.

Treatment
Treated
through
dietary
restriction of
phenylalaine
throughout the
persons
lifetime.
Adequate
prevention will
avoid all
manifestations
of the disease.

Tay-Sachs
Disease
(lysosomal
storage
disorder)

Mitochondrial

phenylalanine,
the brain is the
primary organ
that becomes
affected.
Children in the
US are tested
at birth for PKU
and levels
greater than
6mg/dl of
phenylalanine
require some
form of
treatment.
Is the absence
or deficiency
of
hexosaminidas
e A. This
produces an
accumulation
of gangliosides
(GM2) within
the brain.

There are over

This disease is
an autosomal
recessive
inherited trait
and carried
primarily in the
Eastern
European
(Ashkenazi)
Jewish
population.

Result from

At approx. 6
months of age,
the child will
start to miss
developmental
milestones and
will continue to
deteriorate in
motor and
cognitive skills.
As symptoms
progress, the
pt develops
significant
mental
retardation
and paralysis,
and will usually
die by the age
of 5.
Symptoms

There is
currently no
effective
treatment for
this condition.
Genetic testing
in high risk
populations to
identify the
carriers prior
to pregnancy is
important in
order to avoid
this disorder.

These

Disorders

100 different
forms of
mitochondrial
disease and
each produces
a different
spectrum of
disability and
clinical
manifestations
.

genetically
inherited or
spontaneous
mutations in
the DNA that
lead to
impaired
function of
proteins found
within the
mitochondria.

Wilsons
Disease
(hepatolenticul
ar
degeneration)

Wilsons
disease is a
rare inherited
disorder that is
most common
in eastern
Europeans,
Sicilians, and
southern
Italians, but
may occur in
any group.

An autosomal
recessive
inherited trait
that produces
a defect in the
bodys ability
to metabolize
copper. The
copper
accumulates
over time
within the

vary
depending on
the type of
mitochondrial
disorder,
however, can
include loss of
muscle
coordination,
muscle
weakness,
visual and
hearing
problems,
learning
disabilities,
hear, liver and
kidney
disease,
respiratory,
neurological,
and GI
disorders, and
dementia.
Symptoms
typically
appear
between the
ages of 4 and
6 and include
KayserFleischer rings
surrounding
the iris of the
eye secondary
to copper

diagnoses are
relatively new
and treatment
is varied as the
symptomatolo
gy and
presentation of
the disease.
Treatment is
aimed at
alleviating the
current
symptoms and
slowing the
progression of
the disease
process.

Treatment
consist of
continual
pharmacologic
al intervention
using vitamin
B6 and Dpenicillamine
as both
promote the
excretion of
excess copper

Wilsons
disease
typically
appears in
people under
40 years old
and symptoms
can develop in
children
typically
between 4-6
years of age.

brain, liver,
cornea, kidney,
and other
tissues.

Acid-Base Metabolic Disorders:

deposits,
degenerative
changes in the
brain
(especially
with the basal
ganglia),
hepatitis,
cirrhosis of the
liver, athetoid
movements,
and ataxic gait
patterns. There
may also be
emotional and
behavioral
changes as the
copper
continues to
accumulate.
Overtime, and
with severe
disease, there
will be
deformities of
the MS system,
pathologic
fractures,
osteomalacia,
muscle
atrophy, and
contractures.

form the body.

Treatment will
also focus on
prevention of
hepatic
disease since a
pt will die from
hepatic failure
if the condition
is left
untreated.

The process of metabolism is regulated by the endocrine and nervous systems. The rate of metabolism can be
influenced by body temperature, exercise, hormone activity, and digestion activity. If proper fluid or acid-base
balance is compromised, it can alter metabolic function and cause many signs and symptoms of the dysfunction.
Disorder

What is it

Etiology

Metabolic
Alkalosis

Is a condition
that occurs
when there is
an increase in
bicarbonate
accumulation
or an abnormal
loss of acids.
As a result, the
pH rises above
7.45.

Commonly
occurs when
there has been
continuous
vomiting,
ingestion of
antacids or
other alkaline
substances or
diuretic
therapy. It may
also be
associated
with
hypokalemia
or nasogastric
suctioning.

Metabolic
Acidosis

Is a condition
that occurs
when there is
an
accumulation

Commonly
occurs with
conditions
such as renal
failure, lactic

Signs &
Symptoms
Nausea,
diarrhea,
prolonged
vomiting,
confusion,
muscle
fasciculations,
muscle
cramping,
neuromuscular
hyperexcitabili
ty,
convulsions,
paresthesias,
and
hypoventilatio
n. If left
untreated the
pt can become
comatose,
experience
seizures, and
respiratory
paralysis.
Symptoms
include
compensatory
hyperventilatio
n, vomiting,

Treatment
The most
important
interventions
include
managing the
underlying
cause,
correcting
coexisting
electrolyte
imbalances,
and
administering
potassium
chloride to the
pt.

Managing the
underlying
cause,
correcting any
coexisting

of acids due to
an acid gain or
bicarbonate
loss. As a
result, the pH
drops below
7.35.

acidosis,
starvation,
diabetic or
alcoholic
ketoacidosis,
severe
diarrhea or
poisoning by
certain toxins.

diarrhea,
headache,
weakness, and
malaise,
hyperkalemaia
, and cardiac
arrhythmias. If
left untreated
the continued
increase in
acid can
induce coma
and eventual
death.

electrolyte
imbalances,
and
administering
sodium
bicarbonate.

Other Metabolic conditions: Osteomalacia, Osteoporosis, Pagets Disease (SEE Other chart)
Metabolic System Terminology:
Aerobic
metabolism:
Anabolism:
Adenosine
Triphosphate
(ATP):
Catabolism:
DNA
(deoxyribonuc

The ATP producing metabolic processes that are dependent on

oxygen transported via the circulatory system. Aerobic metabolic
functions typically provide energy for low intensity and/or longer
duration activities.
The metabolic process in which simple molecules (nucleic acids,
polysaccharides, amino acids) are combined to create the complex
molecules (proteins) needed for tissue and organ growth.
The molecular unit within the body which transports the chemical
compounds used for cellular metabolism.
The metabolic process in which complex materials (proteins, lipids)
are broken down in the body for the purpose of creating and
releasing heat and energy.
A double helix molecule that contains the genes that provide the
blueprint for all of the structures and functions of a living bening.

leic acid):
Gene:
Metabolism:

Mitochondria:
Osteopenia:

Osteopetrosis
:
pH:
Pathology
Breast
Cancer

A fundamental unit of heredity.

The physical and chemical processes of cells burning fuel to produce
and use energy. Examples include digestion, elimination of waste,
breathing, thermoregulation, muscular contraction, brain function,
and circulation.
The part of the cell that is responsible for energy production. The
mitochondria are also responsible for converting nutrients into
energy and other specialized tasks.
A condition presenting with low bone mass that is not severe enough
to qualify as osteoporosis. Individuals with osteopenia may not have
actual bone loss, but a naturally lower bone density than established
norms.
A group of conditions characterized by impaired osteoclast function
which causes bone to become thickened but fragile. Osteopetrosis is
an inherited condition that can vary widely in symptoms and
severity.
A measure of the hydrogen ion concentration in body fluid.
Diagnosis

Contributi
ng Factor

A mass that
is composed
of
malignant
altered cells
that
proliferate
and spread
without
control. A
malignancy
can occur
anywhere

Estrogen is
believed to
have some
relationship
to the
disease
process.
Risk factors
include
gender,
age, young
menarche,
late

Clinical
Presentati
on
Breast
cancer
makes up
approx.
30% of all
female
cancers and
is the 2nd
leading
cause of
death in
female
cancers.

Lab/Imagin
g

Management/Out
come

Mammogra
phy is used
to detect
the location
and growth
of a mass,
however
definitive
diagnosis of
breast
cancer is
made only
after

Surgical
management may
range from
excision of the
mass
(lumpectomy) to
total radical
mastectomy with
axillary dissection.
Chemotherapy,
radiation therapy,
and hormone
therapies may

within the
breast
tissue,
however,
the lump is
usually
found
directly
behind the
areola in
men and is
usually
located
behind the
areola or in
the outer
upper
quadrant of
the breast
in women.
There may
or may not
be
generalized
discomfort
in the area.

menopause,
family
history, high
alcohol
intake, high
fat diet,
radiation
exposure,
and past
history of
cancer.
Males
account for
less than
1% of all
breast
cancer
cases.

Approx 70%
of all breast
cancer
occurs in
women over
the age of
50. A pt will
present with
a lump in
the breast
that is
noticed by a
physician
(10%), or by
the pt
through self
examination
(90%).
Breast
cancer is
initially
otherwise
asymptoma
tic. The
breast may
become
painful,
change
shape,
bleed from
the nipple,
and dimple
over the
area of the
mass.

microscopic
examination
of a
suspected
mass by
needle or
excision
biopsy.
Ultrasound
can also be
used to
detect if a
lump is
filled with
fluid or a
solid mass.
Sentinel
lymp node
mapping is
used upon
diagnosis to
identify
exact lymph
node
involvement
.

used. PT may be
indicated to assist
with lymphedema
management, postsurgical breathing
exercises,
positioning, pain
management,
strengthening and
exercises, ROM,
massage,
intermittent
compression, and
pt education. The
risk of recurrence
is always present
and should be
monitored closely.
Overall prognosis
and ten-year
survival rates for
women are over
85% for stage I
disease; 66% for
stage II; 36% for
stage III; and 7%
for stage IV
disease.

Metabolic/Endocrine System Rehab:

Rehab Considerations for pts with Inherited
Metabolic disorders:
-Must have an awareness of dietary
restrictions
-Pt and family training to prevent deleterious
effects from the metabolic disease
-Adapt treatment to facilitate developmental
milestones within pt tolerance
Rehab Considerations for pts with Acid-base
disorders:
-Recognize higher risk populations for
imbalances such as pts with renal,
cardiovascular, pulmonary disease; burns,
fever and sepsis; pts on mechanical
ventilation; diabetes mellitus; pts currently
vomiting with diarrhea or enteric drainage
-Recognize signs of dehydration in a diabetic
pt
-Injury prevention during involuntary
muscular contractions secondary to metabolic
alkalosis
-Recognize that pts using diuretic therapy
may be at risk for potassium depletion
-Recognize that Trousseaus sign during blood
pressure measurements may indicate calcium
deficiency and the early stages of tetany
Rehab considerations for pts with metabolic
bone disease:
-Must have awareness of signs of
compression fx and of pts at higher risk for all
forms of fx

-Focus on both resistance training and

endurance training to build bone density and
increase strength
-Avoid treatments that exacerbate the
condition or place pts at risk for fx
Rehab considerations for pts with Pituitary
Dysfunction:
-Ambulation/exercise encouraged within 24
hours of surgery (post tumor/gland removal)
-Must demonstrate increased awareness for
signs of hypoglycemia
-Bilateral carpal tunnel syndrome, arthritis,
osteophyte formation are common with
hyperpituitarism
-Orthostatic hypotension may be present with
hypopituitarism
-Bilateral hemianopsia that can occur with
hypopituitarism requires special consideration
during treatment
Rehab considerations for pts with adrenal
dysfunction:
-Recognize signs of stress or exhaustion and
avoid treatments that exacerbate the
condition
-Notify the physician with any signs of illness
or increased intracranial pressure
(papilledema), medications may need to be
altered
-Orthostatic hypotension is common
secondary to long term cortisol therapy
-Report sleep disturbances to the physician
-Increased incidence of osteoporosis, bone fx,

degenerative myopathy, tendon ruptures,

ataxic gait
-delayed wound healing may be common
Rehab considerations for pts with thyroid
dysfunction:
-Recognize reduced exercise capacity and
fatigue are typical
-Avoid treatments that exacerbate the
condition such as exercise in a hot acquatic or
gym setting due to heat intolerance (Graves
disease)
-Avoid cardiovascular stress to eliminate
secondary complications from hypotension,
goiter, Graves disease
-Provide close monitoring of vital signs
-Recognize the effects of radioiodine therapy
-Recognize the risk of rhabdomyolysis
(hypothyroidism)
Rehab considerations for pts with parathyroid
dysfunction:
-Must be familiar with all signs and symptoms
of parathyroid dysfunction in order to refer
pts to a physician if a change in their status
occurs
-Recognize symptoms of excessive or
inadequate pharmacological treatment and
side effects of the agents
-Avoid treatments that exacerbate the
condition
-Recognize effects of hypercalcemia
(hyperparathyroidism) and hypocalcemia
(hypoparathyroidism)

