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STROKE: Ischemia: 80% of strokes

Transient Ischemic Attack (TIA) Interruption of cerebral blood flow
- Temporarily interruption of blood supply to the brain Thrombus, Embolus causing ↓ O2, Metabolism = Neural Tissue Death
- Neurological Symptoms < 24 hours Thrombotic Stroke:
- No evidence of Neurological damage on MRI Caused by:
Cause: Abnormal vessel wall Atherosclerosis
Occlusive episode Hypotension Hypotension Hypertension
Arrythmias Cerebralvascular spasm Embolic Stroke:
↓ Cardiac output Hypotension Caused by:
Blood clot
*Precursor for a stroke or myocardial infarction Blood Plaque Causing occlusion or infraction
Cardiac or vascular emboli

Management of Ischemic strokes: Haemorrhagic Stroke: 20% of strokes

Anti-thrombotic meds (Clot busting agents) Bleeding from ruptured cerebral vessel or trauma
Antiplatelet Anticoagulants Types:
Aspirin Heparin - Hypertensive Intracerebral Haemorrhage
Thrombotic Therapy tPA (3.5 – 4h window to be effective) - Aneurism
Neuroprotective agents - Arteriovenous Malformation
- Alters the course of metabolic events - Posttraumatic Haemorrhagic Stroke
Antiedema Agents
- Corticosteroids Neural location of stroke will determine the severity and impairments
Intraarterial treatment
- Clot extraction

Intracerebral Haemorrhage: Stroke Syndrome:

- Putamen, Pons, Thalamus, Cerebellum
- Develops over Minutes
Aneurysm:
- Ballooning or rupture of large arteries (ICA or ECA)
- Acute, abrupt onset, severe headache
Arteriovenous Malformation: (AVM)
- Can occur anywhere in brain
- Abnormal capillary bed, large tangled vessels
Posttraumatic Haemorrhagic:
- Traumatic brain injury after head injury (SAH/ICH)
- Axonal injury
Management: Control ICP, Decompression, maintain perfusion
Internal Carotid Artery (ICA)
Vascular Syndromes: Contributes to major distribution of the MCA
- Common Carotid/Internal Carotid (CCA/ICA) Homonymous Hemianopia:
- Vision loss on the same side of visual field in both eyes
- Middle Cerebral Artery (MCA)
- Anterior Cerebral Artery (ACA) Contralateral Hemiparesis:
- Posterior Cerebral Artery (PCA) - Paralysis on opposite side of body that brain damaged occurred in
- Vertebrobasilar Syndrome Contralateral Hemianesthesia:
- Lacunar stroke Syndrome - Loss of sensation on opposite side that brain damaged occurred

Global Aphasia:
- Wernicke's Aphasia -> Talks clear, but words makes no sense
- Brocha’s Aphasia-> Broken speech
Middle Cerebral Artery (MCA) Anterior Cerebral Artery (ACA)
Supplies the Frontal Parietal Temporal Lobes, Internal Capsule, Globulus Supplies Medial Aspect of the brain, frontal and parietal lobes
Pallidus, Corona Radiata. Contralateral Hemiparesis and sensory loss:
Homonymous Hemianopia: - Paralysis on opposite side of body that brain damaged occurred in
- Vision loss on the same side of visual field in both eyes - LL > UL
Urinary Incontinence:
Aphasia
- Unable to produce speech if lesion occurred in left hemisphere Personality / Disinhibition:

Contralateral Hemiparesis: Aphasia:

- Paralysis on opposite side of body that brain damaged occurred in - Unable to produce speech if lesion occurred in left hemisphere
Sensory loss to face and UL & LL. (Face and UL more affected)
Apraxia:
Perceptual deficits (if lesion is in R hemisphere) - Unable to perform task on demand if lesion occurred in R hemisphere
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Posterior Cerebral Artery (PCA) Vertebrobasilar Artery Stroke:

Supplies the Occipital Lobe, Temporal Lobe, Upper Brain Stem, Pons, Supplies the Cerebellum, Medulla, Pons and inner ear
Thalamus
Lesion here produces both Ipsilateral and Contra Lateral signs
Thalamic Syndrome -> Unable to process information of pain 85% Mortality Rate
Memory Loss, Tremor, Hallucinations:
Webber syndrome -> Eyes are down and outwards, Ocular Motor syndrome Other symptoms include:
Prosopagnosia -> Unable to recognise faces
Vertigo/tinnitus in ear
Visual Agnosia -> Unable to recognise Objects
Wallenberg’s Syndrome
Ataxia -> Imparted muscle coordination, motor control, impaired balance /
gait - Dysphagia, soft voice
Cortical blindness -> Total or partial loss of vision Nystagmus:
- Uncontrolled shaking of eye

Basal Ganglia Stroke: Lacunar Stroke:

Stroke here will affect ability to: Associated with Hypertensive haemorrhage and diabetic microvascular disease
- Prepare and execute movement Affects small vessels deep in the Cerebral cortex -> Executive Function
- Activation and Inhibition of movement
- Organising behaviours, Verbal Skills, Problem solving, mediating socially Accounts for 20% of strokes
appropriate responses
- Procedural Learning Symptoms include:
- Evaluation of sensory Data Can be either pure motor or pure sensory
- Compare motor demands with proprioceptive imputes Ataxic
Sensory Motor
Internal Capsule: Dysarthria -> clumsy hands
Stroke affecting all three parts of the IC will contribute to no motor function Hemiballismus -> Undesired movement of limbs
Anarthria Pseudobulbar -> Unable to articulate words

Right Hemisphere Lesion: Left Hemisphere Lesion:

Behavioural: Intellectual: Behavioural: Intellectual:

