Practical Physiotherapy

Prescriber
Practical Physiotherapy
Prescriber
Gitesh Amrohit mpt (Neuro)
Director
Amrohit Institute of Rehabilitation Sciences
Raipur, Chhattisgarh, India
Director
Amrohit Physio Classes & Physio Solutions
President
Physiotherapist Association®
Chief Editor
Right Sehat (Weekly Newspaper)

Foreword
AT Dabke

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

New Delhi • Panama City • London • Dhaka • Kathmandu
 ®

Jaypee Brothers Medical Publishers (P) Ltd.

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: [email protected]

Overseas Offices
J.P. Medical Ltd. Jaypee-Highlights medical publishers Inc.
83, Victoria Street, London City of Knowledge, Bld. 237, Clayton
SW1H 0HW (UK) Panama City, Panama
Phone: +44-2031708910 Phone: +507-301-0496
Fax: +02-03-0086180 Fax: +507-301-0499
Email: [email protected] Email: [email protected]

Jaypee Brothers Medical Publishers (P) Ltd. Jaypee Brothers Medical Publishers (P) Ltd.
17/1-B Babar Road, Block-B Shorakhute, Kathmandu
Shaymali, Mohammadpur Nepal
Dhaka-1207, Bangladesh Phone: +00977-9841528578
Mobile : +08801912003485 Email: [email protected]
Email: [email protected]

Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com

© 2012, Jaypee Brothers Medical Publishers

All rights reserved. No part of this book may be reproduced in any form or by any
means without the prior permission of the publisher.

Inquiries for bulk sales may be solicited at: [email protected]

This book has been published in good faith that the contents provided by the
author contained herein are original, and is intended for educational purposes
only. While every effort is made to ensure accuracy of information, the publisher
and the author specifically disclaim any damage, liability, or loss incurred, directly
or indirectly, from the use or application of any of the contents of this work. If not
specifically stated, all figures and tables are courtesy of the author.
Practical Physiotherapy Prescriber
First Edition: 2012
ISBN 978-93-5025-986-3
Printed at
 Dedicated to
My parents
Dr Ramadhar Amrohit
Smt Shruti Amrohit
and
My Dearest twin brothers
Jeetesh-Jeevesh
 Foreword

Ultimate outcome of most of disease processes depend on how

correct is management of disease and its follow-up, after the
disease. This includes apart from correct medicines, proper
physiotherapy treatment during the disease process and post-
disease rehabilitation. In many conditions like fractures and
joint diseases, postacute care is more important than actual
treatment. Physiotherapy is also useful in those chronic condi-
tions which have long-lasting effects on functional capacity of
individuals like postmeningitis, stroke and chronic diseases
of lung and majority of the autoimmune diseases. Quality
of life depends primarily on effective rehabilitation which
includes various forms of exercises, electrotherapy, fitness
program, mobilization and manipulations. With advance-
ment of the science, patient surviving in various malignancies
is increasing. Most of the survivals require various forms of
physical therapy interventions, which improve the quality of
life-surviving individuals. Conditions associated with congen-
ital birth defects including malformation survival in some
cases are only depending on physiotherapy.
Dr Gitesh Amrohit incorporates the most aspects of phys-
iotherapy in the book. This is very useful for undergraduates,
postgraduates and physiotherapy professionals. It is equally
useful for physicians, pediatricians, surgeons, orthopedi-
cians, nurses and paramedical staff. Practical hints from
various chapters will help in improving patients’ quality of life.
AT Dabke
Ayush and Health Sciences University
Chhattisgarh, India
 Preface

It gives me immense pleasure to present my first edition of

Practical Physiotherapy Prescriber to all the physiotherapy
students and professionals.
The physiotherapy is a growing branch and became an
integral part of modern medical science. Physiotherapy
plays an important role in preventing, treating and postop-
eratively treating in various medical and surgical conditions.
There are lots of books on physiotherapy available in the
market but for studying physiotherapy management in prac-
tical manner was a great problem, especially during clinical
postings or practice. Now-a-days, newer physiotherapy
concepts being added and obsolete ones are withdrawn. So,
all the common medical and surgical conditions treated by
the physiotherapist have been included in the book, along
with essential of diagnosis as per new concepts. The book is
especially written for the undergraduate and postgraduate
students of physiotherapy and practitioners.
The main aim of the book was to quick diagnosis and
relevant physiotherapy management for various medical
and surgical conditions. The used language is very simple
and the content written in pointed manner. Advanced
physiotherapy management with dosage, duration of exer-
cise therapy and electrotherapy, Do’s/Dont’s, home advice,
orthotic and prosthetic supports should be kept in mind
 while writing the book. I think the book covers various
medical and surgical conditions including skin and psychi-
atric conditions.
Wishing and praying for your bright future and all the
success in your life.

Gitesh Amrohit

x
 Acknowledgments

First of all, I would like to give a heartily thank to my students

in Chhattisgarh, India and my irreplaceable staff, who were
there with me in every step, from bottom of my heart.
I would like to acknowledge with thanks to Mr Khomlal
Chandeshwar; SK Medical Book House and Distributor,
Raipur, Chhattisgarh, India also supported and encouraged
me to keep moving. It was not possible for me to publish the
book without their support.
Last but not least, I would like to thank the entire team of
M/s Jaypee Brothers Medical Publishers (P) Ltd, New
Delhi, India, especially Shri Jitendar P Vij (Chairman and
Managing Director), Mr Tarun Duneja (Director-Publishing)
and Mr Prasun Bhattacharya (Manager, Nagpur Branch), for
their unmatchable contribution in bringing out the book to
present shape.
Thanks one and all, I need your help too, to continue my
achievement.
 Contents

Chapter 1: Skin Diseases..............................................1

• Acne Vulgaris 1 • Alopecia 2 • Carbuncle 3
• Furuncle (Common Boil) 3 • Hyperhidrosis 4
• Leprosy 5 • Mycosis Fungoides 6
• Pityriasis Rosea 6
• Polymorphic Light Eruption (Ple) 7
• Pressure Sores 7
• Psoriasis 9 • Vitiligo 10

Chapter 2: Respiratory Diseases................................12

• Acute Bronchitis 12 • Atelectasis 13
• Bronchial Asthma 14 • Bronchial/Lung Tumors 15
• Bronchiectasis 16 • Chronic Bronchitis 17
• Cystic Fibrosis 17 • Emphysema 18
• Empyema 20 • Lung Abscess 20
• Pleural Effusion 21 • Pleurisy (Dry) 22
• Pneumonia 23 • Pneumothorax 23
• Pulmonary Embolism 24 • Pulmonary Edema 25
• Pulmonary Tuberculosis 25 • Respiratory Failure 26
• Sarcoidosis 27

Chapter 3: Orthopedic Conditions............................28

• Amputations 28 • Ankylosing Spondylitis (As) 28
• Arthrodesis 30 • Arthroplasty 30
• Bicipital Tendinitis 36 • Calcaneal Spur 37
• Calcaneovalgus Deformity 37
• Carpal-Tunnel Syndrome 38
• Cervical Disk Syndrome 39
 • Cervical Rib 40 • Cleidocranial Dysostosis 41
• Club Hand 42 • Compound Palmar Ganglion 42
• Chondromalacia Patellae 43
• Congenital Dislocation of the Hip (Cdh) 44
• Congenital Flat Foot 45
• Congenital Radioulnar Synostosis 46
• Congenital Short Femur 46
• Congenital Talipes Equino Varus (Ctev) 47
• Congenital Torticolis (Wry Neck) 48
• Contracted Fingers 49 • Coxa Vara 50
• Coxa Plana/Legg-Calve-Perthes Disease/Osteochondritis
Deformans Juvenilis 51 • De Quervain’s Disease 52
• Dislocation 53 • Dupuytren’s Contracture 54
• Fracture 55
• Frozen Shoulder (Periarthritis, Adhesive Capsulitis) 56
• Ganglia 57 • Genu Valgum (Knock Knee) 58
• Genu Varum (Bow Legs) 59 • Genu Recurvatum 60
• Golfer’s Elbow 60 • Gout 61 • Hematomas 62
• Hand Infections 62 • Hallux Rigidus 63
• Hallux Valgus 63 • Hammer Toe 64
• Infraspinatus Tendinitis 65 • Injury to Synovium 66
• Klippel-Feil Syndrome 67 • Kyphosis 67
• Lordosis 69 • Madelung’s Deformity 69
• Metatarsalgia 70 • Morton’s Metatarsalgia 71
• Nonunion 71
• Olecranon Bursitis (Student’s Elbow) 72
• Osteoarthritis 73 • Osteomyelitis 74
• Osteoporosi 75 • Osteotomy 75
• Pes Cavus 76 • Plica Syndrome 77
• Plantar Fasciitis 78 • Poliomyelitis 78
• Popliteal Cyst (Baker’s Cyst) 81
• Postinjection Contractures in Infancy 82
xiv
• Recurrent Dislocation of Patella (Rdp) 82
 • Rheumatoid Arthritis 84 • Rickets 87
• Rotator Cuff Lesions 88 • Scoliosis 89
• Spondylolisthesis 90 • Sprains 92 • Strains 94
• Subacromial Bursitis 97
• Subscapularis Tendinitis 97
• Supraspinatus Tendinitis 98
• Sprengel’s Deformity 98
• Tennis Elbow 99 • Thoracic Outlet Syndrome 100
• Traumatic Myositis Ossificans 101
• Trigger Finger/De Quervain’s 102
• Tuberculosis of the Hip Joint 103
• Tuberculosis Spine (Known after Sir Percival Pott) 103
• Tuberculosis Spine with Paraplegia 105
• Volkmann’s Ischemia (Compartment Syndromes) 106

Chapter 4: Neurological Conditions........................107

• Aphasia 107 • Alcoholic Neuropathy 108
• Amyotrophic Lateral Sclerosis 109 • Bell’s Palsy 110
• Brain Tumors 111 • Cerebral Palsy 112
• Deafness 114 • Diabetic Neuropathy 114
• Dysarthria 116 • Dysphagia 116 • Epilepsy 118
• Guillain-Barré Syndrome 119 • Headache 121
• Hydrocephalus 121 • Migraine 123
• Multiple Sclerosis 123 • Muscular Dystrophy 124
• Parkinson’s Disease 126
• Peripheral Nerve Lesions 127
• Peroneal Muscular Atrophy
(Charcot-Marie-Tooth Disease) 134
• Polyneuropathies 135 • Spina Bifida 136
• Spinal Cord Lesions 137
• Spinal Muscular Atrophy 139
• Stroke 141
xv
 Chapter 5: General Surgical Conditions..................144
• Acute Head Injury 144 • Adrenalectomy 144
• Arteriovenous Anomalies 145 • Burn 145
• Cholecystectomy 147 • Colostomy 148
• Cystectomy 148 • Cerebral Abscess 148
• Carotid Artery Stenosis 149
• Cleft Lip and Palate 149
• Compound Fractures 149 • Cosmetic Surgery 150
• Cranial Surgery 150
• Crush Injuries of the Hand 150 • Epilepsy 151
• Facial Fractures 151 • Facial Palsy 151
• Gastrectomy 152 • Head and Neck Surgery 152
• Hernia 153 • Hydrocephalus 153
• Ileostomy 153 • Intractable Pain 154
• Intervertebral Disk Lesions 154
• Jaw Osteotomies 154 • Lymphedema 155
• Malignant Melanoma 155 • Mastectomy 155
• Movement Disorders 156 • Nephrectomy 156
• Policization 157 • Prostatectomy 157
• Replantation 157 • Skin Grafts 158
• Spinal Tumors 158
• Subarachnoid Hemorrhage 159
• Syndactyly 159 • Thyroidectomy 159
• Toe to Thumb Transfer 160 • Tumors (Brain) 160
• Ulcers and Lacerations with Skin Necrosis 160
• Vascular Lesions 161