-Recognize the increased risk for fractures

and effects form osteogenic synovitis
(Achilles, triceps, and obturator tendons most
affected)

Rehab considerations for pts with DM:

-Recognize the risk for peripheral
neuropathies, small vessel angiopathy, tissue
ischemia and ulcerations, impaired wound
healing, tissue necrosis, and amputation
-Recognize acute metabolic changes
-Recognize the signs of sudden hypoglycemia
and necessary treatment
-Focus on consistent management of insulin
intake, diet, and physical activity
-Provide education on proper skin care, shoe
evaluation, and shoe wear
Endocrine System
The endocrine system consists of endocrine glands (specialized ductless glands) that secrete hormones that travel
through the bloodstream to signal specific target cells throughout the body. The hormones travel throughout the
body to the target organs upon which they act. They will bind selectivity to receptor sites on the surface of the
receptor cells. The endocrine system and nervous system both function to achieve and maintain stability
of the internal environment (homeostasis). The systems are capable of working alone or in concert with each
other. The endocrine and nervous systems work together to regulate metabolism, response to stress, sexual
reproduction, blood pressure, and water & salt balances.
Endocrine System
-Secreting cells send hormones throught
the bloodstream to signal specific target
cells
-Hormones diffuse into the blood and

Nervous System
-Neurons secrete neurotransmitters to
signal nearby cells that have an
appropriate receptor site
-Neurotransmitters are sent very short

travel long distances to virtually every

area of the body
-Endocrine effectors consist of virtually
all tissues
-Regulatory effects are slow and tend to
last for long periods

distances across a synapse

-Nervous effectors are limited to muscle
and glandular tissue
-Regulatory effects appear rapidly and
are often short lived

Glands of the Endocrine System:

Hypothalamu
s

Pituitary
Gland

Thyroid
Gland

Is part of the diencephalon located below the thalamus and cerebral

hemisphere. The hypothalamus connects to the pituitary gland
through the infundibular or pituitary stalk. If it responsible for
regulation of the autonomic nervous system (body temp, appetite,
sweating, thirst, sexual behavior, rage, fear, blood pressure, sleep)
and other endocrine glands thorough its impact on the pituitary
gland.
Normally the size of a pea and is located at the base of the brain just
beneath the hypothalamus. The pituitary gland consists of two
separate glands, the adenophypophysis (anterior) and the
neurohypophysis (posterior). The pituitary gland is considered the
most important part of the endocrine system since it releases
hormones that regulate several other endocrine glands. This
master gland is influenced by factors such as seasonal changes or
emotional stress. The pituitary gland secrets endorphins that act on
the nervous system and reduce a persons sensitivity to pain. It also
controsl ovulation and works as a catalyst for the testes and ovaries
to create sex hormones.
Is located on the anterior and lateral surfaces of the trachea
immediately below the larynx and is shaped like a bow tie or
butterfly with two halves (lobes); a right lobe and left lobe joined by
an isthmus. The thyroid produces thyroxine and triiodothyronine that
act to control the rate at which cells burn the fuel from food. An
increase in thyroid hormones will increase the rate of the chemical
reactions within the body.

Parathyroid
Glands

Adrenal
Glands

Pancreas

Ovaries

Testes

There are 4 parathyroid glands found on the posterior surface of the

thyroids lateral lobes. These glands produce parathyroid hormone,
which functions as an antagonist to calcitonin and is important for
the maintenance of normal blood levels of calcium and phosphate.
Parathyroid hormone increases the reabsorption of calcium and
phosphate from bones to the blood. Secretion of parathyroid
hormone is stimulated by hypocalcemia and inhibited by
hypercalcemia. Normal clotting, neuromuscular excitability, and cell
membrane permeability are dependent on normal calcium levels.
The two adrenal glands are located on top each kidney; the outer
portion is called the adrenal cortex and the inner portion is called
the adrenal medulla. The adrenal cortex and the adrenal medulla
secrete different hormones. The adrenal cortex produces
corticosteroids that will regulate water and sodium balance, the
bodys response to stress, the immune system, sexual development
and function, and metabolism. The adrenal medulla produces
epinephrine that increases heart rate and blood pressure when there
is an increase in stress.
The pancreas is located in the upper left quadrant of the abdominal
cavity, extending from the duodenum to the spleen. The pancreas
includes both endocrine and exocrine tissues. The islets of
Langerhans are the hormone-producing cells of the pancreas. Alpha
cells produce glucagon and beta cells produce insulin. These
hormones work in combination to ensure a consistent level of
glucose within the bloodstream and properly maintain stores of
energy within the body.
The ovaries are located in the pelvic cavity on each side of the
uterus. The ovaries provide estrogen and progesterone that
contribute to regulation of the menstrual cycle and pregnancy.
Estrogen is secreted by the ovarian follicles that is responsible for
the development and maintenance of female sex characteristics
such as breast development and the cycles of the female
reproductive system. Progesterone is produced by the corpus luteum
and functions to maintain the lining of the uterus at a level
necessary for pregnancy.
The testes are located in the scrotum between the upper thighs. The

testes secrete androgens (most importantly testosterone) that

regulate body changes associated with sexual development and
support the production of sperm.

Endocrine System: Hormone, Function, & Regulation of Secretion

Hypothalamus:
Hormone
Growth hormone-releasing
hormone Target: pituitary
gland
Growth hormone-inhibiting
hormone Target: pituitary
gland
Gonadotropin-releasing
hormone Target: pituitary
gland
Thyrotropin-releasing
hormone Target: pituitary
gland
Corticotropin-releasing
hormone Target: pituitary
gland
Prolactin-releasing
hormone Target:pituitary
gland
Prolactin-inhibitory factor;
dopamine Target: pituitary
gland
Pituitary:

Function
Increases the release of
growth hormone

Regulation of Secretion
CNS feedback; circulating
levels of hormones

Decreases the release of

growth hormone

CNS feedback; circulating

levels of hormones

Increases the release of

luteinizing hormone and
follicle-stimulating
hormone
Increases the release of
thyroid stimulating
hormone
Increases the release of
adrenocorticotropic
hormone
Stimulates the release of
prolactin

CNS feedback; circulating

levels of hormones

Decreases the release of

prolactin

CNS feedback; circulating

levels of hormones

CNS feedback; circulating

levels of hormones
CNS feedback; circulating
levels of hormones
CNS feedback; circulating
levels of hormones

Hormone
Growth Hormone
Target: bone and muscle
Follicle-stimulating
hormone
Target: ovaries and testes
Luteinizing hormone
Target: ovaries and testes

Thyroid-stimulating
hormone
Target: thyroid gland
Adrenocorticotropic
hormone
Target: adrenal cortex
Prolactin Target:
mammary glands
Oxytocin Target: uterus
and mammary glands
Antidiuretic hormone
Target: kidneys

Function
Promotes growth and
development; increases
the rate of protein
synthesis
Promotes follicular
development and the
creation of estrogen in
females; promotes
spermatogenesis in males
Promotes ovulation along
with
estrogen/progesterone
synthesis from the corpus
lutem in females;
promotes testosterone
synthesis in males
Increases the synthesis of
thyroid hormones T3 and
T4
Increases cortisol
synthesis (adrenal
steroids)
Allows for the process of
lactation
Increases contraction of
uterine muscles; promotes
release of milk from
mammary glands
Increases water
reabsorption; conserves
water; increases blood
pressure through
stimulating contraction of
muscles in small arteries

Regulation of Secretion
Hypothalamus

Hypothalamus

Hypothalamus

Hypothalamus
Hypothalamus
Hypothalamus
Nerve impulses from the
hypothalamus; stretching
of the cervix; nipple
stimulation
Decreased water content

Adrenal Cortex:
Hormone
Adrogen Target: ovaries
and testes

Function
Increases masculinization;
promotes growth of pubic
hair in males and females

Aldosterone
(mineralocorticoid)
Target: kidneys

Increases reabsorption of
sodium ions by the
kidneys to the blood;
increase excretion of the
potassium ions by the
kidney into the urine
Influences metabolism of
food molecules; antiinflammatory effect in
large amounts

Cortisol (glucocorticoid)
Target:GI system

Regulation of Secretion
Influenced by the
hypothalamic production
and release of GnRH and
Luteinizing hormone (LH)
Low blood sodium level;
high blood potassium level

Adrenocorticotrophic
hormone

Adrenal Medulla:
Hormone
Epinephrine Target:
cardiovascular and
metabolic systems
Norepinephrine Target:
cardiovascular and
metabolic systems

Function
Increases heart rate and
force of contraction;
increases energy
production; vasodilation in
skeletal muscle
Vasoconstriction in skin,
viscera, and skeletal
muscles

Regulation of Secretion
Sympathetic impulses
form the hypothalamus in
stress situation

Function
Involved in the regulation
of the female reproductive
system and female sexual
characteristics

Regulation of Secretion
Cyclical rise and fall of
hormone levles

Sympathetic impulses
form the hypothalamus in
stress situation

Ovaries:
Hormone
Estrogen, progesterone
Target: uterus and
mammary glands

Pancreas:
Hormone
Glucagon
Targets: liver
Insulin
Targets: all body systems

Function
Increases blood glucose
by stimulating the
conversion of glycogen to
glucose
Decreases blood glucose
and increases the storage
of fat, protein, and carbs

Regulation of Secretion
Hypoglycemia

Function
Increases blood calcium

Regulation of Secretion
Influenced by pituitary
release of LH

Function
Involved in the process of
spermatogeneiss and
male sexual
characteristics

Regulation of Secretion
Influenced by pituitary
release of LH

Function
Involved with normal
development, increases
cellular level metabolism
Increases calcium storage
in bone; decreases blood
calcium levels

Regulation of Secretion
Thyroid-stimulating
hormone

Hyperglycemia

Parathyroids:
Hormone
Parathormone Targets:
bone, kidney, intestinal
mucosa
Testes:
Hormone
Testosterone Target:
pituitary gland

Thyroid:
Hormone
Thyroxine (T4),
Triiodothyronine (T3)
Targets: all tissues
Calcitonin Targets: plasma

Endocrine System Pathology:

Hypercalcemia

The endocrine system is multifaceted and can develop pathology in one or more areas due to hyperfunction or
hypofunction or one or more glands. In many instances, it is the hypothalamus or the pituitary gland that affects the
function of other endocrine glands when they experience direct or indirect dysfunction.
Hyperfunction of an endocrine gland: usually secondary to overstimulation of the pituitary gland. This can also occur
due to hyperplasia or neoplasia of the gland itself.
Hypofunction of an endocrine gland: usually secondary to understimulation of the pituitary gland. This can also
occur from congenital or acquired disorders.
Hypopituitarism: This condition occurs when there is a decreased or absent hormonal secretion form the anterior
pituitary gland. This is a rare disorder and symptoms are dependent on the age of the effected person and deficit
hormones. Typical disorders may include short stature (dwarfism), delayed growth and puberty, sexual and
reproductive disorders, and diabetes insipidus. Treatment is also based on the deficit hormones and usually includes
pharmacolocial replacement therapy.
Hyperpituitarism: This condition occurs when there is an excessive secretion of one or more hormones under the
pituitary glands control (frequently growth hormone that produces acromegaly in adults). Disorders and symptoms
are dependent on the hormone(s) that are affected. Some disorders include gigantism or acromegaly, hirutism
galactorrhea (abnormal lactation in males or females), amenorrhea, infertility, and impotence. Treatment is hormone
and site dependent and can include tumor resection, surgery, radiation therapy, and hormone suppression or
replacement (if gland becomes dysfunctional after treatment)
Pathology
Addisons
Disease

What is it
Is a form of
adrenal
dysfunction
that presents
with
hyopfunction
of the adrenal
cortex.
Subsequently,
there is

Etiology
When the
adrenal cortex
produces
insufficient
cortisol and
aldosterone
hormones it is
termed
Addisons
disease

Signs &
Symptoms
Symptoms
include a
widespread
metabolic
dysfunction
secondary to
cortisol
deficiency as
well as fluid
and electrolyte

Treatment
Primarily
consists of
long-term
pharmacolocial
intervention
using synthetic
corticosteroids
and
mineralocortico
ids.

decreased
production of
both cortisol
(glucocorticoid
) and
aldosterone.

Cushings
Syndrome

Is a form of
adrenal
dysfunction
that presents
with
hyperfunction
of the adrenal
gland, allowing
for excessive
amounts of
cortisol
(glucocorticoid
) production.