Visual Perceptual Issues Poor Abstract Reasoning Speech and Language affected Disorganised
Impulsive Poor Problem Solving Broca’s & Wernicke’s Difficulty with initiation
Poor judgement Memory Issues Global aphasia Processing delays
Inability to self-correct Spatial/Perceptual Issues Slow and Cautious Memory Issues
Poor Insight Negative Emotions Very aware of disability Language/Preservation Issues
Falls risk Fluctuation is task performance Emotions – Positive
Good task Performance
*Visual ques will be less effective Speech Apraxia
*Need to give clear Verbal Instructions
*Verbal ques and commands will be less effective
*Could use visual cues

Complications associated with a Stroke: Physiotherapy Assessment:

Our assessment is guided by area of pathology
Need to consider the following complications and Rx planning - i.e. ICA vs MCA stroke
- Altered consciousness
- Speech and language issues Have a functional approach to Rx
- Dysphagia -> aspiration pneumonia
- Cognitive issues Establish a Clinical Pattern
- Perceptual Issues
Base treatment around Patient ST & LT goal
- Seizures
- Bladder bowel issues
Plan for DC / referral
- Cardiorespiratory
- DVT
- Osteoporosis
- Falls Risk

Stroke Subjective Examination: Stroke Objective Examination:

- Establish Pt goals - Have functional approach -> test full arm function rather than individual
- Shx Muscles
- Movement analysis
- PMHx
o Observe posture
- Home situation o Look at how they Initiate, can they sustain, can they finish the
- Works status? task
- Interests/Hobby’s? - Compensation OR substitution
- Premorbid activity level (exercise tolerance & establish Base Level) - AROM/PROM
- Strength: Concentric/Eccentric
- Tone: Hypo/hyper
*Goals need to be SMART
- Sensation: Sensation extinction?
i.e ask the pt what is the Top 3 things they want to focus on during the 5
- Mobility, Bed transfers, Ambulation
weeks. - UL function
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Multiple Sclerosis: Features of MS:

- Progressive demyelinating disease of the CNS CNS inflammation:
- Can occur anywhere in the - Cytotoxic T-cells and Macrophages attack the myelinated sheets
- Brain, Spinal cord or Optic Nerve. - This leaves scar tissue and causes hardened patches
Oligodendrocytes are affected - ↓ Impulse conductivity
Nodes of Ranvier is damaged
This ↓ signal volleys & ↓ their amplitude anywhere in the CNS Destruction of oligodendrocytes
Involves white and grey matter - Responsible for the production of Myelination

Caused by: These lesions can occur in the:

- Epstein Bar virus: - Cerebellum
- Genetics (IL&RA & IL2RA) - Periventricular Region
- Environmental Factors: Place of residence, Smoking - Brain stem
Affects more women than men (20-40 years old) - Optic Nerves
-
Types of MS: Exacerbating Factors:
Relapsing or remitting: - Viral OR bacterial Infection
-Discrete attacks with full or partial recovery - Disease of Major organs Relapse is treated by Immunotherapies
-85% of pts w MS - Stress
Secondary Progressive:
-Begins as RRMS progressive axonal loss Pseudoexacerbation:
-Progressive axonal loss Temporarily worsening of MS
Primary Progressive: Symptoms normally dissipate >24H
-Steady functional decline and progression Adverse reaction to heat
-10% of patients
Progressive relapsing: All these Factors can increase the risk of
- Steady deterioration - Pneumonia
-5% of patients - Falls risk
*When the disease is stable, MS is not life limiting

Medical Management: Symptoms:

Immunotherapies: Sensory: Coordination and Balance:
- Works by modifying the activity of the immune system - Parenthesis > anaesthesia -Ataxia
Pain: -Tremors
Disease modifying Therapies: - Paroxysmal limb pain -Truncal Weakness
- CRAB Drugs - Optic Neuritis Gait and Mobility
- Lhermitte’s sign -Ataxic Gait
Steroids: Motor Symptoms: -Scissoring Pattern Gait
- Exacerbation is managed by easing the inflammation - Paresis or paralysis -Fear of falling
- Spasticity Speech and Swallowing:
Symptomatic: - Coordination/balance -Dysarthria, Dysphonia, Dysphagia
- Spasticity -> Baclofen - Gait Mobility Visual:
- Fatigue -> Ampyra Helpful for balance and gait, but ↓ alertness -Speech/Swallowing -Diplopia
- Pain -> Lyrica and motor learning **Fatigued**

Physiotherapy Evaluation: Treatment:

Age PROM *Aim to maintain functional strength as it will improve quality of life*
Diagnosis AROM *Be aware, these patients fatigue fast*
PC Sensation Balance Training: Posture:
History MMT -Task Specific training -Hip Strength
- HPC, PMH, Social Cognition -Functional Training -Core Stability
- Pain Ballance -Progressive strength Training -Scapular Retraction
- Falls -Berg Balance Scale -Vestibular training -Pectoral Stretch
Meds -Dynamic Gait Index -Task with eyes close
Previous therapy Cerebellar - Head movement
Goals ST & LT -Ataxia, tremor, dysmetria -Change surface
Fatigue Vestibular Intermittent Exercise:
Thermosensitivity -Vertigo, nystagmus, VOR testing -Reduce fatigue
UMN signs Gait-> Pattern, endurance -Break exercise down into core components
-Rest at first mention of Fatigue

Gait Training: Diminished Knee flexion (Need 60 degrees Kn F)

-Foot drop (Increased tone in calf and decreased push-off) Could be caused by:
-Plantar flexion contracture - Spasticity of quads Stretch in various positions
-Dorsiflexion weakness -Weakness of Hamstrings Focus on eccentric control of hamstrings
-Decreased push-off (Look at Hip Flexion and Plantarflexion)
Diminished Hip Flexion:
-Trendelenburg Gait (Weak Glute Med) Tight or weak Psoas Major
Cause reduced swing phase in gait cycle
Need to evaluate Emphasis eccentric loading (lower leg down slow & controlled)
-Endurance, Timing, Different Terrains.
-MMT Outcome Measures:
-ROM EDSS MSQLI Fatigue severity scale
-Spasticity/Tone MSFC FAMS EBP-> MS Society Australia
-Use of gait aids
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Parkinson’s Disease: Tremor:

Chronic and progressive neurodegenerative condition - Imbalance of neural connections between BG, Thalamus Cerebellum and
Disorder of the basal ganglia and substancia nigra cerebral Cortex.
Caused by a loss of dopamine - Initially presents unilaterally in the hands
Caused by the presence of Lewy Bodies - Gradually progress to Face, LL, Shoulders and Bilateral involvement
Can lead to both motor and non-motor impairments
Rigidity:
Cardinal signs: - Affects both the agonists and antagonist muscles
- Tremor - Proximal involvement initially then progresses distally
- Rigidity - Two types:
- Akinesia -> Inability to initiate movement -Cogwheel
- Bradykinesia -> Slow movement -Lead pipe
- Postural instability
*test around the wrist for rigidity

Akinesia / Bradykinesia: Other motor signs and symptoms:

- Caused by impaired activation of the SMA Shuffling gait Dystonia of leg/foot (Uncontrolled muscle contraction)
- Motor planning deficits Stooped posture Dysphagia
- Major cause of disability Freezing when turning Dysarthria (Motor speech disorder)
- Cause freezing of gait ↓ arm swing Masked face (Little expression)
- Difficulty w Buttoning Shirt, Clicking of Mouse, Typing Falls risk Sialorrhea (Drooling)
*Add cognitive component to treatment. i.e walking and count back from 100
Postural Instability: Pre-PD Motor Clinical Features:
Flexor dominant -> stooped over position Anosmia Constipation
Loss of rotation Colour discrimination Depression
Difficulty w bed mobility -> can’t roll in bed
Festination-> walking on balls of feet Pre PD Non-Motor Clinical Features:
Retropulsion -> Taking steps backwards to maintain balance Depression Apathy Anxiety Insomnia
-> taking more than 1 step backwards = negative result Dementia (60% prevalence towards end of PD)

Types of PD: Classification of PD:

Primary Parkinson’s: Hoehn and Yahr scale:
- Idiopathic, 78% of cases 1 Unilateral disease, min or no functional disability
2 Bilateral or midline involvement, w/o balance impairment
Secondary Parkinson’s: 3 Bilateral involvement, Mild to mod disability, physically
- Brain Injury from strokes, toxins, trauma (boxing), Infections indep, mild to mod post instability
4 Severe disability, can walk/stand unassisted
Parkinson-Plus Syndromes: 5 Wheelchair/bed based unless assisted
- Progressive supra nuclear Palsy
- Multi system atrophy (CNS more affected) Medical management:
- Lewy body dementia -> App start friendly but then get defensive/angry Pharmacological: Surgical:
- Alien hand syndrome -> Ask to lift both arms but only lifts one - Levadopa/carbidopa - Pallidotomy
- Huntington’s Disease -> Rigid variant (genetic motor for PD) - COMT Inhibitors - Thalamotomy
- Anticholinergics - Deep Brain Stimulation
- Dopamine Agonists
Pharmacological Management: Physiotherapy assessment:
Levadopa/Carbiopa: Anticholinergics: - Posture
- Side effects include nausea - Artane, Benztrop, Cogentin - Coordination
- Dyskinesia - Reduces tremors & dystonia - Balance
- CV issues - Mood changes, - Gait
- Orthostatic Hypotension - Drowsiness - Range/Flexibility
- Tone
- Nausea/Vomiting
- Strength
COMT Inhibitors:
- Pain
- Stalevo, Comtan Dopamine Agonist: *Establish patient goals and base treatment around that
- Makes more L-Dopa available - Sifrol, Simipex, Permax, Parlodel *Identify what cause the patient to move in that pattern
- Diarrhea - Act and mimic dopamine *It’s important to identify ADL that they have difficulty with
- Dizzyness - Nausea/Vomiting *Need to identify ON/OFF periods of medication and perform treatment in both
*Drugs have on and off periods *Involve ADL with Rx. Personalised contextual
*Therapeutic response becomes shorter w time

1) Postural Assessment: 2) Objective assessment:

↓ Trunk extension Strength:
↓ Lumbar lordosis Stooped flex position -> flexor dominant
↑Thoracic Kyphosis -> Reduced extensor strength
↑Posterior Pelvic tilt -> Tight hip flexors -> Ask to actively go into Ext (antigravity)
Scoliosis Coordination:
Pisa syndrome -> Lateral trunk flexion -> Dysdiakokinesia
-> Tight Obliques -> Finger to nose
-> Use verbal cue’s mirror to show -> Finger to finger
Antecollis. -> Excessive forward flexion of cervical spine/neck Flexibility:
-> Difficulty swallowing -> Hamstrings
Camptocormia -> Thoracic and Lumbar flexion >45 -> Rigidity (check at wrist)
-> Weakness of antigravity extensors ->Akinesia/Bradykinesia
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3) Balance: 4) Tone:
Delayed equilibrium reactions Lead pipe:
Lack of ankle, hip, stepping strategy - Slow, sustained resistance
Lack of anticipatory postural control - Smooth resistance throughout range
Instability to adequately respond to perturbations
↓ Sensatory adaption Cogwheel:
Muscle weakness - Jerky, ratchet, catch & release
Postural hypotension
3) Postural Control: 5) Pain:
Test in Sitting and Standing Reactive: -> Perturbations Musculoskeletal
Static -> Sternum & Pelvis Dystonic
Anticipatory -> Give them a nudge Neuropathic
-> Reach out BOS. Adaptive: -> Surface Central
-> Turn head -> Environment Akathisia

6) Gait Assessment: Outcome measures:

Shuffling, high step rate gait Body Structure and Function: Fear of falling:
Slower speed with shorter steps Festination: Walk on Balls of feet - UPDRS revision part 3 - ABC Scale
Shoes scuff on floor COG out BOS - UPDRS Part 1
No heelstrike, Flat foot/ foot slap Chace their COG Activity: Dual Task:
Rigid trunk w reduced Arm swing ↑ falls risk - Mini BEStest - Tug Cognitive
Narrow BOS, COG anterior to BOS - 6MWT - get them to walk and give then a
Difficulty in initiating and terminating a step - 10M Walk a cognitive task such as counting
Gait Freeze -> Motor block prevents initiation of movement - 5x STS (LL strength) from 100 backwards.
- 9 Hole peg test (dexterity)
Freeze gait: Freezing of gait: 360 Turn Test:
Motor block causing the freeze - FOG questionnaire - Measures dynamic balance
Commonly occurs during complex motor sequences (Direction changes, narrow Fatigue: - Time to complete circle
spaces, distractions, doorways) - Parkinson’s disease fatigue scale - PD =6 sec or 9.5 sec

Exercise therapy and PD: 1)Sensorimotor agility training:

Used to increase: Perform each circuit for 10 mins
-Speed -Endurance -Ballance Improve intensity by adding sensory integration, cognitive tasks, speed/resistance
-ROM -Motor Control -ADL’s Other exercises include Kayaking (rotation), Boxing (Balance) Lunges (alter COG)
-Gait -Posture -Flexibility
2)LSVT BIG:
Exercises needs to: Exaggerated training
- Axial Flexibility Get them to perform big “flicks” before activity (↑ Neural activity)
- Limb ROM
- Loss of Strength 3)Tandem Cycling:
- Improve cardiovascular endurance Forced Exercise
- Good for reduction in Tremor and Bradykinesia
*Needs to be functional Helps provide autonomy
*Needs to be high intensity and challenge their balance

4) Dance for PD: 7) Gait Training:

Adds a cognitive aspect to training Early stages of PD:
Low Impact - Address amplitude and symmetry
Improves Balance - Add in dual tasking with cognitive and motor loads
- Vary the environment Open VS Closed
Mid Stage of PD:
5) Yoga for PD: - Pt’s may present with motor fluctuations
Positions force the patient into Extension - Strategies needed for “ON” “OFF” phases
- Start addressing festination and retropulsion and LOB
6) Nordic Walking: Mid-late stage of PD:
Forces them into lumbar and thoracic extension - FOG present *Ask pt what they would like to work on
More COB out BOS - ↑ Falls *Practice weight shifting and stepping
↑ Balance - More Cues needed *Practice in open and small spaces
↑Arm swing *Squeeze when you freeze *Practice stopping starting and turning

Freezing of Gait: Freezing Treatment Ideas:

Identify triggers and don’t rush them - Agility exercises-> to train to increase automatic response
Lean onto one side and allow opposite foot to take step - High Stepping
Train patient to unweigh leg and take a bigger step - Skipping
Encourage high step and big movements - Large amplitude movements/directions
7) Dual Task Training: - Make it contextual- Work on these activities through doorways/obstacles
Helps to improve functionality Example exercises include: - Work on quick turns/close to walls and corners
Adds a cognitive and motor aspect -Battle ropes Turning Treatment Ideas:
Can be achieved by: -Tug of War Avoid pivoting
- High intensity exercises -Drum roll on gym balls Take wider turns when possible
- Multidirectional gait changes Slow down
- Various surface areas Feet apart
Take a bigger step with your outside foot until it passes your inside foot
Quick turns close to walls and corners
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Bradykinesia Treatment Ideas: Other Strategies:

-Boxing Movements -Move while punching, forward back, sideways External Ques:
-Speed, Dual Tasks -Power Punch w trunk rotation Auditory: -> Music, Rhythmic Auditory
-Jab, Hook, then combinations Visual: -> Marked lines, Laser pointers
Tactile: -> Taping on floor
Rigidity Treatment Ideas:
-Slow rocking -Reciprocal limb Movement Attentional Strategies:
-Kayaking -Tai-Chi Think about big steps UStep
*Lay them on their back to get them out of flexion Choose a point of reference Teracycle
Making wider turns
Balance Treatment Ideas: Rocking, Weight, Shifting
-Rhythmic stabilisations (concentric/eccentric) Taking a step backwards before starting to walk
- Use the outcome measure as treatment Rocking backwards and forwards to do a STS
-Postural control

ORTHO: Reverse total shoulder Arthroplasty: (RTSR)

Anterosuperior approach
Total Shoulder Replacement: (TSR)
Not cutting into muscle -> faster recovery
Indicated for: Contra indications:
Deltoid becomes the primary elevator
Complex humeral fracture Rotator cuff insufficiency
Latissimus dorsi is the primary rotator
Advanced OH RA Deltoid paralysis
Decreased functional use Unable to participate Rehab
Post-surgical Instructions for TSR:
- Shoulder immobilisation: (4-6weeks) -> muscle atrophy, frozen shoulder,
Total Shoulder Arthroplasty / Hemiarthroplasty:
↑scar tissue, ↑stiffness. Use PROM to increase range.
Titanium stem -> Humeral Head
- Limited Abd /ER
Polyethylene capsule -> Glenoid fossa
- ER 40o w Humerus 0o Add
Post-surgical Instructions for RTSR:
Cut through Deltoid muscles
- Unstable in Add / Ext
Release subscapularis tendon (IR)
- Not able to reach behind and scratch back or push out of chair.
Recovery is longer and more painful

Rehab Assessment: Rehab exercises of TSR:

SE: OE: - Determine where scapula resides on thoracic spine
History: -ROM (↓subacromial impingement) - Determine potential restrictions to arm elevation: (Tight Levator scap, Pec
- Cause -Rot cuff integrity (Facilitate Sh Abd) Minor, Subscapularis, Infraspinatus Rhomboids)
- How long ago -Scapulohumeral rhythm (↑ ROM) - Start w passive exercises -> (wall/table slide, broomstick, their other arm)
- RA, OA, Pain? -Tenderness / crepitus - Elevation in Scapular Plane
Prior Injuries/surgeries -Strength (RC, Deltoid, Biceps, Tri) - Shorter lever arm
Hand dominance (LHS vs RHS)
Work *Crepitus is normal, arm been in - Use of theraputty pulling -> ↓Edema & Inflammation
Recreational interests sling for 6 weeks - Squeezing ball and resist Elbow F (isometric contraction)
Functional Limitations - Above mentioned exercises will cause RC and Deltoid to start firing
Outcome measures: Objectives of Rehab:
-Quick Dash -The ASES 1) Joint Protection 3) RC function
-SST 2) Subscapularis Protection 4) Deltoid Function

1) Joint Protection: 3) RC Function:

Avoid pushing or pulling on shoulder Most patients have a weak RC
Use a sling initially, even when sleeping Start w short lever arm, involve ADL’s in Tx
No active shoulder movement -> can do submaximal shoulder Isometric As patient improves, gradually increase lever arm
No lifting heavy objects -> 1-2kg
4) Deltoid function:
Humeral Head elevator
2) Subscapularis Protection:
00 ER for few weeks Contributes to dynamic stability of shoulder
50-600 by week 6 Start with isometrics early. (Squeeze ball and resist elbow flexion) this
Start w shoulder girdle isometrics and scapular stabilisation will cause the RC and Deltoid to fire but is not contra indicated.

*can be depressed if RC is weakened

*can be elevated if Pec’s are too tight

Expected ROM: Factors affecting outcome:

2 – 3 weeks 6 – 8 weeks 12 – 16 weeks Better outcomes:
-No previous surgery
Passive ER – 20° Near full PROM 140 – 160° active -Minimal RC pathology
elevation -Better health status prior to surgery
-No history of OA
Passive elevation 140° active 50 -60° active ER
to 100 – 110° elevation Poorer outcomes:
-RA or Trauma -Subluxation on X ray
40° active ER Able to do Apley’s / -Sever loss of PROM -Loss of posterior glenoid bone
Scratch test -Comorbidities -Degeneration of subscapularis & Infraspinatus

Return to sport:
6/12 w permission of surgeon.
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Total Hip Replacement: (THR) THR Physio Assessment:

Seat goals early -> treatment determine by patient goals
Posterior Approach: Precautions: Determine pain levels
Surgical separation of gluteal muscles No Hip flexion past 90o Establish PROM & AROM
Longer recovery time No hip add past neutral Muscle strength
Post-operative restrictions for 6-12 weeks No IR past neutral Postural Control
Assess bed mobility
Anterior Approach: Precaution: WB tolerance (guided by surgeon)
Surgical separation of TFL and Sartorius No Hip Ext past neutral Mobility Assistance
Shorter recovery time No hip ER past neutral - How much assistance
↑ROM sooner No bridging - Need of gait aid
- Home environment
*Metal ball with polyethylene cup most frequently used

THR Rehabilitation: Balance training:

Interventions early post op < 8week include: Need to target dynamic balance -> functionality
Early mobilisation Falls Prevention
Treadmill training w/BWS ↓ Hips strategy and ↓proprioception -> no proprioception
Task specific, repetitive and intensive training Strengthen Hip Rotators, Gluteus Medius and Hamstrings -> Eccentrically
NMES for those who can’t perform resistive exercises
Postural Control:
Interventions late post op < 8 Weeks include: Activation of lower abdominal and glutes
Combination of AROM, WBing and hip Abd eccentric training Elongation of trunk and hip flexors (from pelvis)
(Side lying hip Abd)-> elongation of muscles Place hip on pelvis and tell them “don’t let me rotate you”
*Put hand on their shoulders and ask them to stand tall
- Balance training -Tight Psoas and QL *Progress it to stepping and walking tall
- Postural/pelvic control -Weak glute Medius
- Eccentric muscle training

Facilitating Hip Stabilisers: Total Knee Replacement: (TKR)

Stretch hip flexors (Tight Psoas) 4” incision over the patella
Address tight QL’s & Psoas -> They will use hip flexors in swing phase of gait Minimally invasive and does not severally affect the quads
QL is used to hitch the hip upwards and swing leg forward
Consider UL elevation when Weight shifting -> Isometric contraction of Hip Musc Precautions:
Get them to perform Clams Pain
DVT -> Homan’s test (+ve = no rehab)
Other issues to be aware of:
Length discrepancy -> tight TFL & Add TKA Physiotherapy Assessment:
Trendelenburg -> tight Psoas and weak glute Medius Set goals ASAP Strength (glutes, hamstrings, quads)
WB exercises for glute Medius activation -> more functional Pain management Assistive device
Mobility -> Sit to Stand -Stick
*Return to sport: PROM, AROM -Walking frame
Surgical clearance, able descend 8 steps w/o sxs, LL strength symmetry Swelling

TKR Rehabilitation: Quadricepses Facilitation:

Rx will be protocol based -> check w surgeon Use of NMES
Emphasise early mobility -> better outcome Exercises -> Consider pain
-> Involuntary quads contraction
Factors affecting function following TKR:
Quadricep muscle function -> stabilising factor Stiff Knee:
Motion and balance -> Artificial limb, no proprioception Consider multiplane stretching
Proprioceptive training to ↓ Falls rate Stretch above/below the knee
Patient motivation education and compliance. (Need to be active to get better) Eccentric loading
Quadricepses function -> retro-stepping
-> Sway back and forth w toes/heels on ground Return to Sports:
-> Make sure there is a chair behind them ~ 3-6 months (clearance from surgeon)
Consider hydrotherapy, exercise classes, and Pilates ROM must be complete, Muscle strength must be sufficient, Balance must be
Peddal on a stationary bike w heel = greater Flexion/Extension adequate.
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Gait Cycle: Gait Assessment:

General:
Safety Environment tested in
Independence or assistance required Evaluate footware
Fear of movement Evaluation of walking aids and Ortos
Previous mobility level

Gait assessment:
*Start assessment at ankle/foot
and work your way up*
1) Step Length: 2) Step cadence:
-Is it Symmetrical? -Is it symmetrical?
-80cm for males -Shorter stance time
-60cm for females -Cadence = 117/min

3) Base of support: Also Look at: Pathological gait conditions:

-Heap posture 1) Foot slap:
-Wide/Narrow BOS -Reciprocal arm swing No controlled movement (weak dorsi flexors)
-Distance between heels 7-8cm’s -COG to BOS
-Angle of feet Toe in or Out? 2) Contralateral Vault:
PF stance
4) Endurance: Bobbing upwards onto toes
-Gait speed m/s 3m 5m 10m Assist limb clearance in swing phase
-Number of overbalance/deviations
-2MWT/6MWT 3) Extensor Thrust:
-Speed needs to be functional Forceful extension of knee on loading limb
- Make it across the road Flick leg backwards into extension
Weak quads

4) Circumduction: Functional Mobility Assessment:

Combined hip Abd, flexion & hip hitching Need to determine the patient is:
Associated with ↓ knee flexion - Safe
- Independent
5) Trendelenburg gait:
Lateral pelvic tilt - Amount of Assistance they require
Weak glute med - How movement is achieved
Pelvic drop on LHS = weak glute RHS That involves assessing their ability to:
- Walk in different directions -Carrying objects
6) Glut med gait: - Turning corners -Pick up objects from the floor
Flicking of pelvis side to side - Managing doorways -Navigate crowds
Lateral trunk flexion to affected limb - Uneven surfaces -Crossing roads
- Steps/Stairs -Running, Hopping, Jumping

PD Gait pattern: Ataxic Gait Pattern:

-Narrow BOS -Freeze During turning - ↑ BOS & ↑ER -Rigid Trunk
-↑ Cadence -↓Arm Swing -↓Arm Movement -Uncoordinated limb movement
-Slow/Shuffling gait -Hitching of Hip -↓Step length -Drunken appearance in gait
-Ridged -↓Step length -↓Velocity - Falls Risk
↓ Kn Flexion -Hips are fixed
↑Trunk Flexion -Difficulty initiating/terminating step
Hemiplegic Gait Pattern: *Hip extensors facilitate the swing face
-Slow - Poorly timed muscle contraction *Hip flexors are stretched and resales the stored elastic energy
-↑ stance time on unaffected limb -Kn hyper Extension in stance *Plantar flexor spasticity will cause Knee hyper extension
-↑Hip F, ↓PF at toe off -Hip hiking/circumduction in swing *Knee needs 60 Degree flexion for foot to clear floor
-↓stance time on affected limb -Kn Flexion at IC *Shock absorption in gait is via Hip Flexors
-↓DF at IC
-↓Kn Flexion in swing
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Treatment Planning: 2)Assessment:

-Need to base treatment on O/E findings Functional Mobility:
-Treat what we see -Bed Mobility -Transfers
-Focus on their abilities -Sitting -Standing Setting will determine treatment
-Determine what is causing their weakness (Strength? Length?) -Walking -UL function Modbury = Transfers, Mobility, Gait aid
-What prevents them from being independent
*O/E will help identify the impairment*
1)Goals: 3)Address Impairment:
Need to be patient centred -Strength
STG & LTG What would the they like to achieve in 5 weeks -Range
SMART Use hobbies/interests to guide treatment -Sensation Does it relate to function. Does it ↑Balance ↑Speed, ↑Range
-Endurance
Consider D/C planning: ->Rehab in home *Promote their skill acquisition but slowly withdraw feedback -> Promote Indep
-> Exercise program

4)Types of Practice: 5)Progression:

-Amount ->as much as possible Increase intensity and slowly build capacity
-Whole vs Part ->whole is always best (except reach & grasp) This can be done via:
-Distributed vs Massed ->distributed is better, massed for ↑fatigue -↓Assistance
-Variable vs Constant ->variable= neuroplasticity constant= motor learning -↑Distance
-Discovery vs Guided ->guided used for cognately impaired, initial Rx only -↑Time
-Mental Practice. ->Lights up the same amount of neural content -Use of Cues
-Change environment
Use of feedback/guidance:
Use external feedback 6)Reassessment:
- Auditory, Visual, Tactile, Proprioception This will help recruit motor Quantify results via Outcome Measures
Have pt look at hands, feet shoulder neurons and ↑ accuracy Reassess:
Balance, Strength, ROM, Endurance, Mobility
Why it worked/why it did not work?

Treatment Planning for stroke: (Target affected leg) General Information:

Strengthen Hip Ext/Abd & PF Principles of neuro plasticity:
- Abductors will help restore balance (walk sidewasys) 1 6
- Hip Extensors will help release kinetic energy from Psoas in swing phase 2 7
-Gastrock and Soleus will help w propulsion in push-off 3 8
CV Endurance training 4 9
-Treadmill (increases speed if safe to do so) 60% of HR 5 10
Balance training
-Turning (help with visual input)(use of foam mats, SLS, Hippocampus = Memory
-Reactive PC (help reduce falls) Cerebellum = Controlled movement, tone of trunk
Exercises include: Parietal = Sensory
Single leg push-off (PF) Bouncing: Dynamic (Balance) Thalamus = Relay Station
Alternate push off Claw Occipital = Vision
Heel lifts (Hip Flexion) Hip Extension (step backwards) Postural Control we need Vison, Vestibular, Somatosensory
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AC Abbreviations:
ABG Arterial blood gasses
MAP Mean arterial pressure
PaO2 Partial Pressure of Oxygen
PaCO2 Partial pressure of Carbon Dioxide
HCO3 Bicarbonate
FiO2 Fraction of inspired oxygen
SpO2 Blood oxygen saturation levels
CVP Central Venous Pressure
CVC Central Venous Catheter
ECG Electrocardiograph
ICP Intercranial Pressure
EVD Extra Ventricular Drains
IVT Intravenous Therapy
NGT Nasogastric Tube
IDC Indwelling Catheter
UWSD Underwater Sealed Drain
TED’s Thromboembolism-Deterrent
PEG Percutaneous Endoscopic Gastronomy (Feeding Tube)
PPC Post-Operative Pulmonary Complications