Chapter 6: Pulmonary/Cardiac Surgery.................162

• Cardiac Surgery 162 • Decortication of the Lung 164
• Lobectomy 164 • Pectus Carinatum/Excavatum 166
• Pleurodesis 166 • Pleurectomy 166
xvi • Pneumonectomy 167 • Thoracoplasty 168
• Thoracotomy 169
Chapter 7: Psychiatric Conditions...........................171
• Anxiety 171 • Anorexia Nervosa 172 • Depression 172
• Hysteria 173 • Obsessive Compulsive States 174
• Phobia 174 • Schizophrenia 175 • Stress 176
• Substance Abuse 177

Chapter 8: Obstetrics/Gynecology..........................179
• Abdominal Adhesions 182 • After Pains 183
• Back Pain 183 • Cervicitis 184 • Coccydynia 185
• Compression Syndrome 185 • Costal Margin Pain 186
• Cramp 186 • Diastasis Recti 187
• Displacement and Genital Prolapse 188
• Dysmenorrhea 189 • Dyspareunia 189 • Fibroids 190
• Hysterectomy 190 • Incontinence 191
• Joint Laxity 191 • Morning Sickness 192
• Osteitis Pubis/Diastasis (Separation) of Symphysis Pubis 192
• Painful Perineum 193 • Pelvic Floor Dysfunction 194
• Pruritus 195 • Restless Leg Syndrome 195
• Retention of Urine 195 • Sore and Cracked Nipples 196
• Symphysis Pubis Pain 196 • Uterine Ligament Pain 197
• Vulvitis 197

Chapter 9: Ent..........................................................199
• Acute Otitis Media 199 • Nasal Bleeding 200
• Sinusitis 201 • Tonsillitis 202 • Vertigo 203
• Vertigo due to Meniere’s Disease 205
• Vasomotor Rhinorrhea 206

Chapter 10: Miscellaneous.......................................207

• Arteriosclerosis Obliterans 207 • Constipation 208
• Deep Vein Thrombosis 209 • Diabetes 210
• Filaria 211 • Hemophilia 212
• Hemorrhoids/Piles 213 • Heartburn 213 xvii
• Hemophilic Arthropathy 214 • Hiccup 214
 • Insomnia and Nightmares 215 • Lymphedema 216
• Obesity 217 • Rheumatic Fever 219 • Scar Tissue 220
• Sexual Dysfunction 220
• Temporomandibular Disorders 221 • Ulcers 222
• Varicose Veins 222

Appendix....................................................................224
• National Immunization Schedule 224
• Electrotherapy 225 • Interferential 230
• Short-Wave Diathermy 231 • Ultraviolet Radiation 232
• Laser Therapy 233 • Ultrasound 234
• Transcutaneous Electrical Nerve Stimulation (Tens) 235
• Iontophoresis 236 • Infrared Radiation 237
• Paraffin Wax Bath   238
• Neuromuscular Electrical Stimulation (Nmes) 239
• Microwave Diathermy 240
• Cryotherapy (Cold Therapy) 241
• Hot Packs (Hydrocollator Packs)/Electric Heating Pads 242
• Whirlpool Bath 243 • Contrast Bath 243
• Sauna Bath 244 • Electromyographic Biofeedback 245
• Fluido Therapy 246
• Intermittent Pneumatic Compression 246
• Continuous Passive Motion   247 • Traction 248
• Exercise Prescription 249
• Normal Range of Motion for Various Joints 250
• Common Musculoskeletal Tests 253
• Normal Reference/Lab Values 281
• Other Body Fluids 285 • Caloric Contents of Diet 286
• Sample Diet Chart 287 • Burning of the Calories 289
• Key Development Milestones 290
• List of Pharmacology Abbreviations 291
• Abbreviations 292 • Important Terminologies 311
xviii Index .......................................................................315
 C H A P T E R 1

Skin Diseases

ACNE VULGARIS

Essentials of Diagnosis
• Starts between 9 and 17 years, is associated with puberty
and clear by 30 years.
• At beginning, starts as papules, which have slight
itching, discomfort, tenderness and redness.
• Sometimes cysts may be found, which fluctuates on
palpation with pain.
• If it is untreated and uncared, leading to blackheads in
the surface of the skin.
• Unfortunately, if patient has a keloidal tendency of the
skin, keloids may be seen.
• Found in oily skin and often familial.
• Common sites are face, upper chest, back and shoulders.

Management
• UVR—allow the patient in comfortable position usually
used modified sitting. Spectrum is 190–390 nm. The skin
 burner distance is 45 cm. For the improvement of skin
health, a first degree erythema (E1) dosage is given 2–3
times a week for 3–4 weeks.
For promotion of peeling a second or third degree,
erythema (E2, E3) dosage is given and repeated only when
peeling has stopped. Generally, E2 is used for face and E3
is used for chest and upper back. The treatment will be
respond in 6–8 weeks. Excess UVR therapy more than 12
weeks is dangerous.
• Skin to be washed carefully at least twice a day with oil-
free soap and dried.
• Avoid squeezing out the whiteheads and blackheads as
this leads to scarring.
• Avoid oily foods.

ALOPECIA

Essentials of Diagnosis
• Sudden onset, well-circumscribed, totally bald, smooth
patches are seen, which is usually affecting the scalp.
• Nonscarring, affecting hair bearing area.
• Associated with autoimmune diseases like thyroid, viti-
ligo, Addison’s diseases.
• Sebaceous glands are less active.
• Clumps of hair come away in the comb.
• Often familial but other cause of diffuse hair loss include
telogen effluvium, protein deficiency, high fever, hemor-
rhage, sudden starvation, malignancy, impairment of
2 liver and renal function and certain drugs.
Management
• UVR—for improving the general health theraktin may
be given a suberythema or E1 dosage, daily for 6–8
treatments.
For promotion of nutrition, Kromayer may be given as
E2 or E3 dosage for 2–3 times in a week for 2–3 months.
Two to three patches may be treated in one session.

CARBUNCLE

Essentials of Diagnosis
• Deeper and more extensively infiltrated lesion.
• Starts as a tender, erythematous, indurate deep plaque
on the back, neck or thigh, associated with malaise and
fever.
• Often the whole area sloughs off leaving a deep ulcer.

Management
• UVR—fourth degree erythema or double fourth degree
erythema dose to the affected area.

FURUNCLE (COMMON BOIL)

Essentials of Diagnosis
• Staphylococcus aureus, deep-seated infection of the
hair follicle around the hair root.
• Painful furuncles found around hairy areas of the body, 3
especially those subjected to friction and maceration.
 • Starts as a firm nodules but softens and ruptures after a
few days discharging pus.

Management
• SWD—in early stage, coplanar method.
• Infra-red radiation—when discharge has occurred.
• UVR—when boils are not drained or without
discharging.

HYPERHIDROSIS

Essentials of Diagnosis
• Hyperactivation of exocrine or apocrine sweat glands.
• Seat pours out of the glands even during relative inac-
tivity.
• Generally affects the age group of 14-35 years.
• Commonly affected sides are palms of hand, soles of
feet, axillae.

Management
• Glycopyroneum bromide iontophoresis—low inten-
sity direct current (1–2 mA/in 2 of electrode) for 15–20
minutes. Anode is placed over a pad soaked in the
compound or in the bowl of the water in the compound
and cathode is placed proximal to the anode.
If patient reports dryness of mouth, the dosage
should be reduced. Sips of water during the treatment
may help.
4
 LEPROSY

Essentials of Diagnosis
• Affects mainly peripheral nerves, skin, muscles, bones,
testes and internal organs.
• Hypopigmented patches.
• Loss of cutaneous sensation.
• Thickened nerves.
• Presence of acid-fast bacilli in the skin or nasal smears.
• Tropic ulcers.
• Nasal bridge collapse.
• Loss of fingers or toes.
• Claw hand.
• Foot drop.
• Claw toes.

Management
• Soaking the skin or part in warm water and performing
passive movements.
• Active exercises in all joints.
• Soaking the part in a soap water, rubbing off thick skin,
oiling, self-massage and protecting the part from infec-
tion.
• Teach about skin, hand, foot and eye care to group or
individual.
• Rest body position and POP cast.
• Elevation, active and passive exercises of swelled limbs.
• Muscle re-education after tendon transfer.
5
 After Surgery
• Management depends upon corrective surgery and
physiotherapy measures for those have been discussed
in earlier.

MYCOSIS FUNGOIDES

Essentials of Diagnosis
• Red, scaly patches appear on the any part of the body,
similar to psoriasis.
• Diagnosis is confirmed by the skin biopsy.
• Skin lesions develop plaques or nodular tumors.
• The disease may progress to the lymph nodes and vital
organs.
• Generally distributes in face, particularly around the
eyes.

Management
• PUVA—same as for psoriasis. Patient should wear
goggles to protect the eyes during treatment.

PITYRIASIS ROSEA

Essentials of Diagnosis
• Rash of red or pink erythematous, maculopapular scaly
lesions.
6 • Self-limiting disease but sometimes it persists.
• Commonly distributed in trunk and proximal extremi-
ties. Face and distal extremities in severe cases.

Management
• UVB—suberythema dose of UVB with the Therektin
two or three times a week for 2–3 weeks.

POLYMORPHIC LIGHT ERUPTION (PLE)

Essentials of Diagnosis
• Common photosensitive eruption, in which patient
have extreme sensitive to UVR and visible light.
• Begin at any age but teens and twenties are more
common.
• Itching, erythema, papules and blisters are seen at
lesions.

Management
• PUVA—six week’s course of PUVA in the spring or in
February or March.