When the
pituitary gland
produces
excessive
adrenocorticotro
phic hormone
(ACTH) with
subsequent
hyper
cortisolism, it is
termed
Cushings
disease.

imbalances
secondary to
aldosterone
dysfunction.
The person
may
experience
hypotension,
weakness,
anorexia,
weight loss,
altered
pigmentation,
and if left
untreated this
condition will
result in shock
and possible
death.
Symptoms
evolve over
years and can
include
persistent
hyperglycemia,
growth failure,
truncal
obesity, purple
abdominal
striae, moon
shaped face,
buffalo hump
posteriorly at
the base of the
neck,
weakness,

Treatment may
include
pharmacologic
al intervention
to block
production of
the hormones,
radiation
therapy,
chemo or
surgery.

Graves
Disease

Is the most
specific cause
of
hyperthyroidis
m. Graves
disease is
most common
in women over
the age of 20,
however, it
occurs in men
as well and
can affect any
age group

Is caused by an
autoimmune
disease in which
certain
antibodies
produced by the
immune system
stimulate the
thyroid gland
causing it to
become
overactive

acne,
hypertension,
and male
gynecomastia.
Mental
changes can
include
depression,
poor
concentration,
and memory
loss.
Symptoms are
consistent with
hyperthyroid
presentation.
The classic
signs of
Graves
disease
include mild
enlargement of
the thyroid
gland (goiter),
heat
intolerance,
nervousness,
weight loss,
tremor, and
palpitations.
Also seen,
enlargement in
the area of the
Adams apple
resulting in
difficulty

Management
includes
pharmacologic
al intervention
and/or removal
of the thyroid
gland using
radiation or
surgical
intervention.

eating and
episodes of
dyspnea,
Abnormal
protrusion of
the eyes.

Hypothyroidism
Depression/anxiety, increased
lethargy, fatigue, headache,
slowed speech, slowed mental
function, impaired short-term
memory
Proximal muscle weakness,
carpal tunnel syndrome,
trigger points, myalgia,
increased bone density, cold
intolerance, paresthesias
Dyspnea, bardycardia, CHF,
respiratory muscle weakness,
decreased peripheral
circulation, angina, increase in
cholesterol
Anorexia, constipation, weight
gain, decreased absorption of
food and glucose
Infertility, irregular menstrual
cycle, increased menstrual
bleeding
Hypoparathyrodism

Hyperthyroidism
Tremors, hyperkinesis,
nervousness, increased DTRs,
emotional lability, insomnia,
weakness, atrophy
Chronic periarthritis, heat
intolerance, flushed skin,
hyperpigmentation, increased
hair loss
Tachycardia, palpitations,
increased respiratory rate,
increase in blood pressure,
arrhythmias
Hypermetabolism, increased
appetite, increased peristalsis,
nausea, vomiting, diarrhea,
dysphagia
Polyuria, infertility, increased first
trimester miscarriage,
amenorrhea
Hyperparathyroidism

bone resorption
Hypocalcemia
Elevated serum phosphate
levels
Shortened 4th and 5th
metacarpals
Compromised breathing due to
intercostal muscle and
diaphragm spasms
Cardiac arrhythmias and
potential heart failure
Increased NM activity that can
result in tetany

bone resorption
Hypercalcemia
Decreased serum phosphate
levels
Osteitis fibrosa, subperiosteal
resorption, arthritis, bone
deformity
Nephrocalcinosis, renal
hypertension, and significant
renal damage
Gout
Decreased NM irritability

Pancreas Dysfunction:
Pathology

Diagnosi
s

Diabetes
Mellitus Type
1

Persistent
hyperglyc
emia due
to
diminishe
d or
absent
productio
n of
insulin. In
type 1
DM,
insulin is
functional
ly absent

Contribut
ing
Factor
Unknown,
however
there are
several
theories. It
is an
autoimmu
ne process
with
strong
genetic
componen
t. It is also
believed
that the

Clinical
Presenta
tion
Usually
starts in
children
ages 4 or
older,
with the
peak
incidence
of onset
at 11-13
years. A
relatively
high
incidence
also

Lab/Imagin
g

Management/o
utcome

A test of
blood
glucose
levels will be
necessary.
Other testing
includes
urinalysis for
glucose,
ketones, and
protein and a
white blood
cell count as
well as blood
and urine

Usually require
insulin via
continuous
pump or selfadministered
injection.
Exercise is an
important
aspect in
management of
DM. Pts should
exercise at 5060% of their
predicted
maximum HR.

due to
the
destructio
n of beta
cells of
the
pancreas
where the
insulin
would
normally
be
produced.

genetic
predisposi
tion in
combinati
on with an
unknown
factor,
potentially
environme
ntal,
triggers
the
ongoing
cycle of
destructio
n of the
beta cells
of the
pancrease
.

exists in
people in
their late
30s and
early 40s.
Common
symptom
s are
polyuria,
polydipsia
, and
polyphagi
a, along
with
nausea,
weight
loss,
fatigue,
blurred
vision and
dehydrati
on. A
fasting
glucose
reading of
126 mg/dl
is also a
sign of
DM. This
disease
onset is
usually
sudden or
within a
short
period of

cultures to
rule out
infection.

Type 1 DM is
associated with
a high
morbididty and
premature
mortality rate
due to
complications
such as
ischemic heart
disease, PVD,
chronic renal
disease,
reduced visual
acuity and
blindness.

Type II DM

Systemic
Lupus
Erythematos
us

This form
of DM
typically
occurs in
the
populatio
n over the
age of 40,
however,
there has
been an
increase
in
children
diagnose
d with
type 2
secondar
y to a rise
in obesity.
This form
of DM
typically
retains
the ability
to
produce
some
endogeno
us insulin.
SLE is a
connectiv
e tissue
disorder
caused by

Type 2 DM
occurs
secondary
to an
array of
dysfunctio
ns
resulting
from the
combinati
on of
resistance
to insulin
action and
inadequat
e insulin
secretion.
This
disorder is
characteri
zed by
hyperglyc
emia
when the
body
cannot
properly
respond to
insulin.
Genetic,
environme
ntal, viral,
and
hormonal

time.
Obesity is
found to
contribute
to this
condition
by
increasing
insulin
resistance
.
Symptom
s are
relatively
the same
as with
type 1,
however,
ketoacido
sis does
not occur
since
insulin is
still
typically
produced.

Diverse
symptom
s based
on the
involveme

Treatment of
type 2 DM
includes blood
glucose control
through diet,
exercise, oral
meds, or insulin
injections when
necessary.

Microscopic
fluorescent
techniques
are indicated
to detect the

Focuses on
revering the
autoimmune
response in
order to avoid

an
autoimmu
ne
reaction
in the
body. The
primary
manifesta
tion of the
condition
is the
productio
n of
destructiv
e
antibodie
s that are
directed
in the
individual
s own
body. The
chronic
inflammat
ory
disorder
produces
a variety
of
symptom
s
dependin
g on the
severity
and
extent of

contributi
ng factors.
Environme
ntal
include
ultraviolet
light
exposure,
infection,
antibodies
(penicillin
and sulfa
drugs),
extreme
stress,
immunizat
ion, and
pregnancy
. SLE can
occur at
any age,
but the
most
common
age group
is 15-40
years.
More
common
in women.

nt of the
connectiv
e tissue
throughou
t the
body.
Symptom
s such as
arthralgia
s, malaise
and
fatigue
may
persist
even
during a
remission
period.
Common
clinical
presentati
on is
butterfly
rash
across the
cheeks
and nose,
red rash
over light
exposed
areas,
arthralgia
s,
alopecia,
pleurisy,
kidney

presence of
the
antinuclear
antibody
(ANA) within
the blood. A
positive ANA
test warrants
an additional
test for
antideoxyrib
onucleic acid
antibodies.
These two
tests in
combination
with physical
presentation
support the
presence of
SLE.

complications
and
exacerbations of
symptoms. PT
intervention is
usually
indicated after a
period of
exacerbation
and includes a
slow resumption
of physical
activities,
energy
conservation
techniques,
gradual
endurance
activities, and
significant pt
education
regarding skin
care, pacing,
exercise, and
strengthening.

involvem
ent.

Human
Immunodefic
iency Virus

Is a
retrovirus
that
initially
invades
and
destroys
cells
within the
immune
system;
specificall
y CD4+ Tlymphocy
tes (tcells).
This virus
also
affects
monocyte
s,
macropha
ges, and
B-cells.
Once the
T-cells

HIV is
transmitte
d through
contact
with
blood,
semen,
vaginal
secretions
, and
breast
milk.
Contact
can be
sexual,
perinatal
or through
contact
with blood
or body
fluids that
carry
infected
cells. Risk
factors for
contractin

involveme
nt,
seizures,
depressio
n,
fibromyal
gia, and
cardiac
involveme
nt.
A pt will
not
immediat
ely
present
with
symptom
s after the
initial
transmissi
on of the
infection.
A pt can
be
symptom
free for 12 years
post
infection
or may
exhibit
flu-like
symptom
s
including
rash and

HIV is
diagnosed
through
various blood
tests such as
the enzymelinked
immunosorb
ent test or
Western blot
test. Once
diagnosed
the lab
results can
also assist
with
classifying
the stage of
HIV infection.

Early detection
is important so
that pharm
intervention can
be initiated and
slow the
progression of
the virus. There
is no cure for
HIV, however,
proper medical
intervention can
allow the virus
to remain a
manageable
chronic
condition. PT
may be
indicated during
the course of
HIV/AIDS due to
secondary
impairments. PT
goals &
intervention
should include

decrease
beyond a
specific
level a pt
will begin
to
demonstr
ate
symptom
s of the
HIV
infection.

g HIV
include
unprotect
ed sexual
relations,
intravenou
s drug use
or mother
to fetus
transmissi
on. The
largest
risk
factors for
contractin
g HIV are
homosexu
al male
sex (46%),
intravenou
s drug use
(25%),
and
heterosex
ual sex
(11%).

fever. HIV
immediat
ely begins
a latent
phase
where
replicatio
n of the
virus is
minimal.
The three
phases of
this
disease
process
include
asympto
matic HIV,
symptom
atic HIV,
and
acquired
immunod
eficiency
syndrome
(AIDS).

fitness,
flexibility, stress
management,
relaxation,
aquatic therapy,
pain
management,
breathing
exercises, and
neuro rehab.
Studies indicate
that
psychosocial
factors influence
progression of
the virus as well
as survival.
Presently, the
leading cause of
death is kidney
failure
secondary to the
extended drug
therapies.

Spotlight on safety:
According to the American Diabetes Association, recommended blood glucose levels include 70-130
mg/dl prior to a meal and <180 mg/dl after a meal.
Hyperglycemia: Early signs is blood glucose >180-200 mg/dl, increased thirst and frequent urination. Recognition
of these early signs is crucial in preventing the dangerous onset of ketoacidosis, often referred to as a diabetic
come. Symptoms include dyspnea, fruity breath odor, dry mouth, nausea, vomiting, confusion, and an eventual loss
of consciousness.

Hypoglycemia: Early signs is when blood glucose is <70 mg/dl, hunger, sweating, shaking, dizziness, clumsiness,
and headache. If unaddressed, pts who become hypoglycemic may lose consciousness, at which point immediate
medical attention is necessary. Hypoglycemia is often counteracted simply by ingestion of a glucose or carb rich
substance (sugar, honey, juice, crackers). Pts with significant hypoglycemic issues may be advised by their physician
to carry a glucose source of injectable glucagon with them at all times.
Pharmacology of the Endocrine System:
Drug

Action

Hormone
Replacem
ent
Therapy

These agents
restore normal
endocrine
function when
endogenous
production of a
particular
hormone is
deficient or
absent
These agents
manage
hyperactive
endocrine
function to
allow for
inhibition of
hormone
function. This
is
accomplished
through
negative
feedback loops
or through
hormone

Hyperfunti
on Agents

Indications
in
endogenous
hormone
secretion

Hyperactive
or excessive
endocrine
function,
excessive
hormone
levels

Side
effects
Vary by
exogenous
or
synthetic
hormone
replaceme
nt used for
treatment

Implication
s for PT
Must be
aware of
side effects

Example
s
See
specific
hormone
categories

Vary
depending
on the use
of
hormone
therapy

Must be
aware of
signs of
hyperfunctio
n of
particular
hormones
and side
effects

See
specific
hormones

Bone
mineral
regulating
Agents

antagonists
Attempt to
enhance and
maximize bone
mass along
with
preventing
bone loss or
rate of bone
reabsorption.
Typical agents
can include
estrogens,
calcium and
vitamin D,
bisphosphonan
tes, calcitonin,
and anabolic
agents

Pagets
disease,
osteoporosis,
hyperparathyr
odidism,
rickets,
hypoparathyr
oidism,
osteomalacia

GI
distress,
dyspepsia,
dysphagia,
anorexia,
bone pain,
cardiac
arrhythmia
s

Pts with
bone
mineralizati
on deficit
are at risk
for fracture
and side
effects from
drug
therapy.
Should
attempt to
augment
drug
therapy
through
ambulation
and other
weight
bearing
activities
that
stimulate
bone
formation.