Rehab Abbreviations:
TIA Trans Ischemic Attack
tPA Thrombotic Therapy
ICA Internal Carotid Artery
ETA External Carotid Artery
AVM Arteriovenous Malformations
ICH Intracerebral Haemorrhage
SAH Subarachnoid Haemorrhage
CCA Common Carotid Artery
ICA Internal carotid Artery
MCA Middle Cerebral Artery
ACA Anterior Cerebral Artery
PCA Posterior Cerebral Artery
SMA Supplementary Motor Area
FOG Freezing of Gait
SLS Single Leg Stance
STS Sit to Stand
SOEOD Sitting on Edge of Bed
SOOB Sitting Out Of Bed
LOB Loss of Balance
TSR Total Shoulder Replacement
RTSR Reverse Total Shoulder Replacement
NMES Neuromuscular Electrical Stimulation
W/O Without
SXS Symptoms
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General abbreviations
ADL activities of daily living
A/E accident and emergency
A-P antero-posterior
A & W` alive and well
BP blood pressure
Ca Cancer
CH current history
CNS central nervous system
C/O. complaining of
CRP C-reactive protein
CSF cerebro-spinal fluid
CT computerized tomography
CVS cardio-vascular system
CWMS colour, warmth, movement, sensation
D/C discharge
DD during day
DM diabetes mellitus
DVT deep veined thrombosis
E/O excision of
EOD end of day
FALB fasting after light breakfast
FBC fluid balance chart
FH family history
GA general anaesthetic
GH general health
GIT gastro-intestinal tract/system
Hb haemaglobin
HPC history of presenting complaint
IDC in-dwelling catheter
IDDM insulin dependent diabetes mellitus (juvenile)
ICU intensive care unit
IM intramuscular (or, intermittent)
ISQ condition unaltered (in status quo)
IVT intra-venous therapy
LA local anesthetic
LMO local medical officer
MSS musculo-skeletal system
NAD nothing abnormal detected
NIDDM non-insulin dependent diabetes mellitus (adult)
O/A on arrival/admission
O/E on examination
OPD outpatient department
PAC pressure area care
PC present complaint (present condition)
PCA patient controlled analgesia
PE pulmonary embolus
PH past history
PMHx past medical history
R/O removal of
RIB rest in bed
RMO resident medical officer
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ROS removal of sutures or review of systems

RS respiratory system
S/B seen by
SH social history
SOOB sitting out of bed
TLC tender loving care
TPR temperature, pulse, respiration
TSD to see doctor
UTI urinary tract infection
WBC white blood count

Tests
ABG arterial blood gases
AXR abdominal x-ray
CBE complete blood examination (Hb, WCC and platelet count)
CBP complete blood picture (interchangeable with CBE)
CT CAT Scan
CXR chest x-ray
Dx diagnosis
ECG electrocardiograph
EEG electroencephalograph
ESR erythrocyte sedimentation rate
ERCP endoscopic retrograde cholangiopancreaotlogy
FBE full blood examination
FI for investigation
FOB fibre optic biopsy
Hb haemoglobin
LFT lung/liver function test
MBA 20 multiple biochemical analysis (20 tests) blood test
MRI magnetic resonance imaging
NAD nothing abnormal detected
PFT pulmonary function test
ROS review of systems
TPR temperature, pulse and respiration
WBC white blood count
WCC white cell count
XR x-ray

Orthopaedic abbreviations
# Fracture
ACL Anterior Cruciate Ligament
AE Above elbow
AFO Ankle foot orthosis
AK Above knee
AMP Austin Moore prosthesis
AO Arbeitsgemeinschaft für Osteosynthesefragen
AVN Avasular necrosis (better known as osteonecrosis)
BE Below elbow
BK Below knee
BMP Bone morphogenic protein
CMC Carpo-metacarpal
CPM Continuous passive motion
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DB&C Deep breath and cough

DCP Dynamic compression plate
DCS Dynamic condylar screw
DPC Delayed primary closure
ECRB Extensor carpi radialis brevis
ECRL Extensor carpi radialis longus
ECU Extensor carpi ulnaris
EDC Extensor digitorum communis
EPB Extensor pollicis brevis
EPL Extensor pollicis longus
EUA Examination under anaesthesia
F&A Foot and ankle exercises
FCR Flexor carpi radialis
FDS Flexor digitorum superficialis
FDP Flexor digitorum profundus
FPL Flexor pollicis longus
FWB Full weight bearing
GH Glenohumeral joint
HA Heavy assist
IRQ Inner range quadriceps exercises
KAFO Knee ankle foot orthosis
K wire Kirschner wire
LA Light assist
MA Moderate assist
MBA Motor bike accident
MCL Medial collateral ligament
MCP Metacarpophalangeal
MRI Magnetic resonance imaging
MUA Manipulation under anaesthesia
MVA Motor vehicle accident
NOF Neck of femur
NOH Neck of humerus
NSAID Non-steroidal anti-inflammatory drugs
NWB Non weight bearing
OA Osteoarthritis
OOP Out of plaster
ORIF Open reduction internal fixation
PCL Posterior cruciate ligament
PIP Proximal interphalangeal
POP Plaster of paris
PTB Patellar tendon bearing
PWB Partial weight bearing
RA Rheumatoid arthritis
ROP Removal of plaster
SIJ Sacroiliac joint
SLR Straight leg raise
SOOB Sit out of bed
SG Static gluteal exercises
SQ Static quadriceps exercises
THR (THA) Total hip replacement (arthroplasty)
TKR (TKA) Total knee replacement (arthroplasty)
TPT Total plaster time
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VMO Vastus medialis obliques