PRESSURE SORES

Essentials of Diagnosis
• Any pressure injury which may vary from an area of
erythema to a deep-seated ulceration exposing the
underlying bone. 7
 • Occurs in any age but 75% found in over seventies.
• Found in pressure areas like hip, buttocks, hips, elbows.
• Floor of the sore may be pink and vascular or filled with
infected exudates. Around the cavity the skin is red or
blue.
• Pain is present, if sensory nerve endings are not
destroyed.
• Main cause of sore is immobility.

Management
• Turning—every two hours day and night.
• Special mattress or bed—like water bed, ripple mattress,
net bed, air fluidized bed, low air loss bed, roho cushion
or sorbo packs.
• Balanced diet.
• Exercises—strengthening/active/relaxed passive move-
ment.
• Ice therapy—ice massage over a reddened area.
• Ultrasound—on the surrounding area, 3 MHz head using
a low dosage, e.g. 0.25–0.5 W/cm2 for 5–10 minutes.
• UVR—fourth degree or double fourth degree dose, 2–3
times a week.
• PEME—pulse duration 65 µs, frequency 400 pulses/
minute, up to 30 minutes daily.
• Ionozone Therapy—distance 35 cm from the ulcer, for
10-20 minutes.
• Laser—30 mW for 33 seconds. Prob is held at 90.
• Compression and support bandaging—for ulcer edema
of surrounding tissues and limited joint movement.
8
 PSORIASIS

Essentials of Diagnosis
• It is a familial, chronic, recurrent disease of unknown
origin.
• Clearly defined dry, rounded red patches of various
sizes covered with mica-like silvery scales.
• Silvery scales due to light reflecting from the swollen
stratum spinosum.
• Removal of the scales may expose a thin membrane
giving rise to pinpoint bleeding points.
• Commonly affected sites are extensor aspect of extremi-
ties especially elbows, knee, occiput. Face is rarely
affected.

Management
• Removal of precipitating cause if known.
• Warm climate helps to check relapse.
• The Goeckerman regimen—application of coal tar 2–3
times a day with general UVB radiation given once a
day, as suberythemal or E1 dose.
• Leeds or Ingram regimen—after taking a coal tar bath,
patient is irradiated with maximum erythemal dosage of
UVB. After irradiation the skin lesions are covered with
dithranol cream, which is removed on the next day and
again UVR is given to skin as a wavelength of 311 nm.
• PUVA—patient is given 3–6 tablets of psoralen prefer-
ably with milk 2 hours before exposure. Tablet dosage is
according to body weight. 9
 Patient’s weight in kg Dose (mg)
30 10
30–50 20
51–65 30
66–80 40
81–90 50
90 and over 60

The drug 8–methoxy psoralen is used making the

patient highly reactive to UVA. The erythema in PUVA,
arise later than the erythema with UVB, and may not reach
a peak for 2–4 days.
Treatment is given twice a day, until clearance of
disease, which is usually cleared at 12–20 exposures.

Pustular psoriasis—treated by PUVA with a special piece

of equipment in which the fluorescent tubes are hori-
zontal and the hands and feet are placed on a grid over
them.

VITILIGO

Essentials of Diagnosis
• Irregular patches of the skin become depigmented and
appear white against normal skin.
• Lesions are circumscribed, milky white in color and
often symmetrical.
10 • Acquired, sometimes familial.
• Associated with other autoimmune diseases such as
thyroid disease, Addison’s disease, diabetes mellitus
and pernicious anemia.
• Common sites are face, especially around eyes and
mouth, axillae, groins, genitalia, hands and feet.

Management
• PUVA—psoralens [try-methyl psoralen (TMP) 8-MOP]
may be taken by mouth or painted on the affected areas
topically. E1 dosage is recommended for two treatments
a week for over a year. Initial dosage must be based on
the vitiliginous area and not on the patient’s general skin
type.

11
 C H A P T E R 2

Respiratory Diseases

ACUTE BRONCHITIS

Essentials of Diagnosis
• Productive cough.
• Fever.
• Rhonchi and crepitation in the chest with occasional
wheeze.
• Absence of X-ray findings.

Management
• Bed rest.
• Avoid smoking.
• Take a hot drink such as tea, coffee.
• Humidification—benzoin tincture.
• Postural drainage.
• Breathing exercises.
• Coughing.
 ATELECTASIS

Essentials of Diagnosis
• In acute cases—dyspnea, tachycardia, cyanosis, chest
pain, fever and hypoxemia.
• In chronic cases—no symptoms, only diagnosed on
X-ray.
• Important signs include reduction of the chest wall move-
ment on affected side, mediastinum shifted towards the
affected side, impaired percussion note on the affected
side with hyperresonance on healthy side, decreased or
absent breath sounds on the affected side.
• Radiological findings—lobar or segmental density, often
homogeneous with reduction in size of the affected
lobe. Trachea is deviated to the affected side with eleva-
tion of diaphragm in massive atelectasis.

Management
• Oxygen inhalation.
• Deep breathing exercises.
• Incentive spirometry.
• Thoracic expansion exercises.
• Sustained maximal expiration.
• Manual hyperinflation.
• Ambulatory exercises.
• In postoperative atelectasis the main treatment is
induction of hyperventilation and stimulation of
coughing.
13
 BRONCHIAL ASTHMA

Essentials of Diagnosis
• Acute, recurrent or chronic attacks of dyspnea, cough
with mucoid tenacious sputum and wheezing.
• Expiratory rhonchi is present all over the chest.
• X-ray findings—normal in early cases. In later cases
emphysematous changes with pneumothorax.

Management
• Avoid know allergens.
• Stop smoking.
• Postural drainage along with vibration daily.
• Effective coughing with minimum effort.
• Forced expiratory technique.
• Relaxation exercises with breathing control.
• Thoracic, neck and shoulder mobility exercises.
• Strengthening exercises for weak muscles specially
shoulder girdle, retractors, abdominals and thoracic
spine extensors.
• Advice to the patient for breathing control during all
daily activities.

Acute Attack
• Get out of bed.
• Take extra puff of aerosol inhaler.
• Take some hot tea or beverage or sips of warm water.
• High side lying or half lying position with pillows.
14 • Vibrations.
• Forced expiratory techniques.
• Postural drainage.
• Relaxation and breathing control exercises.

BRONCHIAL/LUNG TUMORS

Essentials of Diagnosis
• Insidious onset of dry cough with localized wheeze.
• In 25 to 30% cases hemoptysis is present.
• Dyspnea is highly variable and may be severe when
there is pulmonary collapse or pleural effusion.
• Dull pain is common, malaise and weight loss are asso-
ciated with late stage of the disease.
• Bronchoscopy and biopsy or exploratory thoracotomy
are the confirmatory diagnosis. As the tumor does not
exfoliate, sputum examination is not helpful.

Management
• Pre-and postoperative physiotherapy is essential for
patients who have a lobectomy or pneumonectomy.
• During/after radiotherapy once the tumor begins to
decreases in size the patient will begin to expecto-
rate sputum, postural drainage with vibrations may be
required.
• Avoid percussion and shaking, in that condition when
there is a danger of pathological fractures in ribs or
vertebrae.
• In terminal stage of the disease modified postural
drainage and vibrations with breathing exercises. 15
 BRONCHIECTASIS

Essentials of Diagnosis
• Chronic cough with profuse, purulent sputum.
• Bilateral basal coarse crepitation with rhonchi.
• Signs of general toxemia, e.g. anemia, anorexia, weight
loss, etc.
• Clubbing fingers, hemoptysis, night sweats.
• Dyspnea, pulmonary osteoarthropathy.
• Fever with chills. Sputum production is more during
change of posture.
• X-rays findings—bronchovascular markings, multiple
cysts with fluid levels.

Management
• Bed rest.
• Avoid exposure to smoke, dust, and fumes.
• Warm, dry climate is preferable.
• Adequate nutrition.
• Postural drainage along with vibration and shaking
daily. A hot drink before postural drainage may help to
liquefy sputum.
• Forced expiratory techniques.
• Localized expansion breathing exercises.
• Thoracic mobility exercises.
• Advice for sports activity.

16
 CHRONIC BRONCHITIS

Essentials of Diagnosis
• Sweating, dyspnea.
• Productive cough of longer duration.
• Fever is abscent except during acute exacerbations.
• Rhonchi, basal crepitations and prolonged expiration.
• X-ray—prominent bronchovascular markings.

Management
• Avoid the possible chronic irritation should be avoided
like fumes, dust, smoking, allergenic agents and other
irritants.
• Postural drainage—20 minutes session—twice a day.
• Clapping, shaking.
• Breathing exercises.
• Thoracic mobility exercises.
• Active shoulder exercises.
• Advice for graded ambulatory exercises.

CYSTIC FIBROSIS

Essentials of Diagnosis
• Abnormal heart rhythm, dyspnea, malabsorption.
• Recurrent respiratory infection, poor growth, malnutri-
tion.
• Dull or hyperresonant percussion note, but sometimes
normal. 17
 • Bronchial or bronchovesicular breath sounds.
• X-rays findings—shows hyperinflation.

Management
• Postural drainage twice a day even when the patient
is appertainly well. If upper respiratory tract infection,
postural drainage six times a day with twenty minutes
session.
• Breathing exercises specially localized expansion.
• Percussion, shaking, along with postural drainage is
very effective.
• Inhalations/humidification.
• Coughing and huffing.
• Shoulder girdle and thorax mobility exercises, e.g. in
sitting arm circling, elbow circling in backwards direc-
tion. Trunk bending backwards, trunk turning with loose
arm flinging and trunk bending side to side exercises.
• Advice for physical activity such as jogging, swimming,
etc.
• Also advice for correct erect posture.

EMPHYSEMA

Essentials of Diagnosis
• Prolonged expiration with wheezing.
• Dyspnea, productive cough with recurrent respiratory
infection.
• History of asthma, bronchitis, fibrotic pulmonary disease
18 or a familial predilection.
• Signs of respiratory acidosis and anoxia.
• In terminal stages right heart failure with depressed/
enlarged liver.
• Hyperresonant percussion note with diminished breath
sound.
• Acting of accessory respiratory muscles, barrel-shaped
chest.
• X-ray findings—over aerated lung fields with flattened
diaphragm.
• Lung function test—FEV1/FVC is usually below 70%.
RV is increased. The simple test being the inability in
putting out a burning matchstick at a distance of one
feet or exhaling the total vital capacity in more than 5
seconds.

Management
• Avoid pulmonary irritant, i.e. smoking, dust exposure,
humid or cold air.
• Controlled diaphragmatic breathing.
• Lower lateral costal and posterior basal expansion
exercises.
• Postural drainage.
• Shaking during expiration.
• Bronchodilator may be administrated with a nebulizer.
• Free active exercises for whole spine.
• Walking with breathing control.
• Teach the patient for rapid inhalation and contracting
abdominal muscles during expiration.