Estrogens
:
Premarin;
Calcium
and
vitamin D:
Tums,
Calderol;
Bisphosph
onates:
Fosamax,
Boniva;
Calcitonin
:
Cibacalcin

Genitourinary System PT examination: (Consists of all the reproductive organs and the urinary organs. These
are often considered together due to their common embryological origin)
Anatomy and Function:
Muscles of the
Pelvic Floor
Pelvic diaphragm

Description
Levator ani: pubococcygeus, puborectalis, iliococcygeus, &

Urogenital
diaphragm
Urogenital triangle

Anal triangle

coccygeus (ischiococcygeus)
Deep transverse perineal, urethrae sphincter
Female:bulbocavernosus, ischiocavernosus, superficial
transverse perineal
Male: bulbospongiosus, ischiocavernosus, superficial
transverse perineal
Internal and external anal sphincter

Genital System
Female:
External genitalia: Mons publis, labia
majora, labia minora, clitoris, vestibule
of vagina, bulbs of vestibule, greater
vestibular (Bartholins) glands, Skenes
gland
Vagina: Musculomembranous tube
connected to the cervis
Uterus: hollow muscular organ
Uterine tubes: Extend laterally from
the ovaries to the uterus
Ovaries: almond shaped glands
suspended in the broad ligaments

Provides protection and hydration of

vaginal tissue and urethra

Receptacle for male sperm

Birth canal
Excretory duct for menstrual fluid
Houses the fetus during development
Provides transport for the ovum from
the ovary for fertilization and
implantation within the uterus
Produce hormones such as estrogen
and progesterone
Storage of oocytes prior to ovulation

Male:
Penis

External genitalia that expels urine during voiding and semen during the
act of copulation

Scrotum
Testes
Dustus/v
as
deferens
Epididy
mis
Seminal
vesicles
Prostate

Cutaneous fibromuscular external sac for the testes, ductus deferens,

epididymis, nerves, and blood vessels
Produce sperm and hormones such as testosterone
Carries sperm from the testes to the seminal vesicle to form the
ejaculatory duct
Encased within the scrotum, stores sperm
Internal tubes that secrete a thick fluid to combine with sperm within the
ejaculatory duct
Internal organ lying inferior to the bladder
Produces and secretes fluid to combine with sperm, seminal vesicle fluid,
and bulbourethral gland fluid to create semen

Renal System: two kidneys, two ureters, the urinary bladder, and the urethra that function to form and eliminate
urine.
Kidneys

Ureters
Urinary
bladder
Urethra

Remove water, salt, and metabolic waste from the blood through
excretion of urine
Contribute to homeostasis including: acid-base balance, regulation of
electrolyte concentrations, control of blood volume, and regulation of
blood pressure through the control of hormones secreted into the blood
stream.
Muscular tubes connecting the kidneys to the urinary bladder to
transport urine
Temporary muscular reservoir for urine
Muscular tube for excretion of urine
Semen transport during ejaculation in males

Genitourinary System Pathology

Genital Components

Common Pathologies

Uterus
Vagina
Prostate
Penis
Renal Components
Kidneys
Bladder

Cervical cancer, endometriosis, uterine prolpase

Dyspareunia, vulvodynia, vulvovaginal candidasis
(yeast infection)
Prostatitis, prostate cancer
Erectile dysfunction
Common Pathologies
Glomerulonephritis, nephrolithiasis, renal failure
Cystocele, dysuria, hematuria, interstitial cystitis,
neurogenic bladder, nocturia, polyuria, urgency,
frequency, urinary incontinence, urinary tract
infections

Genitourinary Conditions/Pathology:
Pathology

What is it

Etiology

Uterus:
Endometriosis

Is the
development
of endometrial
tissue, which
normally lines
the uterus, in
extrauterine
locations
within the
abdomen and
pelvis. The
most common
location of
growth occurs
at the
uterosacral
ligaments. The
level of pain
does not

Unknown.
During each
menstrual
cycle the
endometrial
tissue bleeds
causing
subsequent
scarring and
adhesions.

Signs &
Symptoms
Typically
include
moderate to
severe lower
abdominal,
pelvic, or low
back pain
before or
during
menstruation,
irregular
menstrual
cycles,
premenstrual
spotting,
dyspareunia,
pain during
defecation,
and infertility.

Treatment
PT may include
manual
techniques
such as
myofascial
release,
visceral
mobilization
and soft and
deep tissue
massage to
break up scar
tissue and
adhesions.
Mobility
exercises are
performed to
sustain
elongation of

always
correlate with
the severity of
tissue growth.

Uterine
Prolapse

Is the descent
of the uterus
and cervis into
the vagina.
The BadenWalker System
is the most
widespread
classification
of prolapsed
using a 5 point
grading
system
ranging from
no prolapsed
to maximum
descent of

Typically
consists of
genetics,
denervation or
direct muscle
trauma (labor
& delivery)

Primary
symptoms
include pelvic
pressure that
increases with
exertion,
urgency,
frequency,
urinary
incontinenece,
incomplete
bladder
empyting,
discomfort,
vaginal
dryness or
irritation,

tissues.
Relaxation
exercises such
as breathing
routines and
restorative
poses are
performed to
regulate the
pain cycle.
TENS is also
indicated.
Surgery to
remove
scarring and a
total
hysterectomy
may be
recommended.
PT may include
pelvic floor
muscle training
using
biofeedback,
Kegel
exercises, core
strengthening
exercises, body
mechanics,
and symptom
dependent
lifestyle
modifications.
In severe
cases, an
intravaginal

vaginal tissue
outside the
body.

dysparenunia,
and lower back
pain that is
relieved by
lying down.

Prostate:
Prostatitis

An
inflammation
of the prostate
gland

Most common
include
bacterial
infection or the
backup of
prostate
secretions
within the
gland.

Common
symptoms
include watery
urethral
discharge,
urgency,
frequency,
discomfort
with urination,
and pain with
ejaculation.

Penis: Erectile
Dysfunction

Also known as
impotence, is
estimated to
range from 2585% in men
with diabetes,
which makes
this population
3x more likely

Diabetes is a
primary
etiology, while
other risk
factors include
CAD, HTN,
hypothyroidis
m,
hypopituitaris

Primary
symptom is
the consistent
inability to
maintain an
erection
adequate for
sexual
intercourse.

mechanical
support device
called a
pessary may
be indicated.
Pt may require
reconstructive
surgery.
Management
includes
lifestyle
modifications,
biofeedback
training,
stretching
exercises,
myofascial
techniques,
and bladder
retraining.
Pharmacologic
al intervention
such as
antibiotics,
alpha blockers
or NSAIDS may
be indicated.
Pharmacologic
al intervention,
surgical
intervention,
injections
directly to the
penis, and
Kegel
exercises.

than the
general
population.
Onset of ED in
individuals
with diabetes
usually occurs
10-15 years
earlier than in
men without
diabetes.

Kidneys: Renal
Failure

Renal failure is
a condition
where the
kidneys
experience a
decrease in
glomerular
filtration rate
and fail to
adequately
filter toxins
and waste
from the blood.
There are two
forms: acute
and chronic
renal failure.

m, multiple
sclerosis,
psychiatric
disorders,
excessive
alcohol
consumption,
smoking,
vessel disease,
kidney
disease,
pharmacologic
al side effects,
& hormonal
imbalances.
Renal
pathology
typically
occurs
sencondary to
DM or HTN, but
can also occur
from poison,
trauma, and
genetics. The
nephrons are
usually
damaged and
lose their
ability to filter
the blood.
Renal failure
can be
classified as:
Acute
(damage

Nausea,
vomiting,
lethargy,
weakness,
hiccups,
anorexia,
ulceration
within the GI
tract, sleep
disorders,
headache,
peripheral
neuropathy,
anemia,
pruritis,
osteomalacia,
ecchymosis,
pulmonary
edema,
seizures, and
coma

Includes
management
of primary
etiology,
pharmacologic
al intervention,
diuretics,
nutritional
etiology,
hydration,
hemodialysis
and/or
transfusions if
applicable. Tx
of chronic
failure includes
conservative
management
(slowing the
process and
assisting the

occurs quickly)
Chronic
(damage
occurs slowly)
End-stage
(nearly total or
total renal
failure, dialysis
required)
Acute: Sudden
decline in renal
function,
increase in
BUN and
creatinine,
oliguria,
hyperkalemia,
sodium
retention
Chronic:
progressive
deterioration
in renal
function, DM,
HTN,
interstitial
nephritis,
polycystic
kidney disease
Bladder:
Neurogenic
Bladder

Is a
dysfunction
where there is
damage to the
cerebral

Diabetes,
diminished
bladder
capacity,
hyperactive

Frequent
urinary tract
infections,
leakage of
urine, inability

body in its
compensation)
. Nutritional
support,
hydration,
avoidance of
protein. Renal
replacement
therapy
includes some
form of
hemodialysis
and/or organ
transplant.
Peritoneal
dialysis is a
form of renal
replacement
therapy that
uses the
peritoneal
cavity as a
semipeermeable
membrane
between the
dialysate fluid
and blood
vessels of the
abdominal
cavity.
Dependent on
the actual
etiology with a
goal of
preventing

Stress Urinary
Incontinence
(SUI)

Urge Urinary
Incontinence
(UUI)

control that
allows for
urinary
dysfunction. If
the urine
cannot be
properly
released, there
may be an
increase in
urinary tract
infections and
kidney
damage.

detrusor
muscle, CVA,
other disease
processes,
infection, and
nerve damage

Loss of urine
due to
activities that
increase
intraabdominal
pressure, such
as sneezing,
coughing,
laughing,
running, and
jumping.
Loss of urine
after a sudden,
intense urge to
void due to the
detrusor
muscle of the

See page 686

in
scorebuilders

Detrusor
muscle
overactivity,
overactive
bladder
syndrome,

to empty the
bladder or loss
of the urge to
urinate when
the bladder is
full. Diagnosis
should include
an evaluation
by a physician,
X-rays, and
urodynamics
to assist with
diagnosis.

bladder
overdistention,
UTIs, and renal
damage. Pt
education,
bladder
techniques,
lower
abdominal
massage,
temporary
catheterization
,
pharmacologic
al intervention,
and a timed
urination
program may
be indicated.

Triggered by
certain events
dut to a
conditioned
reflex. Two of
the most

Behavior
modification is
the primary
goal of
treatment for
this condition.

bladder
involuntarily
contracting
during bladder
filling. UUI is
the most
common
incontinence in
the geriatric
population and
among
residents in
long-term care
facilities.
Overflow
Urinary
Incontinence
(OUI)

Loss of urine
when the intrabladder
pressure
exceeds the
urethras
capacity to
remain closed
due to urinary
retention.

Functional
Urinary
Incontinence

Is the loss of
urine due to
the inability or

changes in the
smooth muscle
of the bladder,
increased
afferent
activity,
increased
sensitivity of
the detrusor to
acetylcholide,
and idiopathic.
Also
associated
with MS, SCI,
CVA, and
parkinsons.
Caused by
outflow
obstruction
secondary to a
narrowed or
obstructed
urethra that
results from a
prolapsed
pelvic organ, a
stricture, an
enlarged
prostate,
chronic
constipation or
neurological
disease.
A decreased
level of mental
awareness or a

common
triggers are
key in the
lock when
arriving home
and running
water.

Biofeedback,
pelvic floor
strengthening,
and bladder
retraining.
(scheduled
voiding) are
key
components.

Difficulty
initiating the
urine stream.
One stream is
initiated, its
weak and
presents with
post void
dribble.

Surgical
intervention if
there is an
obstruction. If
there is
weakness of
the detrusor
muscles,
double voiding
is recommened
for these pts
as well as
other
strengthening
measures.

Impaired
cognition
and/or mobility

Treatment
should be
directed to

(FUI)

unwillingness
of a person to
use the
bathroom
facilities prior
to involuntary
bladder
release.

decrease in
mobility.