WBAT Weight bearing as tolerated
Physiotherapy outpatient abbreviations
Abd abduction
Add adduction
AROM active range of movement
C1 1st cervical vertebra
C1/2 posterior intervertebral joint between C1 and C2
CE cauda equina
Cx cervical spine
DF dorsiflexion
ER external rotation
E/Ext extension
Exs exercises
F/Flex flexion
HBB hand behind back
IFT interferential
IM intermittent
IR internal rotation
L limit of range
L1 1st lumbar vertebra
L1/2 posterior intervertebral joint between L1 and L2
LF lateral flexion
L/S lumbosacral
Lx lumbar spine
MMF modulated medium frequency
MMT manual muscle test
nerol neurological examination normal
obs observation
p pain
P1 onset of pain
P2 limit of pain
PAIVM passive accessory intervertebral movement
Palp palpation
PF plantar flexion
PIV posterior intervertebral joint
PPIVM passive physiological intervertebral movement
P&N pins and needles
˚p&n/numb no pins and needles or numbness
PROM passive range of movement
Pron pronation
P√R√S√ power, reflexes and sensation normal
R1 onset of resistance
R2 limit of resistance
R/Rot rotation
RD radial deviation
ROM range of movement
RSC resisted static contraction
Rx treatment
SB side bending
Sl slight
S√√W√√ sensation test performed and passed, warning given and understood
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Sup supination
Sust F sustained flexion
SWD short wave diathermy
T1 1st thoracic vertebra
T1/2 posterior intervertebral joint between T1 and T2
Tx thoracic spine
UD ulnar deviation
US ultrasound
VBI vertebro-basilar insufficiency
Wt weight
WL weight loss

Medication abbreviations
PRN as occasion arises (as required)
Daily once daily
BD twice daily
TDS three times daily
QID four times daily
Meds medication
nocté at night
mane in the morning
T one tablet
TT two tablets
PO orally

Cardiovascular System
AB5LICSMCL apex beat, 5th left intercostal space, mid clavicular line
AF atrial fibrillation
BBB bundle branch block
BP blood pressure
bruits added sounds in the heart
CCF congestive cardiac failure
CVP central venous pressure
CVS cardio-vascular system
HS heart sounds
J,A,(or P)Cl,Cy jaundice, anaemia, (or pallor) cyanosis, clubbing
JVP jugular venous pressure
JVPNE jugular venous pressure not elevated
JVPNR jugular venous pressure not raised
MI myocardial infarct
PVD peripheral vascular disease
PWP pink warm and perfused
SOA swelling of ankles
SBE sub-acute bacterial endocarditis
SVT supraventricular tachycardia

Respiratory System
AE air entry
AFB acid fast bacilli
BE basal expansion
BS breath sounds
CPAP continual positive airway pressure
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FEV1 forced expiratory volume in 1 second

FEF 50% forced expiratory flow when 50% of the vital capacity has been exhaled
FVC forced vital capacity
FRC functional residual capacity
haemoptysis coughing up blood
IMV intermittent mandatory ventilation
IPPB intermittent positive pressure breathing
IPPV intermittent positive pressure ventilation
mmHg mercury (millimetres)
OSA obstructive sleep apnoea
PaO2 arterial partial pressure of O2
PaCO2 arterial partial pressure of CO2
PE pulmonary embolus
PEEP positive end expiratory pressure
PEP positive expiratory pressure
PN percussion note
PND paroxysmal nocturnal dyspnoea
PS pressure support
RS respiratory system
RV residual volume
SOB shortness of breath
SOBOE shortness of breath on exertion
TML trachea mid-line
URTI upper respiratory tract infection
UWSD underwater seal drain
VC vital capacity
VF vocal fremitus
VR vocal resonance
Vt or TV tidal volume
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CNS:

CVA cerebrovascular accident

T.I.A. transient ischaemic attack
RIND resolving ischaemic neurological deficit
SDH subdural haemorrhage (or haematoma)
EDH extradural haemorrhage
SAH subarachnoid haemorrhage
HI head injury
CHI closed head injury
TBI traumatic brain injury
AVM arteriovenous malformation
N.P.H. normal pressure hydrocephalus
ICP intracranial pressure
LOC loss of consciousness
T.P.P. time, place, person
STM short term memory
F.F.F.T. fits, faints, funny turns
PERLA pupils equal & reacting to light and accommodation
EOM external ocular movements
A.J. ankle jerk
K.J. knee jerk
B.J. biceps jerk
T.J. triceps jerk
S.J. supinator jerk
F.J. finger jerk
J.J. jaw jerk
Pl plantar response (Babinski sign)
AER/P auditory evoked response / potential
VER visual evoked response
SER sensory /somatosensory evoked response
BER brainstem evoked response
GCS Glasgow coma scale/score
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Gastro-intestinal tract
BNO bowels not open
Ca cancer
GIT gastro-intestinal tract
haematemesis blood in vomit
LUQ left upper quadrant
LSKK liver, spleen, kidney (R) & (L)
malaena blood in stools

Genito-urinary system
CRF chronic renal failure
CUD continual urinary drainage
dysuria painful or difficult urination
GUS genito-urinary system
Haematuria blood in urine
HNV has not voided
IDC in-dwelling catheter
IVP intra-venous pyelogram
MSSU mid-stream specimen or urine
nocturia getting up to urinate at night
PV per vagina
PR per rectum
TUR (P) transurethral resection (prostate)
UO urinary output
UTI urinary tract infection