19
 EMPYEMA

Essentials of Diagnosis
• Chest pain increasing on inspiration, coughing, sneezing,
laughing.
• Dyspnea, fever, anorexia, malaise, weight loss.
• Signs of pleural effusion.
• Frankly purulent exudates on thoracocentesis, lack of
bacterial growth suggests tuberculosis.
• X-ray findings—D-shaped shadow seen.

Management
• Postural drainage.
• Breathing exercises 3–4 times a day.
• Stretching to the opposite side from the lesion.
• General exercises for leg, arm, and trunk.
• Walking with breathing control.

LUNG ABSCESS

Essentials of Diagnosis
• Fever, chest pain, weight loss, anorexia, anemia.
• Expectoration of large amounts of purulent, foul smelling
or rusty sputum, occasional hemoptysis.
• Signs of consolidation with cavernous breathing on
physical examination.
• X-ray findings—cavity with fluid level.
20
Management
• Postural drainage 10–15 minutes, every 4 hours.
• Shaking.
• Mild breathing exercises.
• Deep inspiration should not be encouraged because
increase the negative pressure may move the pus
through healthy lung tissues.
• Supportive therapy as rest, high protein diet, vitamins
supplements, etc.

PLEURAL EFFUSION

Essentials of Diagnosis
• Dyspnea which depends on rate of collection of fluid.
• Pleuritic pain often precedes the effusion.
• Stony dullness on percussion, decreased breath sounds,
decreased to vocal fremitus, shifting away from the
mediastinum.
• The underlying pulmonary or cardiac disease may be
a source of major symptoms, e.g. bronchogenic carci-
noma, pulmonary tuberculosis, infraction, thoracic duct
obstruction.
• Symptoms of toxemia—malaise, fever, anorexia.
• X-ray findings—obliteration of costophrenic angle is
the earliest sign. In later cases, triangular homogeneous
shadow of the fluid with apex in the axilla is noted.
• Thoracocentesis is the confirmatory diagnostic proce-
dure.
21
 Management
• Rest in bed till fluid gets absorbed, nourishing diet,
vitamins.
• Breathing exercises—localized expansion of the affected
side with the help of the belt/several times a day.
• Stretching the affected side—lie on unaffected side over
a firm pillow.
• Thoracic mobility exercises.

PLEURISY (DRY)

Essentials of Diagnosis
• Pleuritic pain aggravated by inspiration.
• Limited thoracic expansion at the affected area.
• Pleural rub sound heard on auscultation.
• Cough.
• Tachycardia.
• Pyrexia.
• X-ray findings—diaphragm may be raised on the
affected side.

Management
• Localized lung expansion exercises with manual resist-
ance.
• General deep breathing exercises.
• Mobility exercises such as sitting trunk bending side to
side.
22
 PNEUMONIA

Essentials of Diagnosis
• Pleuritic pain, fever, chills, cough with rusty sputum.
• Toxemia and tachypnea, fatigue after few days.
• Leukocytosis.
• Signs of consolidation, i.e. dullness, inspiratory crepi-
tation, absent breath sound to bronchial breathing VF
and VR increased.
• X-ray findings:
–– In pneumococcal infection—hazy lung appearance.
–– In staphylococcal infection—abscess appears like
thin walled cyst.
–– In legionella infection—bilateral patchy lesion.
–– In mycoplasma infection—patchy infiltration.

Management
• Humidification.
• Postural drainage along with clapping, shaking.
• Breathing exercises.
• Graded active exercises for limbs and trunks.

PNEUMOTHORAX

Essentials of Diagnosis
• Sudden onset of chest pain, associated with dyspnea,
cyanosis.
• Increased respiration distress, hypotension, tachycardia, 23
and decreased movement of the chest wall, obliteration
 of the liver and cardiac dullness depending upon the
side involved.
• Coin sound or bell sound test positive.
• X-ray finding—absence of lung markings, edges of
collapsed lung can be seen.

Management
• Active exercises of the shoulder/3-4 times/day.
• Thoracic mobility exercises/3-4 times/day.
• Breathing exercises (simply).
(Above managements for those patients who has an under-
water drainage system).

PULMONARY EMBOLISM

Essentials of Diagnosis
• Chest pain, dyspnea, hemoptysis and circulatory
collapse.
• Sign of tachycardia, hypotension, shock, impaired
concentration and low urine output.
• Raised JVP, diastolic gallop to left of midsternum,
central cyanosis, fever.
• Syncope or death may occur when degree of pulmo-
nary arterial obstruction is sudden and severe.
• X-ray findings—wedge-shaped opacities in peripheral
lung fields.
• Lung scanning and pulmonary angiography are
con­firmatory.
24
Management
• Bed rest with the end of the bed elevated. Patient is
allowed up when all symptoms have disappeared.
• Active exercises of lower limbs.
• Graded ambulatory management.

PULMONARY EDEMA

Essentials of Diagnosis
• Orthopnea, dyspnea, chest pain
• Cough with copious frothy expectoration often blood
tinged.
• Sometimes sweating and hypothermia.
• Bubbling rales over lower lobes then spreading all over
chest.
• X-ray findings—bat wing appearances.

Management
• Relaxed positioning.
• Relaxed exercises.
• O2 inhalation by continuous or intermittent positive
pressure method.

PULMONARY TUBERCULOSIS

Essentials of Diagnosis
• Cough, hemoptysis, apical crepitation and weight loss. 25
• Fatigue, malaise, anorexia, night sweats.
 • Cavity, bronchitis, signs of consolidation.
• Positive tuberculin skin test, positive AFB sputum test.
• X-ray findings—cavity formation and calcification can
be seen.

Management
• Bed rest for few days during the acute stage, i.e. with
cough, fever and hemoptysis.
• Deep breathing exercises.
• Graded ambulatory exercises.
(Physiotherapist should stand behind the patient to avoid
the droplet infection as the patient cough).

RESPIRATORY FAILURE

Essentials of Diagnosis
• Reduction of the function of the lungs due to lung
diseases, skeletal or neuromuscular disorder.
• Important causes are chronic airway obstruction, chronic
bronchitis, emphysema, asthma.
• Headache.
• Restlessness.
• Tachycardia, confusion.
• Hypotension, central cyanosis.
• Depresses respiration.

Management
• Postural drainage.
26
• Clapping, shaking and vibrations.
• Breathing exercises.
• Coughing.
(Treatment has to be for shortly spell at 1 or 2 hourly
intervals. All treatment is monitored by regular blood gas
analysis).

SARCOIDOSIS

Essentials of Diagnosis
• Very rare.
• AFB negative so also Mantoux test.
• Skin, bone, uveal tract, salivary glands and myocar-
dium are also involved.
• Biopsy of lymph nodes and skin shows noncaseating
epithelioid cell granuloma.
• Often asymptomatic in spite of gross pulmonary
changes.
• X-ray findings—hilar adenopathy, nodular or fibrous
infiltration of both lungs.

Management
• Physiotherapy management is purely symptomatic.

27
 C H A P T E R 3

Orthopedic
Conditions

amputations

Management
• Cryotherapy, thermotherapy.
• Repeated spinal flexion, extension and rotational exer-
cises.
• Deep breathing exercises.
• Localized thoracic expension exercises.

ANKYLOSING SPONDYLITIS (AS)

Essentials of Diagnosis
• More common between 15 and 40 years of the age. More
common in men.
• Morning stiffness, pain in the lower back.
• Fatigue and the radiating pain on the back of the leg.
• Muscle spasm of the lumbar paravertebral muscles and
the flattening of the lumbar spine.
• Pump handle test, pelvic compression test and Fleche’s
are positive.
• Acute iritis, pericarditis, aortic incompetence, subluxa-
tion of the atlantoaxial joints, apical lobe fibrosis, and
osteoporsis.
• X-ray findings—SI joint shows haziness, subchondral
erosions, sclerosis, and widening. Squaring of vertebra,
loss of lumbar lordosis, calcification of anterior longi-
tudinal ligament bringing osteophytes and bamboo
spine.

Management
• Cryotherapy, thermotherapy.
• Repeated spinal flexion, extension and rotational exer-
cises.
• Deep breathing exercises localized thoracic breathing
exercises.
• Active ROM exercises, PRE, passive ROM exercises for
the spine, hip and other joints.
• Proper postural corrections should be suggested like
–– Chin should be tucked in.
–– Repeated prone lying.
–– Hip hyperextension in prone.
–– Trunk lateral bending in the prone with deep
breathing.
–– Avoid stooping posture. Chest should be held up
and the shoulder should be braced back.
• Avoid using of spinal support for a long time.
• Avoid prolonged bed rest.
• Swimming especially with front crawl and breast stroke. 29
 • Gymnasium, and pool therapy.
• Use a firm bed with one pillow at night for sleeping.
• No smoking.
• Occupational therapy.

ARTHRODESIS

Management
• Thermotherapy.
• Elevation.
• Compression.
• Active exercises to the unaffected joints.
• Mobilization.
• Strengthening exercises.
• Ambulation.
• Gait training.

ARTHROPLASTY

Excision Arthroplasty of the Hip

Management
During the first 15th days:
• Skeletal traction.
• Chest physiotherapy.
• Treatment for DVT and pulmonary embolism on the
requirement basis.
• Active exercises for the unaffected limb.
30 • Isometric exercises for the glutei, quadriceps and
hamstrings.
During 15th to 30th days:
• Relaxed passive movements.
• Full ROM active movements to hip, knee and the
ankle.
• Advice for sitting up.

During 30th to 45th days:

• Same as for the 15th to 30th days.
• Passive stretching of the hip.

After 45th days:

• Same as for the 30th to 45th days.
• Weight bearing activity with assistive devices.
• After 12 weeks full weight bearing exercises.
• After 15th to 16th weeks starts the stair climbing.
• Advice for prone lying.

Hemireplacement of the Hip

Management
• Immobilization.
• Positioning with limb in abduction.
• If required skin traction.
• Advice for prone kneeling.
• Self-assisted exercises specially flexion of the hip in
supine or sitting position.
• Squatting exercises.
• After 3 weeks partial weight bearing.
• After 6 to 8 weeks full weight bearing.
• After 12 weeks advice for all ADL.
31
 Total Hip Replacement
Management
During the 1st week:
• Fully bed rest.
• Chest physiotherapy.
• Active exercises for the toe and ankle.
• Isometric exercises to the glutei, quadriceps, hamstrings,
ankle dorsi flexion and plantar flexion for both limbs.
• Put the pillows between the legs for both lying and side
lying.
• Measures to prevent DVT and pulmonary embolism.
• Relaxed passive movements.

During 2nd week:

• Passive/active assisted and active exercises.
• ROM exercises.
• Suspension exercises.
• Roller skates exercises.
• Turning activities.
• Advice for sitting with knees hanging.
• Advice for wheelchair for some days.

During 3rd week:

• Partial weight bearing in parallel bar.
• Crutch walking.
• Strengthening exercises for the hip, knee and the ankle.
• Knee standing, and walking.
• Single leg standing on operated limb.
32
After 1 month:
• Ambulatory exercises.
• Stair climbing.
• Bicycle exercises.
• After 12 weeks allow for all ADL.
• Avoid cross leg sitting and long sitting.