Urinary Tract
Infections (UTI)

Very common
and occur
within the
general
population,
however there
is a higher
incidence in
women and
the geriatric
population.

Occur when
bacteria
infiltrate the
urethra or
further into the
bladder itself.
Untreated, this
type of
infection and
spread and
cause a kidney
infection
(pyelonephritis
).

Frequency of
urination, pain
and or burning
with urination,
cloudy urine,
pressure above
the public
bone in
women,
shakiness,
fever, back
pain, and
fatigue.

Stages of Kidney Disease:

Stage
1:

Kidney damage with normal BFR (90 or greater)

alleviate the
underlying
tissue.
Improving
mobility,
modifying
clothing style,
increasing
independence.
Early
treatment has
the best
results.
Pharmacologic
al treatment
includes
bacteriaspecific
antibiotics
based on the
bacteria found
in the bladder.
Pts are also
encouraged to
drink an
excess of fluids
to assist with
treatment of
the infections.

Stage
2:
Stage
3:
Stage
4:
Stage
5:

Mild decrease in GFR (60-89)

Moderate decrease in GFR (30-59)
Severe reduction in GFR (15-29)
Kidney failure (GFR less than 15)

Hemodialysis:
-Treatment process for pts with advanced and permanent kidney failure
-Kidney failure creates excess toxic waste, increase BP, retention of excess body fluids, and a decrease in red blood
cell production.
-Hemodialysis removes the blood from the body along with waste, excess sodium, and fluids.
-The process cleanses the blood and returns it to the body.
-A patient requires this process on average 3x per week and each visit requires 3-5 hours to complete the treatment.
-Side effects that may be associated with dialysis include anemia, renal osteodystrophy, pruritus (itching), sleep
disorders, (restless legs), and dialysis-related amyloidosis.
Rehab considerations for pts with renal failure/dialysis:
Modify treatment plan based on fluid and electrolyte staus
Standard precautions should be followed at all times for protection
Recognize pts abilities post dialysis and potential for dehydration and hypotension
Monitor vital signs closely, however, avoid placement of the blood pressure cuff over the fistula
Avoid mobilization activities as they are contraindicated during dialysis
Energy conservation techniques and pacing skills should be incorporated into therapy
Genitourinary System Terminology:
Anuria
Benign
prostatic
hypertroph
y

Inadequate urine output in a 24 hour period; less than 100 ml (severe

dehydration, shock, endstage renal disease)
A non-cancerous enlargement of the prostate gland that is progressive.
Common in males over 60 and can interfere with normal voiding.

Cystocele
Ectopic
Entometriu
m
Glomerular
filtration
rate (GFR)
Glomerulus
Hematuria
Impotence
Myometriu
m
Nephrolithia
sis
Nocturia
Oliguria
Polyuria
Perimetriu
m
Radical
mastectom
y
Rectocele
Seminiferou
s tubules
Urea
Urinary
frequency
Urinary

Bulging of the bladder into the vagina

Implantation of a fertilized ovum outside of the uterus (fallopian) tube is
the most common site of an ectopic pregnancy)
The inner lining of the uterus that is shed monthly in response to
hormonal influence
An estimate of the filtering capacity of the kidneys; volume of filtrate
produced per minute by the kidneys
The specialized tuft of capillaries that are needed for the filtration of
fluid as blood passes through the arterioles of the kidneys
Presence of blood in the urine (cancer, faulty catheterization, serious
disease)
Impairment with ejaculation, orgasm, erection, and/or libido
The muscular outer layer of the uterus
The condition of developing kidney stones. There are various types of
crystal formations that create stones.
Urinary frequency at night (DM, congestive heart failure)
Inadequate urine output in a 24 hour period; less than 400ml (acute
renal failure, DM)
Large volume of urine excreted at one time (DM, chronic renal failure)
The serous peritoneal coat of the uterus
A surgical procedure in which the entire breast, pectoral muscles,
axillary lymph nodes, and some skin are removed usually secondary to
breast cancer
The bulging of the anterior wall of the rectum into the vagina secondary
to weakening of the pelvic supporting structures
Coiled tubes found within each lobe of the testes where
spermatogenesis takes palce
Major nitrogen-containing end product of protein metabolism normally
cleared from the blood by the kidney into the urine
Voiding more than 8x in a 24 hour period
Sudden desire to urinate that is stronger than usually and difficult to

urgency

defer

1st Practice Exam (3rd exam in Scorebuilders) 130.

Gastrointestinal System:
GI Anatomy and Function
Upper GI
Mouth
Esophagus
Stomach

Initiation of mechanical and chemical

digestion
Transports food from the mouth to the
stomach
Grinding of food, secretions of
hydrochloric acid and other exocrine
functions, Secretions of hormones that
release digestive enzymes from the
liver, pancreas, and gallbladder to
assist with digestion
Lower GI-Small Intestine

Duodenum
Jejunum
Ileum

Neutralizes acid in food from stomach

and mixes pancreatic and biliary
secretions with food
Absorbs water, electrolytes, and
nutrients
Absorbs bile and intrinsic factors to be
recycled
Lower GI-Large Intestine

Ascending Colon
Transverse Colon

Pathology

Signs &
Treatment
Symptoms
Gastroesophagea GERD is the
Weakness of
Heartburn,
Treatment is
l Reflux Disease result of an
the LES,
regurgitation of usually through
(GERD)
incompetent
Intermittent gastric content, pharmacologic
lower
relaxation of belching, chest al intervention.
Descending Colon
Continues to absorb water and
esophageal the LES, Direct
pain,
Sigmoid
electrolytes; stores and eliminates
sphincter
damage to the hoarseness
Rectus
undigested food as feces
(LES) that
LES through and coughing,
Anus
allows reflux
NSAIDS,
esophagitis,
or gastric
alcohol,
and
Gland Organs
contents.
infectious
hematemesis.
agents,
Gallbladder
Stores and releases bile into the
smoking,duodenum
and
to assist with digestion
certain
RX
Liver
Bile is produced and is necessary for
medications.
absorption of lipid soluble substances,
Erosive Gastritis
Is the
Bleeding
fromwithSymptoms
supportive
assists
red blood cell Is
and
vitamin K
inflammation the gastric
include
with
production, regulates serumremoval
levels ofof
of the gastric
mucosa
dyspepsia,
the and
stimulus
carbohydrates,
proteins,
fats of
mucosa or secondary
to
nausea, bicarbonate
the disease
Pancreas
Exocrine-secretes
and
inner layer of
stress,
vomiting
and
process
and
digestive enzymes into the duodenum;
the stomach.
NSAIDS,
hematemesis.
pharmacologic
Endocrine-secretes insulin, glucagon,
Symptoms
alcohol
At times,
the into
Pt the blood
al
and other
hormones
to
are similar to utilization,
may
be
interventions.
regulate serum glucose level.
GERD,
viral infection asymptomatic
however,
or direct
they tend to
trauma.
have a higher
Gastrointestinal Pathology
intensity.
Non-erosive
Is the
This condition
The Pt is
H. pylori is a
Gastritis
inflammation is usually a
usually
carcinogen and
of the gastric
result of
asymptomatic
must be
mucosa or
helicobacter but will show
treated
Abdominal Pain Quadrant and
inner layer of Pylori infection symptoms if
aggressively. Potential Etiologies
theRight
stomach.
the gastritis Right
Pharmacologic
Left upper
upper
Left lower
lower
Symptoms
progresses al
interventions
Quadrant
Quadrant
Quadrant
Quadrant
are similar to
are most
Gastric ulcer
Hepatomegaly
Perforated colon
Kidney stone
GERD,
common
Perforated colon Duodenal ulcer
Ileitis
Ureteral stone and
however,
typically
Pneumonia
Cholecystitis
Sigmoid
Meckel diverticulum
they tend to
include
a
Diverticulitis
have
a
higher
proton
pump
Spleen injury
Pneumonia
Kidney stone
Appendicitis
intensity.
inhibitor and
antibiotics.
Peptic ulcer
Disease

What is it

Etiology

Is a condition Many ulcers Symptoms are Treatment is

where there are caused by dependent on usually through
is a disruption the H. pylori
the location pharmacologic

Spleen rupture
Aortic aneurysm

Hepatitis
Biliary stones

Ureteral stone
Intestinal
Obstruction

Cholecystitis
Intestinal
obstruction

Gastrointestinal Pharmacology
Name
Antacid
agents

H2
receptor
blockers

Action

Indicatio Side effect

n
Are used to Episodic Acid rebound
chemical
minor
phenomenon,
neutralize gastric
constipation,
gastric acid indigestion or diarrhea,
and
or
may effect
increase the heartburn, metabolism of
intragastric peptic
other
PH.
ulcer,
medications.
GERD

Implication

Examples

Since these Aluminumagents are containing:

well
basaljel,
tolerated
Calcuim
there are no carbonateside effects containing:
that interfere tums,
with physical Magnesiumtherapy.
containing:
Milk of
magnesia,
Sodium bicar.
Containing:
Bromo seltzer
Bind
Dyspepsia, Headache,
Since these Tagament,
specifically acute and dizziness, mild agents are Pepcid,
to histamine long term GI distress,
well
Zantac
receptors to treatment tolerance,
tolerated
prevent the of peptic arthralgia, acid there are no
istamineulcer, or rebound with side effects
activated
GERD
dicontinuation that interfere
release f
of medicine.
with physical
gastric acid
therapy.
normally

stimulated
during food
intake.
Proton
Inhibit the Dyspepsia, Acid rebound Since these Prevacid,
Pump
H+K+GERD
when
agents are nexium,
Inhibitors
ATPase
discontinued well
prilosec,
enzyme that
after prolonged tolerated
protonix,
blockes
use
there are no acipHex
secreations
side effects
of acid from
that interfere
gastric cells
with physical
into the
therapy.
stomach
Anticholine Block the
Gastric
Dry mouth,
PT should be Gastrozepin,
rgics
effects of
ulcers
confusion,
aware of
Muscarinic
acetylcholin
constipation, potential
cholinergic
e on parietal
urinary
side effects antagonist.
cells in the
retention
in order to
stomach
respond
and
appropriately
decrease
.
the release
of gastric
acid.
Antibiotics Are
H. pylori Hypersensitivit PT should be Metronidazole
prescribed bacteria y, nausea
aware of
, tetracycline,
to treat H.
potential
clarithromycin
pylori
side effects , amoxicillin
infection
in order to
with the
respond
goal of
appropriately
facilitating
.
more rapid
healing of
associated
gastric

ulcerations.
Antidiarrhe Are used to
al Agents
slow the
serious
debilitating
effects of
dehydration
associated
with
prolonged
diarrhea.
Laxative
Are used to
Agents
facilitate
bowel
evacuation
and should
be used
sparingly

Emetic
agents

Antiemetic
Agents

Prolonged Constipation,
diarrhea Abdominal
discomfort

Since these Donnagel,

agents are Kapectolin,
well
peptpBismol,
tolerated
Motofen,
there are no Imodium
side effects
that interfere
with physical
therapy.

To
Nausea,
If the
Citrucel,
promote abdominal
laxative was Metamucil,
defecation discomfort,
recently
colace, fleet
cramping,
ingested
Glycerin
electrolyte
physical
suppository,
imbalance,
discomfort senokot
dehydration, may
dependence, temporarily
with prolonged limit patient
use
participation
in therapy
interventions
.
Are used to To induce With
Therapy
Apomorphine,
induce
vomiting, inappropriate should be
Ipecac
vomiting
usually
or prolonged deferred if a
after
usage
patient is
ingestion dehydration, actively
of a toxic electrolyte
vomiting
substance imbalance, and
upper GI
erosion may
occur
Are used to Nausea
Agent
Antihistamin Scopolamine,
decrease
associated dependent, but e antiemetic meclizine,

symptoms
of nausea
and
vomiting

with
can include
motion
sedation,
sickness, dysrhythmias,
anesthesia and pain
, pain or
oncology
treatment

Gastrointestinal System Interventions/Rehab:

Rehab considerations for pts with GI disease:
-Recognize electrolyte imbalances from
diarrhea, vomiting, and weight loss
-Recognize the potential for orthostatic
hypotension secondary to electrolyte
imbalances
-Increased risk for muscle cramping
secondary to alteration in the sodiumpotassium pumps
-Potential for difficulty swallowing secondary
to disk protrusion or esophageal pathology
-Recognize that back pain and/or shoulder
pain may be secondary to an acute ulcer or GI
bleed
-Observation of Kehrs sign indicates free air
or blood within the abdominal cavity
Rehab considerations for pts with GERD:
-Avoid certain exercise secondary to an
increase in symptoms with activity;
recumbency will induce symptoms
-Recognize increased incidence of neck and
head discomfort secondary to perception of a
lump in the throat and subsequent

agents
dolasetron,
frequently
phenergan.
cause
sedative
effects which
can be
limiting to PT
interventions

compensation
-Left sidelying preferred since right sidelying
may promote acid flowing into the esophagus
-Recognize conditions such as chronic
bronchitis, asthma, and pulmonary fibrosis
may all present with GERD
-Consider that certain positioning during
postural drainage may encourage acid to
move into the esophagus
Rehab considerations for pts with Gastritis:
-pts with gastritis secondary to chronic NSAID
use may be asymptomatic
-Knowledge of blood in the stool should result
in physical referral
-Educate each pt to take medications with
food and avoid certain types of food and drink
-The pt should avoid all aspirin-containing
compunds
Rehab considerations for pts with Peptic Ulcer
Disease:
-Asymptomatic pts with history of ulcer
should be monitored for signs of bleeding
-Fatigue level, pallor, and exercise tolerance
must be monitored for signs of bleeding
-Recognize that heart rate increase or blood
pressure decrease may be sings of bleeding
-Recognize that back pain is a sign of
perforated ulcer located on the posterior wall
of the stomach and duodenum
-Recognize that pain that radiates form the
midthoracic area to the right upper quadrant
and shoulder may signify blood and acid

within the peritoneal cavity secondary to a

perforated and bleeding ulcer
Rehab considerations for opts with
malabsorption syndrome:
-Recognize increased risk for osteoporosis
and pathologic fractures
-Monitor fatigue level, pallor, bone pain, and
exercise tolerance
-Recognize weight loss and abdominal
bloating
-Recognize increased risk for muscle spasms
secondary to electrolyte imbalances
-Recognize increased risk for generalized
swelling secondary to protein depletion
Rehab considerations for pts with Irritable
bowel syndrome:
-Emphasize physical activity to assist with
bowel function and relieve stress
-Emphasize breathing techniques to assist in
stress reduction and with breath holding
patterns
-Recognize that biofeedback training may be
beneficial
Rehab considerations for pts with diverticular
disease:
-Physical activity assists the bowel function
and is extremely important during periods of
remission
-Breathing techniques will assist in stress
reduction and with breath holding patterns
-Avoid any increase in intra-abdominal

pressure with exercise or activity

-Back pain and/or referred hip pain must be
examined for possible medical diseases
Rehab considerations for pts with Hepatitis:
-Heath care workers that are at risk for
contact with hepatitis should receive all
immunizations for HBV, and if exposed to
blood or body fluids of an infected person
must receive immunoglobulin therapy
immediately
-Standard precautions should be followed at
all times for protection
-Enteric precautions are required for pts with
hepatitis A and E
-Recognize that arthralgias may be noted,
especially in older pts, and will not typically
respond to traditional therapeutic
intervention
-Energy conservation techniques and pacing
skills should be incorporated into therapy
-Balance activities along with periods of rest,
avoid prolonged bed rest, and provide pt
education regarding signs of relapse or
chronic hepatitis
Rehab considerations for pts with cirrhosis of
the liver:
-Recognize that ascities may develop as well
as fluid accumulation in the ankles and feet
-Report any blood loss through nose bleeds,
gum bleeds, tarry stools or excessive bruising
-Avoid all activities that produce the valsalve
maneuver (increase in intra-abdominal

pressure)
-Adequate rest is required to lower the
demands on the liver and improve circulation;
avoid unnecessary fatigue with therapeutic or
daily activities
Rehab considerations for pts with
cholecystitis and cholelithiasis:
-Must be familiar with all signs and symptoms
of cholecystitis in order to refer pts to a
physican if a change in their status occurs
-Post surgical exercises and ambulation are
appropriate post laparoscopic
cholecystectomy such as breathing exercises,
splinting while coughing, and mobility training

Genitourinary System:
Pathology

Diagnosis

Urinary
Stress
Incontinen
ce

Involuntari
ly loss of
urine. May
occur
during
activities
when
there is an
increase in
abdominal
pressure
through
straining,

Contribut
ing
Factor
Occurs
from a loss
of strength
and or
integrity of
the tissues
that
maintain
bladder
control. It
is caused
by
weakness

Clinical
presentat
ion
Dribbling
of urine,
urgency,
frequency,
nocturia,
and a
weak
stream
while
voiding.

Lab/Imagi
ng

Management/o
utcome

Cystometry
is used to
evaluate
bladder
capacity,
control,
contractility
, and
sensation.
During this
procedure
provocative
stress

Usually consists
of convervative
measures (PT) as
a first line of
defense followed
my
pharmacological
and surgical
interventions. PT
intervention for
pelvic floor
muscle weakness
that is ststed as

sneezing,
coughing
or lifting.

of the
pelvic floor
muscles.
Risk
factors
include
pregnancy
, vaginal
delivery,
episiotomy
, prostate
or pelvic
surgery,
aging, DM,
recurrent
UTIs.
Obesity
(due to
increased
intraabdominal
pressure)

testing will
be
performed
when stress
incontinenc
e is
suspected.
Urodynamic
testing
observes
the stability
of the
bladder and
electromyo
graphy
observes
bladder
contraction
s. Urinalysis
is used for
DD to rule
out
infection,
diabetes,
and other
conditions.

0/5-2/5 includes
biofeedback, estim, bladder
retraining, and
therapeutic
exercise. Pelvic
floor muscle
strengthing at
this level
includes
facilitation and
tapping of the
pelvic floor
muscles,
overflow
exercises uring
the buttocks,
adductors, and
lower
abdominals, and
implementation
of Kegel
exercises. PT for
muscle weakness
graded 3-5-5/5
includes
continued
biofeedback and
bladder
retraining,
weighted vaginal
bones for
resistance
training, and
implementation
of pelvic floor

muscle exercises
during activities.
Outpatient PT for
urinary stress
incontinence
should alleviate
pelvic floor
weakness and
involuntary
leakage of urine
within 8-12
weeks.
Obstetric Musculoskeletal Pathology:
Pathology

What is it

Etiology

Coccydynia

After childbirth
the joint
between the
coccyx and
sacrum can
become
hypermobile
causing the
soft tissue
surrounding
the coccyx to
become
painful.

Subluxation
during
delivery,
adherence to
tear or
episiotomy
scar

Signs &
Symptoms
Difficulty
sitting on hard
surfaces,
referred pain
to the low
back, sacroiliac
joint, hip,
buttock, groin
or rectum
areas, pain
with bowel
movements,
dyspareunia,
and formation
of hemorrhoids

Treatment
Heat, external
joint
mobilization,
myofascial
release,
muscle energy
techniques,
biofeedback
for pelvic floor
muscle
relaxation,
postural
training,
abdominal
strengthening
exercises,
stretching
exercises for
surrounding

Diastasis Recti

Is a separation
of the rectus
abdominis
muscle along
the linea alba
that can occur
during
pregnancy.
Testing for
diastasis recti
should be
performed on
all pregnant
women prior to
prescribing
exercises that
require the use
of the abs.

Hormonal
changes in
women may
cause the
separation.
The therapist
must note how
many fingers
fit into the
separation and
modify
treatment
accordingly.

A pt is
considered to
have diastasis
recti if the
therapist
detects a
separation
greater than
the width of
two fingers
when the
woman lifts
her head and
shoulders off
the plinth.

Piriformis
Syndrome

Refers to a
persistent,
severe
radiating low
back and
buttock pain
spanning from
the sacrum to
the hip and

During
pregnancy the
piriformis may
shorten or
spasm due to
postural
changes and
hip lateral
rotation while

The primary
symptom is
sciatic
paresthesia
due to
nerveentrapm
ent as the
sciatic nerve
passes under

muscles and
the use of a
cushion for
sitting.
Stabilization
and support
with abdominal
strengthening
exercises,
postural
awareness
exercises, and
body mechanic
training. A
newborn can
also have
diastatis recti
secondary to
incomplete
development,
however, in
infants this
condition
usually
resolves itself
without
intervention.
Manual
techniques for
correcting
pelvic or sacral
alignment such
as METs, joint
mobs, selfcorrection
techniques for

Symphysis
Pubis Pain

posterior thigh.
However,
controversy
exits over
piriformis
syndromes
efficacy as an
accurate
diagnosis.

walking.

or through the
pirifiormis
muscle.

To prepare for
delivery, the
symphysis
pubis joint
become mobile
in order to
allow the joint
to slightly
separate
during
delivery.

Postural
adaptations,
ligamentous
laxity and
complications
during delivery
or birthing of a
large infant
can result in
more sever
injury

Sever pain in
the symphysis
pubis and SI
joint as well as
blood in the
urine due to
injury to the
urethra or
bladder neck.

alignment,
heat
application,
deep tissue
massage,
myofascial
release, straincounterstrain,
ab
strengthening,
stretching for
piriformis,
body
mechanics,
and postural
education.
Pharm
intervention
for pain,
surgical
intervention
based on the
degree of
separation.
Heat or ice if
acute, manual
techniques for
correcting
pelvic/sacral
alignment.
Lumbar
stabilization
and the use of
a lumbo-pelvic
brace or
binder.

Women should not exercise in the supine position after the first trimester.
Prolonged periods of motionless standing should be avoided.
Left sidelying is the position of choice to reduce the pressure on the inferior vena cave, maximize
cardiac output to enhance maternal and fetal circulation, and reduce the risk if incompetent cervix.
Relative
Contraindications to
terminate exercise
during pregnancy:
-Severe anemia
-Unevaluated maternal
cardiac dysrhythmia
-Chronic bronchitis
-Poorly controlled type 1 DM
-Extreme morbid obesity
-Extreme underweight (BMI
<12)
-History of sedentary
lifestyle
-Poorly controlled HTN
-Orthopedic limitations
-Poorly controlled seizure
disorder
-Poorly controlled
hyperthyroidism
-Heavy smoker
Absolute
Contraindications to
terminate exercise
during pregnancy:
-Hemodynamically
significant heart disease
-Restrictive lung disease

-Incompetent
cervix/cerclage
-Multiple gestation at risk
for premature labor
-Persistent 2nd or 3rd
trimester bleeding
-Placenta previa after 26
weeks of gestation
-Premature labor during the
current pregnancy
-Ruptured membranes
-Preeclampsia/pregnancyinduced hypertension
Pharmacology of the Genitourinary System:
Pharm intervention is used for treating bladder symptoms related to urgency, frequency, infection, and pain.
Drug
Overactive
bladder
agents

Urinary
Anti-

Action

Indications

Side Effects

Relive the
symptoms
of an
overactive
bladder.
This
condition is
noted by
involuntary
contractions
of the
bladder
(detrusor
muscle)
Treat
urinary tract

Urinary
urgency,
frequency,
incontinenc
e, nocturia

GI distress,
nausea,
dizziness,
photosensitiv
ity,
headache,
constipation,
pulmonary
reactions

Cystitis,
urinary

GI distress,
nausea,

Implicatio
ns for PT
These
agents do
not typically
interfere
with rehab

These
agents

Examples
Ditropan
(oxybutynin
chloride),
Detrol
(tolterodine
tartrate)

Cinobac
(cinoxacin),

Infective
Agents

infections,
but are not
traditional
antibiotics
or
sulfonamide
agents.
These
agents can
be used
independen
tly or in
combination
to treat
urinary
infections.

urgency,
burning
with
urination,
UTI,
nocturia

dizziness,
photosensitiv
ity,
headache,
constipation,
rash

typically do
not interfere
with rehab

Furadantin
(nitrofuranto
in)

System Interactions:
Oncology-Cancer, malignancy, neoplasm, and tumor are all terms referring to abnormal uncontrolled cell growth
within the body. There are more than one hundred different cancers of various types and tissue origins currently
recognized, including lymphoma and hematologic cancers. Malignant cancer cells are characterized by their ability
to grow uncontrollably, invade other tissues, remain undifferentiated, initiate growth at distant sites, and avoid
detection and destruction by the bodys immune system. The origins of malignant cells vary widely from
environmental factors and lifestyle choices to genetic predisposition.
Carcinoma is a malignancy originating from the epithelial cells of organs. Carcinomas in specific organs may be
named more specifically depending on the characteristics present. For example, large cell carcinoma,
adenocarcinoma, and squamous cell carcinoma are all subsets of lung carcinoma. The American Cancer Society
reports that at least 80% of all cancers in the US are carcinomas.
Risk factors:
Increasing
Age
Tobacco Use
Alcohol Use