Total Knee Replacement

Management
During 1st week:
• Chest physiotherapy.
• Isometrics exercises to the glutei, quadriceps and
hamstrings.
• Active exercises for the toe and ankle.
• SLR.
• Advice for sitting up with knee supported in extension
at the afternoon of the 2nd day of operation.
• By the 4th and 5th day, advice the patient to stand and
ambulate with walkers.
• Self-assisted passive flexion of the knee or CPM with 1
cycle/minute.
• Active or active-assisted knee flexion exercises.

During 2nd week:

• Same as for the 1st week.
• Partial weight bearing.
• Ambulation with crutches.

33
 During 3rd week:
• Same as for the 2nd week.
• Stationary bicycle or ped-o-cycle exercises.
• Full weight bearing with crutches.
• Staircase walking.
• Quadriceps drill.
• Hydrotherapy.

After 6 weeks:
• Advice to walk with a cane.
• Balancing on his knees.
• After 12th week advice for all ADL.

Total Ankle Arthroplasty

Management
• Active exercises to the hip, knee and toes of the oper-
ated limb.
• If swelling, limb elevation and pressure bandage.
• At the 5th day of operation, active dorsi/plantar flexion
exercises of the ankle and foot.
• After 2 to 3 weeks, partial weight bearing on the affected
limb.
• Full weight bearing with sticks.
• Walking.
• Stair climbing.
• Relaxed passive stretching of the scar.
• ADL.

34
Shoulder Arthroplasty
Management
• Active exercises for the normal limb.
• Wrist, hand and finger movement of the operated limb.
• All movements of the shoulder joint.
• Avoid lateral rotation of the shoulder joint. It starts after
6 weeks of operation.
• Shoulder shrugging exercises.
• Shoulder pendulum exercises.
• Active and active-assisted movements of the shoulder
in the supine/sitting.
• After end of 3 months advice all ADL.

Elbow Arthroplasty
Management
• Active Rom exercises.
• Sling suspension.
• If swelling, limb elevation and pressure bandaging.
• Active exercises to all joints of the unaffected limb.
• Mobilization exercises of the elbow.
• Active flexion/pronation-supination exercises.
• Gentle passive exercises.
• Splinting.
• Avoid heavy lifting.
• Strengthening exercises for the biceps and triceps.
• ADL.

35
 Total Wrist Arthroplasty
Management
• Active exercises to the shoulder, elbow and fingers on
the operated side.
• After 4 weeks of operation, active and active-assisted
movements to the operated wrist.
• Passive relaxed wrist flexion and extension in gravity
eliminated position.
• If swelling, elevation and pressure bandaging.
• ADL.

Hand Arthroplasty
Management
• Active exercises of the shoulder, elbow, wrist on the
affected side.
• If swelling, elevation and pressure bandaging.
• Strengthening exercises.
• Progressive ROM exercises.
• If patient develops flexion contracture or ulnar devia-
tion, bracing.

BICIPITAL TENDINITIS

Essentials of Diagnosis
• Common in elderly males.
• Pain in the intertubercular groove.
• During lifting or pulling weight patient complains a
36 sense of gravity way.
• Resisted supination.
• Bulge may also be seen in the anterior aspect of the
upper arm.
• Pain during forearm supination clinches is the diag-
nostic criteria.

Management
• Slings for 2–3 days.
• Thermotherapy.
• Cryotherapy.

CALCANEAL SPUR

Essentials of Diagnosis
• Spike of the bone at the anterior edges of the calcaneal
tuberosity.
• Pain over the ball of the heel.
• Tenderness over the ball of the heel.
• Swelling at the attachment of plantar fascia.

Management
Same as for the plantar fasciitis.

CALCANEOVALGUS DEFORMITY

Essentials of Diagnosis
• Highly dorsi flexed foot at the ankle joint. 37
• Eversion of the foot at the subtalar joint.
 • Deformity may get correct itself as the child starts
walking.

Management
• Passive correction in the some cases.
• Stretching in the direction of plantar flexion.
• Active exercises.
• Strengthening exercises for the plantar flexors.

CARPAL TUNNEL SYNDROME

Essentials of Diagnosis
• Pain in hand.
• Morning stiffness.
• Tingling, numbness and paresthesia are localized to
areas supplied by the median nerve.
• Clumsiness in hand.
• Impairment of digital functions.
• Sensory loss over the median nerve distribution area.
• Phalen’s test and tourniquet test is positive.

Management
• Ultrasound.
• SWD.
• Gentle relaxed passive movements, active-assisted and
active movements of the wrist and fingers.
• Carpal Tunnel splint.
38
 CERVICAL DISk SYNDROME

Essentials of Diagnosis
• Pain in neck which is gradual or acute in onset.
• Morning stiffness.
• If nerve root is compressed, tingling and numbness, but
it does not follow the dermatomal pattern.
• Radiating pain along the neck, shoulder, upper arm,
forearm and hand.
• Decreased neck movement.
• Pain increases on hyperextension of neck.
• Tenderness over the spinous process.
• Trigger point over the scapular region.
• If disk herniation occurs, sensory, motor and reflex
changes will be seen.
• X-rays shows, narrowing of disk space, anterior and
posterior osteophyte formation and narrowing of
intervertebral formation.

Management
• SWD.
• MWD.
• TENS.
• IR.
• Hydrocollateral packs over the neck region along with
scapular region.
• Ultrasound.
• Ice massage.
• Strengthening exercises of the neck muscles. 39
 • Strong isometric of neck.
• Active-assisted exercises to the neck.
• Relaxed passive exercises for all the neck move-
ments.
• PNF techniques.
• Manipulation.
• Continuous cervical traction/24 hours/day/weight of
5 to 15 Ibs.
• Static cervical traction/20 to 30 minutes with weights
ranging from 10 to 30 Ibs.
• Intermittent traction.
• Polyaxial cervical traction.
–– For upper cervical vertebrae—traction is given in
hyperextension.
–– For middle cervical vertebrae—traction is given in
neutral position.
–– For lower cervical vertebrae—traction is given in
flexion.
• Cervical color.
• Advice for butterfly pillow.

CERVICAL RIB

Essentials of Diagnosis
• Transverse process of the 7th cervical vertebrae may be
abnormally large, or small fibrous band may run from it
to the first rib or the sternum.
• Sometimes fully developed rib may be present.
40
• Wasting of thenar, hypothenar or interossei muscles.
• Tingling in the radial side of the hand.
• Pain radiates downwards from the arm.
• Cold and blue finger.
• Feeble or absent radial pulse.
• Sometimes supraclavicular lump may be present.

Management
• Heat therapy.
• Circulatory exercises for hands, and fingers.
• Strengthening exercises of the whole arm.
• Shoulder girdle movements.
• Resisted exercises for the scapular muscles.
• PNF.

CLEIDOCRANIAL DYSOSTOSIS

Essentials of Diagnosis
• Aplasia of clavicles.
• Exaggerated development of transverse diameter of the
cranium.
• Delay in closure of clavicle.
• Often discovered accidentally.

Management
• Same as described for Sprengel’s shoulder.

41
 CLUB HAND

Essentials of Diagnosis
• Excessive radial or ulnar deviation associated with
distortion of the hand at the wrist from the long axis of
the forearm.
• Deviation depends upon whether radius or ulna is
absent.
• Absence of radius is more common.
• Inability to make the grasp action.
• Soft tissues tightness.
• Developmental contractures.

Management
• Splinting in neutral position.
• Passive stretching.

Postoperative Physiotherapy
• Splinting.
• Gentle passive movements.
• Strengthening exercises to weaker muscles.
• ADL.

COMPOUND PALMAR GANGLION

Essentials of Diagnosis
• It affects the flexor tendons of the fingers mainly the
42 ulnar bursa.
• Due to tuberculosis through rheumatoid arthritis may
also be a cause.
• Melon seed bodies are present.
• Effusion may be seen.
• Pain is not a feature.
• Features of median nerve compression but there is
definite evidence of wasting of the hand and forearm
muscles.

Management
Same as for the Carpal Tunnel syndrome.

CHONDROMALACIA PATELLAE

Essentials of Diagnosis
• Aching at the front of the knee.
• Aggravated by prolonged sitting or by knee flexion-
extension.
• Swelling with chronic effusion.
• Patellofemoral griding test is positive.

Management
• Ice packs two or three days.
• Quadriceps strengthening exercises.

After Surgery
• SWD.
• Ultrasound. 43
 • Isometrics to hip, quadriceps.
• Assisted SLR.
• Active and passive ROM exercises of the knee joint.
• Gradual PRE to the knee joint muscles.
• Shoe raise on the normal leg during ambulation.
• Avoid excessive hyperextension of the knee.

CONGENITAL DISLOCATION OF THE HIP (CDH)

Essentials of Diagnosis
• Partial or complete displacement of the femoral head
from the acetabular cavity since birth.
• Features of the hip dislocations.
• Gluteal and thigh folds are not symmetrical.
• Widened perineum.
• Decreases hip abduction and increased internal rota-
tion.
• Waddling or sailor’s gait.
• Telescopy and Trendelenburg tests are positive in
children and adolescents.
• In adults, secondary osteoarthritis features are seen.
• X-ray findings—Von Rosen’s line is helpful.

Management
During immobilization:
• Isometric exercises for glutei and quadriceps.
• Active ROM exercises for the hip and the knee.

44
During mobilization:
• Active ROM exercises for the hip, knee and the ankle.
• Relaxed passive adduction.
• Strengthening exercises for the glutei and quadriceps
(Isometric, isotonic and progressive resistive exercises).
• Weight training.
• Weight bearing exercises.
• Gait training.

CONGENITAL FLAT FOOT

Essentials of Diagnosis
• Flattening of the arches.
• A high valgus index.
• Rocker bottom foot (Inward rotation of the great toe in
relation to the ground).
• Positive great toe extension test.
• Associated hypermobility of foot.
• Increased pressure under the medial columns of the
foot in footprints.

Management
• Walk on irregular surfaces.
• Advice for walking on outer border of the foot.
• Give modified shoes with 1/6th crooked and elongated
heel on medial side.
• Faradic foot bath.
• Postoperative physiotherapy.
45
 • In immobilization phase, toe and other free joint move-
ments.
• Strengthening exercises for intrinsic muscles.
• Cupping and toe curling movements.

CONGENITAl RADIOULNAR SYNOSTOSIS

Essentials of Diagnosis
• Radius and ulna are fused together.
• Restricted forearm pronation and supination.
• Limited extension of the elbow.

Management
• Strengthening exercises for the muscles of upper limb.
• Free active exercises.
• Rotatory movements.