Poor diet
Stress
Occupational

Gender
Virus
exposure
Environmental
influence

Hazards
Ethnic
Background
Genetic
influence
Sexual/reproduc
tive behavior

General Signs & Symptoms of Cancer

C-Change in bowel/bladder routine
A-A sore that will not heal
U-Unusual bleeding/discharge
T-Thickening/lump develops
I-Indigestion or difficulty swallowing
O-Obvious change in wart/mole
N-Nagging cough/hoarseness
Cancer Prevention:
Primary
Prevention

Secondary
Prevention

-Screening for high

population
-Elimination of
modifiable risk
factors
-Use of natural
agents (teas,
vitamins) to
prevent cancer
-Cancer vaccine
-Early detection
-Selective
preventative
pharmacological
agents (Tamoxifen)
-Multifactorial risk

Tertiary
Prevention

reduction
-Prevent disability
that can occur
secondary to
cancer and its
treatment
-Manage
symptoms
-Limit
complications

Tissue & Tumor Classification:

Tissue Classification
Epithelium: Protect,
absorb, and excrete
Pigmented Cells
Connective Tissues:
elastic, collagen, fibrous

Examples
-Skin, Lines internal
cavities, Mucous
membrane, Lining of
bladder
-Moles
-Striated muscle, blood
vessels, bone, cartilage,
fat, smooth muscle

Nerve Tissues: neurons,

nerve fibers, dendrites,
glial cells

-Brain, nerves, spinal cord,

retina

Lymphoid Tissues

-Wherever lymph tissue is

present throughout the
body, lymph nodes,
spleen, can appear in
stomach, intestines, skin,

Tumor Classification
Carcinoma;
Adenocarcinoma
(glandular tissue)
Malignant Melanoma
Sarcoma, fibrosarcoma,
liposarcoma,
chondrossarcoma,
osteosarcoma,
hemangiosarcoma,
hemangiosarcoma,
leiomyosarcoma,
rhabdomyosarcoma
-Astrocytoma, Glioma,
Neurilemic sarcoma,
neuroblastoma,
retinoblastoma
Lymphoma

Hematopoietic Tissues

CNS, bone and tonsils

-Bone marrow, plasma
cells

Diagnostic tools:
Family history
Physical exam

Pap smear
Blood tests

Radiography
CT scan

Biopsy
Mammograph
y
Endoscopy
Isotope scan

Bone scan
Stool guaiac

Genitourinary System Intervention/ Rehab:

Rehab considerations for pts with renal
failure/dialysis:
-Modify treatment plan based on fluid and
electrolyte status
-Standard precautions should be followed at
all time for protection
-Recgonize pts abilities post dialysis and
potential for dehydration and hypotension
-Monitor vital signs closely, however, avoid
placement of the blood pressure cuff over the
fistula
-Avoid mobilization activities as they are
contraindicated during dialysis
-Energy conservation techniques and pacing
skills should be incorporated into therapy

-Leukemia,
Myelodysplasia,
Myeloproliferative
syndromes, multiple
myeloma

Lifestyle Modifications to address bladder symptoms:

-Daily fluid intake should be 2,500 mL, or 10 cups, to regulate excessively high or low fluid intake
-Reduce bladder irritants including carbonated, caffeinated, and alcoholic beverages, spicy foods, citric juices, and
artificial sweeteners. Caffeine reduction should be tapered slowly to avoid severe headaches.
-Schedule voiding for every 3-4 hours to reduce bladder distension. An average person voids 6-8 times in a 24 hour
period. A bladder diary assists with baseline measurements and goal setting
-Regulate bowel function to prevent constipation and straining during bowel movements by monitoring dietary fiber,
fluid intake, and exercise.
-Avoid fluid intake 2-3 hours prior to bedtime to reduce nocturia.
-A smoking cessation program may decrease the occurrence of coughing and subsequent bladder leakage.
-A weight loss program, if moderately obese, may decrease pressure on the pelvic tissues and organs.

Spotlight on Safety: Rehab Considerations for pts undergoing chemotherapy and radiation:
-Strenuous activity should be initially avoided following implantation of radioactive seeds utilized for brachytherapy.
Communication with the radiation oncologist and/or referring physician is imperative as further activity
contraindications or precautions may be advised depending on the individual care.
-Skin tattoos are used to guide beam alignment with external beam radiation. PTs must be cautious and defer
interventions which may alter the position of alignment tattoos (taping interventions, certain soft tissue or
myofascial mobilizations)
-Irradiated skin requires special care to protect tissues prone to erythema, rash, and dry desquamation, as well as
more painful wet desquamation and superficial burns.
-Massage and heat are contraindicated over irradiated areas for a minimum of 12 months.
-Certain chemotherapy agents may cause the pt to have a level of toxicity that requires staff and visitors to take
additional precautions before making physical contact.

-Pt vomiting during therapy should be reported to the nurse/physician, especially if the pt it taking antiemetic
medications to control nausea and vomiting.

Stage
Stage 0

Stage I
Stage II
Stage III

Stage IV

Definition
Early malignancy that is present
only in the layer of cells in which it
began. For most cancers, this is
referred to as carcinoma in situ.
Not all cancers have a stage 0.
Malignancy limited to the tissue to
origin with no lymph node
involvement or metastatis.
Malignancy spreading into adjacent
tissues, lymph nodes may show
signs of micrometastases.
Malignancy that has spread to
adjacent tissue showing signs of
fixation to deeper structures. The
likelihood of metastatic lymph
node involvement is high.
Malignancy that has metastasized
beyond the primary site, for
example, to bone or another organ.

Oncology Pathology:
Pathology
Brain Cancer

What is it

Etiology

May occur as a
primary tumor
arising from
astrocytes,
meninges,

Most primary
cancers outside
of the brain
metastasize to
the brain during

Signs &
Symptoms
Dependent on
the tumor and
typically
progresses
rapidly.

Treatment
Surgical
resection along
with radiation
or other
combined

Cervical
Cancer

nerve cells, or
tissues within
the brain.
Metastatic
brain cancer
occurs when a
brain tumor
develops as a
consequence
of cancer in
another
primary area
of the body.
Starts in the
cells on the
surface of the
cervix,
typically
squamous
cells. This
precancerous
condition is
called
dysplasia and
is easily
treatable.
Annual cervical
screening is
recommended;
diagnosis is
made through
a Pap smear.
Prognosis is
good with
timely
intervention. If

progression of
the cancer.

Symptoms
include
headache,
seizures,
intracranial
pressure,
cognitive and
emotional
impairment,
and motor
and sensory
function.

therapies are
typically
indicated.

The human
papilloma virus
(HPV) is the
primary cause of
cervical cancer;
it is slow
growing. Risk
factors include
smoking,
maternal use of
diethylstilbestrol
(DES), African
American
ethnicity, oral
contraceptive
use, and certain
sexually
transmitted
dieases.

Asymptomatic
during the
early stages,
however,
symptoms can
include
abnormal
bleeding,
pelvic and low
back pain,
impairment
with bladder
and bowel
function.

Dependent on
staging of the
cancer and
may include
laser therapy,
excision,
cryotherapy or
hysterectomy
with adjunct
chemotherapy
or radiation.

Colorectal
Cancer

dysplasia goes
undetected,
changes can
develop into
cervical cancer
and
metastasize to
the bladder,
intestines,
lungs, and
liver.
Accounts for
approx 15% of
cancer deaths
annually.
Adenocarcino
ma and
primary
lymphoma
accoudnt for
the majority of
intestinal
cancers.

Risk factors
include
increasing age,
history of
polyps,
ulcerative colitis,
Crohns disease,
fam history, and
a diet high in fat
and low in fiber.

Colon cancer
does not
provide early
signs of
disease and
the most
prominent
symptom is a
continuous
change in
bowel habits.
Bright red
blood from the
rectum is
another
prominent sign
of colon caner.
The pt may
experience
symptoms of
fatigue, weight
loss, anemia,
and overt
rectal
bleeding.

Based on type
and stage and
may include
surgical
resection of
the tumor and
potentially a
portion of the
bowel, with
subsequent
radiation
therapy or
chemo.
Colostomy
may be
required.
Prognosis is
good for early
diagnosis if the
cancer is
contained;
prognosis is
poor if it has
metastasized.

Lung Cancer

Lymphoma
(Hodgkins,
non-Hodgkins
disease)

Is cancer of
the epithelium
within the
respiratory
tract. It is the
most frequent
cause of death
from all
cancers. Rapid
metastasis can
occur through
the pulmonary
vascular
system,
adrenal gland,
brain, bone,
and liver.
Lymphoma is
classified as
cancer found
in the
lymphatic
system and
lymph tissues;
lymphomas
are
categorized as
Hodgkins
disease or nonHodgkins
lymphoma.

Risk factors
include smoking,
environment,
geography,
occupational
hazards, age,
and fam history.

Early
symptoms
include cough,
sputum, and
dyspnea.
Progression
may include
adventitious
breath sounds,
chest pain, and
hemoptysis.

There is a poor
prognosis
secondary to
expedited
metastaiss
(less than 14%
for a 5 year
survival rate).
Surgical
intervention
along with
combination
therapies may
be required.

Risk factors for

Hodgkins
disease include
association with
Epstein-Barre
virus, drug
abuse,
immunosuppres
sant use,
obesity, chronic
or autoimmune
diseases. Risk
factors for nonHodgkins
lymphoma
include
exposure to
benzene
(cigarette

A painless
lump is
typically the
first sign.
Hodgkins
disease is
distinguished
by the
presence of
Reed-sternberg
cells and
Hodgkins
disease can
metastasize to
extralympthati
c sites
including the
liver, spleen,
and lungs.

Hodgkins
disease is one
the most
curable
cancers
depending on
age, disease
stage, overall
health, and
responsiveness
to treatment.
Treatment
options are
based on the
pts age and
staging
classification
and include
chemo,

smoke), auto
emissions, and
pollution.

Pancreatic
Cancer

Prominent type
of cancer with
an extremely
high mortality
rate. Cancer of
the exocrine
cells within the
ducts is the
most common
form of
pancreatic
cancer. It will
metastasize to
the liver,
lungs, pleura,
colon,
stomach, and
spleen.

Risk factors
include tobacco
use, gender,
increasing age,
and
cholecystectomy
.

Symptoms are
very vague
during the
initial stages of
the disease
which often
results in
delayed
diagnosis.
Common
symptoms
include weight
loss, jaundice,
and epigastic
pain that can
radiate to the
thoracic
region.
Advanced
cancer may
present with
severe pain
that may
indicated the
cancer has

radiation, stem
cell transplant,
and highly
active
antiretroviral
therapy. NonHodgkins
progression
varies based
on
classification.
Usually
directed to
assist in the
relief of
symptoms.
Pancreatic
cancer has a
very poor
survival rate
with a
mortality rate
of almost
100%. Surgical
resection along
with
chemotherapy
and radiation
assist to
relieve
symptoms.

Prostate
Cancer

Skin Cancer

Adenocarcino
ma is the most
common type
of prostate
cancer.
Typically
affects men
over 50, it is
the second
highest cause
of death from
cancer in men.
Diagnosis is
found through
prostate
biopsy and
prognosis is
good with
appropriate
treatment.
There is an
approximate
10% fatality
from this
diagnosis.
Basal cell
carcinoma is a
slow growing
form of skin
cancer that
rarely
metastasizes.
It originates
from the
epidermis and

Risk factors
include age,
high fat diet,
genetic
predisposition,
African
American
descent, and
exposure to
cadmium.

Sun exposure is
a common
cause, with risk
factors including
frequent sun
exposure, light
eyes, and fair
skin.

metastasized.
Most times this
is
asymptomatic
until the
cancer reaches
the advanced
stages.
Symptoms
include urinary
obstruction,
pain, urgency,
and decreased
stream/flow of
urine.

Treatment
varies and may
include
surgical
incision of the
prostate gland,
radiation, or
hormonal
therapy; can
metastasize to
the bladder,
MS system,
lungs and
lymph nodes.

Open sores
that can bleed
or curst and
remain for
three or more
weeks, reddish
patches of
skin, a shiny
bump on the
skin that is

Prognosis is
good, basal
cell carcinoma
can routinely
be cured.
Surgical
excision may
be required to
remove the
cancer cells.

is the most
common form
of skin cancer.
Malignant
Melanoma

Originates
from
melanocytes
and can be
classified as:
superficial
spreading,
nodular,
lentigo
maligna or
acral
lentiginous
melanomas.
Peak incidence
is between 4060 years of
age. Early
diagnosis is
vital to
prognosis, as it
can spread
and
metastasize
quickly. Areas
of metastases
include the
brain, lungs,
liver, bone,
and skin.

Risk factors for

malignant
melanoma
include a history
of blistering
sunburns prior
to 20 years of
age, family
history,
immunosuppres
sion, light eyes,
fair skin, and a
previous history
of cancer.

PharmacologyOncology Management:

often pink, or a
scar-like area
that has poorly
defined
borders.
Lesions can be
elevated on
the surface of
the skin and
appear
keratotic or
scaly. Other
symptoms
when
observing the
skin or a mole
may include
asymmetry,
irregular
borders, varied
color, and a
diameter of
greater than
6mm.

This form of
cancer is 100%
curable with
early
diagnosis.
Excision may
solely be
required with
early
treatment. If
melanoma has
metastasized,
surgical
intervention
along with
combination
therapies may
be required.

Drug

Action

Indications

Side Effects

Alkylating
Agents

Bind the
DNA strands
together to
prevent
replication.
If the DNA
cannot
untwist,
then it
cannot
divide and
replicate its
genetic
code. These
agents
initiate cell
death by
disrupting
DNA
function
and
releasing
enzymes
that destroy
the cell.

Various
malignancie
s

Vary by class
of drugs and
by specific
agent;
multisystem
involvement
with mild to
severe side
effects,
however,
potential risks
are typically
warranted
secondary to
the diagnosis
of malignancy

Anitmetabol
ite Agents

Impair
biosynthesis

Various
malignancie

Vary by class
of drugs,

Implication
s for PT
Therapists
must be
aware of the
chemo
regimen and
modify
treatment
based on
the pts
symptoms
and side
affects from
cancer
treatment.
Extreme
fatigue, GI
distress,
cancer pain
and blood
disorders
are
common.
Therapists
must
provide
support and
encouragem
ent without
pushing the
pt beyond
their
abilities.
Therapists
must be

Examples
Mustargen,
Busulfex,
Leukeran

Leustatin,
Adrucil,

Antibiotic
Agents

of genetic
material
and
interrupt
the cellular
pathways
that
synthezise
the DNA
and RNA.
These
agents
create an
imposter to
the
endogenous
metabolites
within the
body to
form a
nonfunction
al genetic
product that
is incapable
of
reproductio
n.

s,
particularly
rapidly
dividing
neoplastic
cells

potential risks
are typically
warranted
secondary to
the diagnosis
of malignancy

Certain
antibiotic
agents are
used with
treatment
of cancer

Various
malignancie
s

SOB,
dysrhythmias,
blood
disorders,
myelosuppress
ion, pedal

aware of the
chemo
regimen and
modify
treatment
based on
the pts
symptoms
and side
affects from
cancer
treatment.
Extreme
fatigue, GI
distress,
cancer pain
and blood
disorders
are
common.
Therapists
must
provide
support and
encouragem
ent without
pushing the
pt beyond
their
abilities.
Same as
previous

Fludara,
Trexall
(methotrexa
te)

Adriamycin,
Mithracin,
Cosmegen

Plant
Alkaloid
Agents
(Mitotic
Inhibitors)

due to their
high toxicity
and ability
to interfere
with DNA &
RNA
synthesis
and
subsequent
cell division.
Agents in
this
classificatio
n are
nitrogen
based and
largely
derived
from plants.
They
directly
target the
replication
process
prior to and
during
mitosis to
inhibit cell
division.
This limits
cell division
and cancer
growth in
various
types of
malignancy.

edema

Various
malignancie
s

Vary by class
of drugs,
potential risks
are typically
warranted
secondary to
the diagnosis
of malignancy

Same as
previous

Oncovin,
Taxotere,
Taxol

Hormones

Biologic
Response
Modifier
Agents

Certain
hormones
can
exacerbate
or facilitate
proliferation
of particular
forms of
cancer
while other
hormones
can
attenuate
particular
cancers.
Hormones
are typically
used as
adjunct
therapy
along with
other form
of
treatment
specific to
the
malignancy.
Include
interferons,
interleukin2, and
monoclonal
antibodies
that are
responsible
for

Various
malignancie
s,
particularly
hormone
sensitive
neoplasms

Masculinizatio
n in women,
hot flashes,
general
catabolic
effects

Same as
previous

Nolvadex,
Lupron,
Casodex

Various
malignancie
s,
particularly
leukemias,
lymphomas,
Kaposi
sarcoma,
organ and

Vary by class
of drugs,
potential risks
are typically
warranted
secondary to
the diagnosis
of malignancy

Same as
previous

Proleukin,
Avastin,
Intron-A

Heavy
metal
compounds

enhancing
the bodys
own ability
to respond
to
neoplastic
growth.
These
agents are
not
cytotoxic,
but
facilitate
the pts
immune
response to
destroy
malignant
tissues.
Used as
antineoplast
ic agents
are also
known as
platinum
coordination
complexes.
They act as
askylating
agents that
inhibit DNA
translation
are
replication.

Oncology Terminology:

tissue
malignanici
es

Various
malignancie
s,
particularly
epithelial
malignancie
s, ovarian,
testicular
and bladder
cancer

Vary by class
of drugs,
potential risks
are typically
warranted
secondary to
the diagnosis
of malignanc

Same as
previous

Platinol,
Paraplatin,
Eloxatin

Adjuvant
Benign
neoplasm
Cancer

Differentiated
Cells
Dysplasia
Hyperplasia
Malignant
neoplasm
Metaplasia
Neoadjuvant
Tumor
(neoplasm)

Treatment provided, in addition to other

cure-focused inverventions, with the
intension of preventing cancer recurrence
An abnormal cell growth that is usually
slow growing and harmless, closely
resembling the composition of adjacent
tissues
A group of diseases characterized by
uncontrolled cell proliferation with
mutation and spreading of the abnormal
cells. The etiology is based on the type
and location of the cancer. The most
common causes include cigarette
smoking, diet and nutrition, chemical
agents, physical agents, environmental
causes, viral causes, and genetics.
Cells that have matured from a less
specific to a more specific cell type
An abnormal development of cells or
tissue that is often an early sign of
neoplasia
An increase in cell number that may be
normal or abnormal depending on
additional characteristics
An abnormal uncontrolled cell growth that
invades and destroys adjacent tissues and
may metastasize to other sites and
systems of the body
A change in a cell from one type to
another that may be normal or abnormal
Chemotherapy or radiation given prior to
surgical oncology intervention
An abnormal new growth of tissue that
increases the overall tissue mass. Tumors
are benign (non-cancerous) or malignant
(cancerous) as well as primary or

Undifferentiat
ed cells

secondary. Primary tumors form from cells

that belong to the area of the tumor.
Secondary tumors grow from cells that
hae metastasized (spread) from another
affected area within the body. Tumor
classification is defined by cell type, tissue
of origin, amount of differentiation, benign
versus malignant, and anatomic site.
Cells which have not differentiated into a
specific into a specific type (primitive,
embryonic) or have no special structure or
function.

Psychological Disorders:
Affective Disorders: are classified by disturbances in mood or emotion. States
of extreme happiness or sadness occur and mood can alternate without cause.
These extreme emotions can become intense and unrealistic.
Depression:
-Slower mental and physical activity; poor self-esteem
-Immobilized from everyday activities; sadness, hopelessness, and helplessness
-Desire to withdraw; delusions in severe cases
Mania:
-Constantly active
-impulses immediately expressed
-Unrealistic activity
-Elation and self-confidence
-Disagreement with a patient may produce patient aggression
-Disorganized thoughts and speech
-Very few pts are diagnosed with only manic disorder
Bipolar:
-Alternating periods of depression and mania
-Females are at a greater risk; typically begins in a pts twenties

Neuroses Disorders: refer to a group of disorders that are characterized by

individuals exhibiting fear and maladaptive strategies in dealing with stressful or
everyday stimuli. Pts with neuroses are not dealing with psychosis, do not have
delusions, and usually realize they have a problem.
Obsessive-Compulsive Disorder:
-Obsessions-persistent thoughts that will not leave
-Compulsions-repetitive ritual behaviors the pt cannot stop performing
-Thoughts or ritual behaviors that interfere with daily living
-Unable to control irrational behavior
-Most commonly beings in young adulthood
Anxiety Disorder:
-Constant high tension; overreacts in certain instances
-Presents with apprehension and chronic worry
Acute anxiety attacks:
-Lasts a few minutes in duration
-Excitation of the sympathetic autonomic nervous system
-Fear of impending doom or death
-Shortness of breath, heart palpitations, dizziness, nausea
-Initiated by unconscious and internal mechanisms
Phobia Disorder:
-Excessive fear of objects, occurrences or situations that is considerably out of
proportion/irrational
-Fear creates difficulty in everyday life
-Subclassifications include agoraphobia, social phobia, and simple phobia; simple
phobia is easiest to treat
-May develop from traumatic experiences, observation, classical conditioning
Dissociative Disorders: Develop when a person unconsciously dissociates
(separates) one part of the mind from the rest.
Psychogenic Amnesia:
-Produced by the mind with no physical causes
-Forgets all aspects of the past
Multiple Personality:
-A rare dissociative disorder; includes two or more independent personalities
-Each personality may or may not know about the other

-Causative factors are not understood; believed to allow a person to engage in

behaviors that are against the pts morality and normally produce guilt
Somatoform Disorders: are classified based on the physical symptoms
present in each disorder.
Somatization Disorder:
-Primarily in women, has familial association, and often chronic and long lasting
-Complaints of symptoms with no physiological basis
-Symptoms usually lead to medications and medical visits and alter the pts life
-Resembles hypochondriasis disorder
Conversion disorder:
-Physical complaints of neurological basis with no underlying cause
-Paralysis is the most common finding; other findings include deafness,
blindness, paresthesia
-Frued believed this is mental anxiety transformed into physical symptoms
-Diagnosis can be made once testing is negative for physical ailments
Hypochondriasis Disorder:
-Excessive fear of illness
-Believes that minor illnesses or medical problems indicate a serious or life
threatening disease
Schizophrenia Disorders: Psychotic in nature and present with disorganization
of thought, hallucinations, emotional dysfunction, anxiety, and perceptual
impairments. Causative factors include traumatic events, genetic inheritance,
biochemical imbalances, and environmental influence.
Catatonic Schizophrenia:
-Motor disturbances with rigid posturing
-Episodes consist of uncontrolled movements, however, pts remain aware during
episodes
Paranoid Schizophrenia:
-Delusions of grandeur; delusions of persecution
-May believe they possess special powers
Disorganized Schizophrenia:
-Usually progressive and irreversible with inappropriate emotional responses;

mumbled talking
Personality disorders: is classified by observing a pts pattern of behavior,
dysfunctional view of society, and level of sadness. Personality disorders are
usually ongoing patterns of dysfunctional behavior.
Psychopathic Personality:
-Low morality, poor sense of responsibility, no respect for others
-Impulsive behavior for immediate gratification; high frustration
-Little guilt or remorse for all actions; inability to alter behavior, even with
punishment
-Expert liar
Antisocial Behavior:
-Results from particular causes (need for attention or involvement in a gang)
-Typically has some concern for others
-Blames other institution (family, school) for their actions
-Symptoms are typically seen before 16 years of age
-Violates the rights of others; lacks responsibility and emotional stability
Narcissistic Behavior:
-Incapable of loving others
-Self-absorbed; obsessed with success and power
-Unrealistic perception of self-importance
Borderline Behavior:
-Instability in all aspects of life
-Can identify self from others
-Uses projection, denial, defensiveness; unpredictable mood or behavior
-Intense and uncontrolled anger; chronic feelings of emptiness
Tips for interaction with an escalating patient:
-Be empathetic when setting boundaries
-Use a low, calm tone of voice when speaking
-Do not respond defensively to pt comments
-Offer choices, options or small concessions if appropriate
-Do not force constant eye contact, allow the pt to look away
-Be respectful and acknowledge the pts complaints or frustration
-When speaking, wait for the pt to pause rather than raising your voice to be heard

-Be aware of your supportive resources, including the option to leave the area if necessary
-Avoid physical contact
-Do not turn your back to an agitated or escalating pt
-Do not allow an agitated or escalating pt to block your exit route
-Maintain more space than usual between yourself and the pt for safety
-Stand at an angle facing the pt so that it is easier to sidestep if necessary
-Always stay at the same eye level as the pt (both standing, both sitting)
-Keep hands out of your pockets both for self-protection and to avoid the appearance of concealment