CONGENITAL SHORT FEMUR

Essentials of Diagnosis
• Shortening of the leg due to short proximal femur.
• Difficulty in walking and standing.

Management
• Raising of the shoe on the affected side. 1/2’’ or less
shortening does not require any raise. 1” or more
require 3/4’’ raising.
46
Postoperative Physiotherapy
• Strong quadriceps contraction.
• SLR.
• Full weight bearing with POP.
• After removal of plaster cast, if knee is stiff-stiff reducing
measures.
• Hydrotherapy.

CONGENITAL TALIPES EQUINO VARUS (CTEV)

Essentials of Diagnosis
• Plantar flexion of the ankle joint.
• Inversion of the subtalar joint.
• Adduction of the forefoot.
• Diagnosis is fairly simple.
• Stumbling gait, callosities, degeneration and arthritic
changes in the ankle and foot joints.
• X-ray findings—talocalcaneal angle are reduced.

Management
• First 6th month of the age Phelps brace and Dennis
brown splint for night.
• After 18th months, below knee walking calipers or
CTEV shoes given up to 4 years of the age.
• Advice to mother for manipulation in order of forefoot
adduction, inversion.

47
 Postoperative Physiotherapy
• Hip, knee, and toe movements in the plaster.
• Nonweight bearing active and resisted foot and ankle
exercises.
• Partial then full weight bearing exercises.
• Night splints.
• Gait training.
• CTEV shoes.

CONGENITAL TORTICOLIS (WRY NECK)

Essentials of Diagnosis
• Sternomastoid muscle of the neck undergoes contrac-
tures and results in pulling of the neck to the same side
and turn the face to the opposite side.
• Tumor palpable at birth or during the first two weeks of
the life.
• Most common on the right side.
• Raised shoulder on the affected side.
• Muscle diffusely is seen but more often it is localized
near clavicular attachment of the muscle.
• In later stage facial changes and macular problems in
the retina may develop.

Management
• Thermotherapy and gentle massage.
• Slow relaxed passive movements of the neck in supine
position.
48
• Gentle sustained passive stretch in the opposite direc-
tion of the affected muscle.
• Passive correction by supporting measures.
• PNF for neck extension.
• Positioning.

Postoperative Physiotherapy
• Thermotherapy and hydrotherapy.
• Active ROM exercises of the sternocleidomastoid
muscle.
• Self-correction in front of the mirror with the help of
active movements.
• Advice for cervical collar.
• Proper posture guidelines.

CONTRACTED FINGERS

Essentials of Diagnosis
• Results due to contractures of fascia and skin of the
fingers.
• Flexion contracture over the proximal interphalangeal
joint and extension contracture over the distal-inter-
phalangeal joints.

Management
• Splinting.
• Stretching.
• Postoperative physiotherapy.
49
 • Splinting along with stretching.
• Strengthening exercises to the fingers.
• ADL.

COXA VARA

Essentials of Diagnosis
• Deformity is diagnosed when the child begins to walk.
• Child’s walk with painless limp or waddling gait.
• Decreased rotation and abduction of hip.
• Pain and stiffness.
• Flexion contractures.
• Compensatory lordosis or scoliosis.
• Positive Trendelenburg’s sign.
• Patient’s stand with abducted and externally rotated
hip.
• Elevated greater trochanter.
• Limb length discrepancy in unilateral cases.

Management
Postoperative Physiotherapy
During immobilization:
• Isometrics exercises for quadriceps and glutei.
• Active movements for ankle and toes.

During mobilization:
• Relaxed passive ROM exercises specially hip abduction
and internal rotation.
50
• Partial weight transfer on affected joint.
• Advice for orthosis.
• Walking retraining.
• Ambulatory exercises.

COXA PLANA/LEGG-CALVE-PERTHES DISEASE/OS-

TEOCHONDRITIS DEFORMANS JUVENILIS

Essentials of Diagnosis
• Disorder affecting the capital femoral epiphysis.
• Avascular necrosis.
• Common in boys between 4 to 8 years, but can also
occur in less than 2 years and more than 12 years.
• Painless limp.
• Mild pain in the hip or anterior thigh or the knee.
• History of trauma may be present or absent.
• Onset of pain may be acute or insidious.
• Muscle spasm.
• Antalgic gait.
• Proximal thigh atrophy.
• Decreased range of abduction and internal rotation.

Management
• Thermotherapy.
• Cryotherapy.
• Active isometric exercises to the gluteal muscles, quadri-
ceps and hamstrings.
• Active, active-assisted, resistive exercises to the flexors,
extensors and abductors of the hip, quadriceps and 51
 hamstrings, dorsiflexors, plantar flexors and intrinsic
muscles of the foot.
• Passive ROM exercises to the hip.
• Active-assisted and active ROM exercises to the hip,
knee and ankle joints.
• Slow passive stretching of the hip joint.
• Repeated prone lying position.
• Progressive walking measures.
• Pool exercises.
• Proper shoe raise, if the limb is short.
• Educate to patient for posture.

Management After Surgery

• Same as for the conservative management.
• During immobilization isometrics for the hip and knee
muscles inside the plaster cast and resistive toe move-
ments for the affected side.
• Full range resistive movements to the hip, knee, and
ankle joints.
• Isometrics to the hip abductor and extensors of the
normal limb.

DE QUERVAIN’S DISEASE

Essentials of Diagnosis
• Pain and the swelling over the radial styloid process.
• Tenderness over the radial styloid process.

52
• Pain is aggravated by adducting the thumb across the
palm.
• Finkelstein’s test is positive.

Management
• Cryotherapy specially in acute stage.
• Thermotherapy specially TENS, SWD, and US.
• Wrist splinting in functional position.

DISLOCATION

Essentials of Diagnosis
• Total loss of contact between the two ends of bones.
• Main region is trauma.
• Pain.
• Swelling.
• Deformity.
• Loss of movement.
• In shoulder—abduction deformity.
• Elbow—flexion deformity.
• Hip—anterior-flexion, abduction, and external rotation
deformity.
–– Posterior-flexion, abduction and internal rotation
deformity.
• Knee-flexion deformity.
• Ankle-varus deformity.

53
 Management
• Same as for fracture.
• After immobilization, ROM exercises, resistive exer-
cises, passive and strengthening exercises should be
advocated on a war footing to prevent joint stiffness.

DUPUYTREN’S CONTRACTURE

Essentials of Diagnosis
• Onset is usually less than 40 years of the age.
• Frequent and severe in epileptics and alcoholics.
• Whites are affected more than the black.
• Ten times more common in the male.
• Begins with ring finger at the distal palmar crease and
latter involves little finger.
• Nodule in the deep palmar fascia at the level of meta-
carpophalangeal joint.
• Fibrotic bands over the affected fingers.
• Occasionally itching or pain.

Management
• Wax bath.
• Deep friction massage.
• Passive stretching.
• Ultrasound.
• Iontophoresis.
• Hand splints in extension position.
54
Management after Surgery
• Same treatment is followed.

FRACTURE

Essentials of Diagnosis
Immediately After the Fracture
• Shock, depend upon extent of injuries and the position
of the fracture.
• Pain.
• Deformity, according to the displacement of the bone
fragments.
• Edema, localized, immediately after the injury and
then gradually become more extensive.
• Marked local tenderness.
• Muscle spasm.
• Abnormal movements and crepitus.
• Loss of function.
Following reduction and fixation
• Pain.
• Edema.
• Loss of function.
After removal of the fixation
• Pain.
• Edema.
• Limitation of the joint movements.
• Loss of muscle power, which have not been used, or not
properly used for several times.
55
• Loss of function.
 Management
During immobilization:
• Elevation of the affected limb.
• Active or static contraction of the muscle.
• Isometric and isotonic contractions of the affected
muscles.
• Encourage functional activity when possible.
• Actively exercises for those joints who not involved.
• Encourage the normal pattern of movement. In LL
during non or partial weight bearing by using walker or
crutches the patient is taught to bear weight and walk.

During the postimmobilization:

• SWD.
• Ultrasound.
• TENS.
• Isotonic exercises.
• Active, active-assisted exercises.
• Progressive resisted exercises.
• Gait training, in lower limb fracture.

FROZEN SHOULDER
(PERIARTHRITIS, ADHESIVE CAPSULITIS)

Essentials of Diagnosis
• Two layers of synovial membrane becomes adherent to
each other.
• Usual onset occurs from 50 to 70 years of age.
56 • More frequent in sedentary workers than in laborers.
• Progressively increasing pain in the shoulder joint.
• Stiffness of joint.
• All movements are restricted.
• Disease is self-limiting and patient may recover sponta-
neously in about two years.
• Positive apprehension test indicates impending frozen
shoulder.
Note: Continuous pain throughout abduction indicates
some of arthritis. Pain between 60° to 120° of abduction
suggest supraspinatus tendonitis or bursitis.

Management
• Thermotherapy specially focuses on the anterior-infe-
rior border of the axilla.
• Passive mobilization techniques.
• Pendulum exercises.
• Shoulder elevation exercises.
• Hand to back position.
• Self-stretching of the affected limb.
• Shoulder wheel exercises.
• Pulley exercises.

GANGLIA

Essentials of Diagnosis
• Localized, tense, painless, cystic, swelling, containing
clear gelatinous fluid.
• Commonly seen over dorsum of the wrist, flexor aspects
of the fingers and dorsum of the foot. 57
 • Clear gelatinous fluid may be due to leakage or subse-
quent fibrous encapsulation of synovial fluid through
the capsule of the joint or a tendon sheath.
• Chronic repetitive stress and sometimes injury are a
predisposing factor.

Management
• Active exercises to the wrist and fingers.

GENU VALGUM (KNOCK KNEE)

Essentials of Diagnosis
• Outward deviation of the longitudinal axes of both tibia
and femur.
• 75% children have genu valgum up to four years of age.
• Primary deformity is the medial angulation of the knee.
• Secondary deformities develop in the femur, tibia and foot.
• The severity of the deformity is measured by noting the
intermalleolar distance.
• Deformity is the only complaint.

Management
• Special notes:
– < 4 years—no treatment.
– 4 – 10 years—heel raise, knock knee brace.
– 10 –14 years—epiphyseal stapling.
– 14 – 16 years—wait till skeletal maturity.
– > 16 years—osteotomy.
58
• Advice for boots with inner side of heel raised by 3/8”
and elongated forward heel (Robert Jones heels).

Postoperative Physiotherapy
• Thermotherapy.
• Gradual knee mobilization.
• Strengthening exercises for quadriceps, hamstrings
and glutei.
• When patient is able to walk, give training for standing,
balancing, weight transferring and walking.

GENU VARUM (BOW LEGS)

Essentials of Diagnosis
• Lateral angulation of the knee. The longitudinal axis of
femur and tibia deviates medially.
• Commonly seen unilaterally and seen in condition such as
rickets, Paget’s disease and severe degree osteoarthritis of
the knee.
• The deformity involves tibia alone or the femur or tibia
and fibula.
• The degree is measured by the distance between the
two medial femoral condyle when the patient is lying.

Management
• Knee-ankle-foot orthosis with medial bar and lateral
strap.
• Postoperative physiotherapy.
59
• Heat physiotherapy.
 • Gradual knee mobilization.
• Strengthening exercises for the lower limb.
• Balancing exercises.
• Walking.
• Weight bearing exercises.

GENU RECURVATUM

Essentials of Diagnosis
• Backward bending of the knee.
• Sometimes 5° of genu recurvatum is seen in women
due to laxity of ligaments.
• Quadriceps contracture.
• Limitation of knee flexion.
• Effusion and other evidence of knee abnormality is
absent.
• Proximally locked patella.

Management
• Stretching of the quadriceps.
• Active knee flexion exercises.
• Strengthening exercises of the hamstrings.
• Patellar mobilization.

GOLFER’S ELBOW

Essentials of Diagnosis
60 Same as for the Tennis elbow except that they are confined
to the medial side.
Management
Same as for the Tennis elbow.

GOUT

Essentials of Diagnosis
• Arthritis in specific joints, deposition in the tissues of
sodium urate crystals.
• 30–50 years is commonest.
• Sometimes seen familial tendency.
• Recurrent synovitis with intervening periods of remission.
• Metatarsophalangeal joints of big toes, ankles, knees,
wrists and hands are most affected.
• Thickened swelling with deformity of the hands or feet.
• Radiographic evidence of joint damage.
• Family history of renal or heart disease.

Management
• Rest and elevation of the limbs.
• Iontophoresis forms soluble lithium urate in place of
insoluble sodium urate.
• Ice packs.
• Nonthermal modalities.
• Weight reduction exercises.
• Take high fluid diet.
• Avoid—foods with high purine content like liver, kidney,
sweet bread, brain, meat extracts, sardines, gravies,
lobster, poultry, fish, peas, beans and lentils, asparagus,
chiku, custard apple, mushrooms, pulses, alcohol, 61
diuretics, salicylates.
 HEMATOMAS

Essentials of Diagnosis
Intramuscular:
• Blood within the muscle.
• Bleeding, following injury.
• Localized swelling.
Intermuscular:
• Blood between muscle and fascial planes.
• Bleeding.
• Discoloration of the skin.
• Severe pain.

Management
• Rest and limb elevation.
• Immobilized the affected part with splint.
• Cryotherapy.
• Pressure bandage.

HAND INFECTIONS

Management
• SWD.
• Ultrasound.
• Mobilization.
• Sustained passive stretching.

62
 HALLUX RIGIDUS

Essentials of Diagnosis
• Pain and the stiffness in the MTP joint of the great toe.
• Limited dorsiflexion.
• First phalanx is fixed in flexion.
• Hyperextended interphalangeal.
• Sometimes osteophytes formation.

Management
• Thermotherapy.
• Advice for footwear modification like metatarsals bar,
soft soles, etc.
• Modified gait training with minimum toe extension.

Postoperative Physiotherapy
• Early mobilization of the great toe.
• Strengthening exercises.
• Active exercises of great toe in warm water.
• Gait training.

HALLUX VALGUS

Essentials of Diagnosis
• Deviation of the great toe at the metatarsophalangeal
joint away from the midline.
• Deformity is only symptoms.
• Sometimes pain.
63
 • Wearing of tight socks and footwears are common
causes.
• A false bursa develops over the first metatarsal.

Management
• Advice for shoes with straight inner border and wedge
between great and second toe.
• Passively stretching of the great toe in abduction.
• Active exercises for lumbricals and interossei.
• Faradic foot bath.
• Advice for proper guidelines on weight bearing.
• Avoid excessive pressure on lateral aspect of the foot.
• Night splint.

Postoperative Physiotherapy
• Same as mentioned above.
• Training in weight bearing, gait and transfer.

HAMMER TOE

Essentials of Diagnosis
• Fixed flexion deformity of an interphalangeal joint.
• Commonly in second toe.
• Proximal interphalangeal joint is in flexion and the
distal interphalangeal joint may be either in flexion or
extension.
• Deformity is commonly due to bad or narrow pointed
footwear.
64
• Pain.
• Subluxation of the MTP joint.

Management
In children:
• Strapping.
• Relaxed passive stretching.
• Splinting.
• Adults required surgical correction.

Postoperative Physiotherapy
• Early mobilization of all joints.

INFRASPINATUS TENDINITIS

Essentials of Diagnosis
• Pain only in resisted external rotation.
• Patient exhibits the painful arc.
• Loss of 30° external rotation.
• Pain in full passive elevation.
• Pain during the terminal stages of active external rota-
tion of the shoulder joint is diagnostic criteria.

Management
• Slings.
• Cryotherapy.
• Thermotherapy.
• Full range passive external rotation. 65
 • Self-assisted external rotation movement of the shoulder
in the sitting position.
• Progressive resisted external rotations.

INJURY TO SYNOVIUM

Essentials of Diagnosis
• It may be acute due to trauma or chronic due to diseases
like TB, RA.
• Swelling of the joint.
• Redness of the joint.
• Pain over the injured structure.
• Position of ease.
• Muscle atrophy.

Management
During first 24 hours:
• Cryotherapy.
• Compression bandage.
• Limb elevation.
• Isometric contraction of the affected muscles.
• Active movements of the ankle joint.
• Active movements of the unaffected joint.
• Splinting of the affected joint.

After 48 hours:
• Sustained isometric contraction.
• Active movements.
66 • Partial weight bearing.
• Gradual progressive resisted exercises.
 KLIPPEL-FEIL SYNDROME

Essentials of Diagnosis
• Fusion of two or more adjacent vertebrae, commonly
lower cervical and upper dorsal vertebrae.
• Commonly seen in combination with other congenital
anomalies such as wedged vertebra or spina bifida.
• Short or abscent neck.
• Lower hair line upto thoracic region.
• Tense trapezius muscle.
• Restriction in movement specially lateral movement.

Management
No physiotherapy treatment is required.

KYPHOSIS

Essentials of Diagnosis
• Increase in normal posterior convexity of the thoracic
spine.
• Bad posture is a common cause.
• Gentle backward curvature of the spinal column, due to
disease affecting a number of vertebrae is called round
Kyphosis.
• Sharp backward prominence of the spinal column
known as angular kyphosis.
• Depending upon the severity, kyphosis, is graded as
first, second and third degrees. 67
 • Special notes:
–– Kyphosis in children—Scheuermann’s disease.
–– Kyphosis in older—TB spine children and young
adults.
–– Kyphosis in middle age—anlylosing spondylitis.
–– Kyphosis in old age—senile osteoporosis.

Management
First Degree Kyphosis
• Deep diaphragmatic breathing.
• Control of pelvic tilt and rocking.
• Relaxation exercises.
• Spinal mobilization exercises.
• Respiratory exercises.
• Strengthening exercises for abdominal muscles and
extensors.
• Stretching of hamstrings.
• Gluteal and abdominal contraction.

Second and Third Degree Kyphosis

• Advice for Milwaukee brace.
• Along with bracing spinal mobilization exercises.

Postoperative physiotherapy
• Chest physiotherapy.
• Lower limb and neck movements, when who are on
traction.
• Spinal mobilization exercises.
68 • Strengthening exercises for the spine.
 LORDOSIS

Essentials of Diagnosis
• Excessive anterior curvature of the spinal column.
• Commonly in the lumbar region.
• Sometimes forward tilting of pelvis.
• Weakness of glutei and lengthening of the hamstrings.

Management
• Spinal mobilization exercises.
• Postural correction exercises.
• Strengthening exercises for abdominal muscles, gluteus
and hamstrings.
• Spinal extension exercises.
• Advice for brisk walking.
• Advice for Taylor brace.
• Avoid SLR.

MADELUNG’S DEFORMITY

Essentials of Diagnosis
• Defective growth of the distal radial epiphysis resulting in
deformity of the distal end of the radius, dislocation of the
head of ulna and subluxation of inferior radioulnar joint.
• Commonly in adolescent females.
• Often present bilaterally.
• Prominent lower end of ulna.
• Limited dorsiflexion. 69
• Enlarged wrist.
 • Weakness of hand, and wrist.
• Wrist pain.

Management
No treatment is required.

Postoperative physiotherapy
• Mobilization of the hand, and wrist.

METATARSALGIA

Essentials of Diagnosis
• Pain beneath the metatarsal heads or shafts.
• Splay foot.
• Atrophy of the interosseous muscles.
• Clawing of the toes.
• Callosities formation over the affected area.

Management
• Advice for metatarsal bar with soft cushion and less
heel shoes.
• Intrinsic muscles exercises.
• Wax therapy.
• Faradic stimulation.

Postoperative Physiotherapy
• Strengthening exercises for lumbricals and interossei.
70 • Advice for proper footwear.
• Gait training.
 MORTON’S METATARSALGIA

Essentials of Diagnosis
• Pain in the region of the third and fourth metatarsal
head.
• Pain aggravates during walking.
• Pain relieve at rest.
• Mulder’s click is present.

Management
• Thermotherapy.
• Toe curling exercises.
• Foot cupping exercises.
• Gripping a piece of cloth with affected foot.
• Walking on the outer boarder of the foot.
• Provide metatarsal bar in the sole of the footwear.
• Avoid high heel footwear.

NONUNION

Essentials of Diagnosis
• Nonunion to be stabilized when a minimum of nine
months has elapsed since the injury and the fracture
shows no radiologically visible progressive sign of
healing continuously for three months.
• Most common in compound fracture.
• Minimal pain.
• Deformity. 71
• Loss of function.
 • Painless abnormality.
• No crepitus.
• Shortening.
• Scars and sinuses.
• Wasting of the limb muscles.

Management
• Active exercises to the unaffected joints.
• Isometric to the immobilized joints.
• Active ankle exercises.

OLECRANON BURSITIS (STUDENT’S ELBOW)

Essentials of Diagnosis
• Chronic inflammation of the olecranon bursa.
• Maybe the result of the repetitive minor injuries or
irritation, microcrystalline deposition.
• Swelling over the tip of the olecranon.

Management
• TENS.
• Ultrasound.
• SWD.
• Immobilization in the slings.
• Gradual mobilization of the shoulder is done by relaxed
passive movements and resistive exercises.

72
 OSTEOARTHRITIS

Essentials of Diagnosis
• Hip, knee and hands are the most affecting joints.
• During acute inflammation heat, redness, pain, and
swelling is seen.
• Pain around the joint, onset is low intensity but aggra-
vate during weight bearing, after exercises and at night
specially after a very active day.
• Chronic edema, stiffness, and loss of joint movement.
• Muscles become weak, which is opposite to contrac-
ture.
• Joint enlargement, deformity, crepitus and lastly loss of
function.
• Radiological findings—loss of joint space, sclerosis,
altered shape of bone ends and osteophytes.

Management
• Pulsed electromagnetic energy or inductothermy for
reducing dull ache.
• Wax therapy.
• Infrared radiation, heat pad or hot pack for reducing
muscle spasm.
• Ice therapy for reducing acute pain and swelling.
• Ultrasound is useful for treating chronic pain.
• Free active exercises and mobilization.
• Muscle strengthening at high repetition rate and against
low resistance.
• Frenkel’s exercises and slow reversal PNF.
73
 • Hydrotherapy.
• Gait reeducation.
• Advice for walking through walking aids with resting
intervals.
• Avoid crossed knee sitting and sudden strain on the
joints.

OSTEOMYELITIS

Essentials of Diagnosis
• Fever associated with sweating, chills and rigors.
• Swelling at the ends of the long bone.
• Limitations of the movement.
• Most commonly in children.
• Anemia.
• Dehydration.
• Toxicity.

Management
• Splinting of the affected joints.
• Affected limb elevation.
• Cryotherapy.
• Vigorous exercises of the unaffected joints.
• Mild isometric exercises.
• Strengthening exercises of the weakened muscles.
• Graded ambulation and weight transferring exercises.
• Deep ultrasonic massage for adherent scar.
• Sustained passive stretching exercises for scarred and
74 contracture tissues.
• Deformities are corrected by proper splinting.
• Range of motion exercises for affected and unaffected
exercises.

OSTEOPOROSIS

Essentials of Diagnosis
• Acute pain in middle or low thoracic or high region.
• Pain aggravates by vigorous work or activity.
• Back pain.
• Gibbus on thoracic vertebra.
• Frequently fracture occurs.

Management
• High protein and calcium-rich diet.
• Rest.
• Spinal orthosis.
• Posture exercises.
• General fitness exercises.
• Maintain good health.

OSTEOTOMY

Management
During immobilization:
• Active exercises of uninvolved joints.
• Isometric exercises to the immobilized muscles.
• NWB crutch walking. 75
 During mobilization:
• Active exercises to the affected joints.
• Thermotherapy.
• Mobilization to the affected joints.
• PRE to the affected muscles.
• Ambulation and weight bearing training.

PES CAVUS

Essentials of Diagnosis
• High longitudinal arch that results from an equinus
position of the forefoot in relation to the hindfoot.
• First metatarsal drop and pronation.
• Tight plantar fascia.
• Cock-up deformities of the all toes at the MTP joints.
• In the later stage varus heel and clawing of the toes.
• Fatigue on walking and standing.

Management
• Heat therapy.
• Strengthening exercises for intrinsic muscles.
• Faradic foot bath.
• Resisted toe extension.
• Self-stretching by placing normal heel over the
abnormal one.
• Advice for thermoplastic foam sole in footwear.

76
Postoperative Physiotherapy
During immobilization:
• Regular exercises for mobilized joints.

During mobilization:
• Friction massage over the scar.
• Active exercises for every joint of the foot.
• Balancing, weight transfer and gait training.

PLICA SYNDROME

Essentials of Diagnosis
• Injury to the interpatellar fat pad and the associated
synovial lining.
• Pain at the medial border of the patella at the lower end.
• Pain aggravates after long time sitting with knee flexed.
• Medial displacement of patella with knee at 30° flexion
cause pain.
• During active extension of the knee, patella slips
between 45–60°.

Management
• Transverse friction massage.
• Hamstring stretching.
• Knee joint rehabilitation.

77
 PLANTAR FASCIITIS

Essentials of Diagnosis
• Pain in the sole during weight bearing.
• Pain relieved during rest.
• Pain at the insertion of the plantar fascia.
• Commonly seen in gout, RA and inflammatory
conditions.

Management
• Patient is educated to bear weight on toes instead of the
heel.
• Wedge in the heel.
• Dip the foot in warm water and curl the toes for some-
times, specially in morning.
• Faradic stimulation of the foot.
• Walking on the outer border of the foot.
• Sarborubber heel paid.
• SLR exercises.
• Isokinetic exercises of the quadriceps and hamstrings.
• Bicycle peddling exercises.
• Prone lying knee flexion exercises.

POLIOMYELITIS

Essentials of Diagnosis
• Viral infection of the anterior horn cell of the spinal
78 cord of nerve cell of brainstem resulting in temporary
or permanent paralysis.
• Commonly affected in children less than 5 years, often
attacks young adults.
• Fever, headache, and diarrhea.
• Mild neck stiffness and difficult to move the affected limb.
• Lower limb is more commonly affected than the upper
limbs.
• Asymmetric involvement.
• Generally tibialis anterior is paralyzed.
• Most of the time quadriceps is more often affected.
• Sensory system is not affected.
• In the postpolio residual stage, common deformities are:
Hip—flexion, abduction and external rotation.
Knee—flexion, triple deformity and genu valgum.
Foot—talipes equinovarus.
• Any residual paralysis after two years of affection is
permanent and no chance of recovery.
• Bulbar poliomyelitis is rare and affects the respiratory
muscles.

Management
During early stage:
• If respiratory paralysis due to bulbar polio, give venti-
lator support.
• Warm and moist packs over the joints/2–4 hours.
• Avoid intramuscular injection.
• Immobilized the affected joint by plaster splint in the
functional position.
• ADL that a child of his/her age.

79
 During recovery stage (4 weeks to 18 months):
• Splinting.
• Tricycle exercises.
• Warm water pool therapy.
• PNF.
• Avoid the unnecessary splinting.
• Orthotic support for weight bearing and walking.
• Regular follow-up.
• After 6 months to 1 year graded resistive exercises.
• Swimming, jogging, walking and other aerobic exercises.
• Stage of postpolio residual paralysis.
• Advice for self-care, schooling, playing and ADL.
• Social rehabilitation.
• Psychotherapy, if required.

Postoperative Physiotherapy
After release of soft tissue contracture:
• Good joint support.
• Active and passive ROM exercises.
• Strengthening exercises.
• Home advice for positioning, exercises and weight
bearing.
• Gait reeducation.

After tendon transfer:

• Passive stretching exercises.
• Active and active-assisted movements.
• Electrical stimulation.
• Advice for dynamic orthotic.
80
After orthodesis:
Same as for the orthodesis.

After limb lengthening procedure:

• Active Rom exercises to unaffected joints.
• Isometrics exercises to quadriceps and glutei.
• Balancing exercises.
• Weight bearing, weight transfer and gait training.

POPLITEAL CYST (BAKER’S CYST)

Essentials of Diagnosis
• Commonly symptoms are seen in bursa of the head of
the gastrocnemius and semimembranosus.
• Pain.
• Stiffness.
• Swelling.
• Intraarticular pathology.
• Stiffness.
• Duck waddle test is diagnostic parameter.

Management
After Surgery
• Thermotherapy.
• Isometric exercises to the quadriceps.
• Active ROM exercises to the knee.
• PRE to the knee joint muscle.
• Avoid excessive compression or stretching of the
81
knee.
 POSTINJECTION CONTRACTURES IN INFANCY

Essentials of Diagnosis
• Due to repeated injections and infusions.
• Dimples at the skin over the site of the injection.
• Most commonly in twins and vastus lateralis, rectus
femoris, and vastus intermedius are usually involved,
but vastus medialis is not involved.

Management
• Passive exercises.

After Surgery
• SWD.
• Ultrasound.
• Isometric quadriceps exercises.
• CPM.
• Vigorous knee exercises.

RECURRENT DISLOCATION OF PATELLA (RDP)

Essentials of Diagnosis
• Diffuse pain in the knee joint.
• Pain aggravates during strenuous work.
• Swelling, but mild.
• Crepitus in the knee joint.
• Patient feels like go away patella.
82
• Apprehension test is positive.
• In X-ray—patella is above the Blumensaat line.

Management
After Surgery
During the first 4 to 5 weeks:
• Active exercises to the hip, ankle and toes.
• Ambulation by nonweight bearing crutch walking.
• Assisted SLR.
• Isometrics.

After 5 weeks:
• SWD.
• Ultrasound.
• Assisted SLR.
• Hydrotherapy.
• CPM.
• Knee swinging exercises.
• Isotonic, isokinetic exercises of the knee joint.
• Self-resisted hamstrings exercises.
• Advice for knee orthosis.

After 10 weeks:
• Squatting.
• Jogging.
• Running.
• Climbing.

83
 RHEUMATOID ARTHRITIS

Essentials of Diagnosis
• Pain, swelling, stiffness of the small joints of hands and
feet.
• Weight loss, lethargy and depression.
• Symmetrical joint swelling.
• In later stage, deformities of bones and joints.
• History of remissions and exacerbation of symptoms
with seasonal variations.
• Subcutaneous nodules are seen over elbow, sacrum
and occiput.
• Rheumatoid arthritis factor is +ve in 70%.
• Inhibition test is most sensitive.
• In later stage, various extraarticular features are seen.
• Typical X-ray changes.

Management
During the acute phase:
• Rest.
• Wax therapy.
• Ultrasound.
• SWD.
• Cryotherapy, thermotherapy.
• TENS and interferential current of 90–100 Hz.
• Deep breathing exercises.
• Isometric exercises to the shoulder, hip and knee muscles.
• Active ROM exercises.
84
• Splints.
• Postural guidance.
• Pool therapy.
• PRE exercises.
• Advice for lipid lowering diet.

During the chronic phase:

• Splinting.
• Prone lying position on firm bed.
• Active and active-assisted exercises for the knee joint.
• Active ROM exercises for the ankle and foot.
• Full ROM exercises for the shoulder with hand in collar
and cuff.
• Active Rom exercises to the hand.
• Advice for aids—like walking aids or wheelchair as
required.

Self-help measures:
• Medication.
• Regular exercises.
• Positive mental attitude.
• Massage.
• Good sleeping.
• Relaxation therapy.
• Use splints, braces, walking aids or wheelchairs.
• Avoid the stress work.
• Modify your daily living activity like high chairs, hard
surfaces.
• Advice for the western toilet.
85
 Postoperative Physiotherapy
For pain relief or reducing muscle spasm:
• Relaxation exercises.
• TENS.
• Cold or heat therapy.
• CPM.

For treating or reducing edema:

• Elevation of the affected limb.
• Active pumping exercises of distal joints.
• Massage.

For prevention of vascular and respiratory complications:

• Active exercises for the distal extremity.
• Deep breathing exercises.

For preventing stiffness or joint contracture:

• Passive exercises.
• CPM.
• Self-assisted exercises.

For preventing muscular atrophy:

• Isometric exercises.
• Strengthening exercises.

For maintaining strength above and below the operated

side:
• Active exercises.
• Graded exercises.
86
For improving ADL:
• Advice for assistive devices.

RICKETS

Essentials of Diagnosis
• Metabolic disease of the childhood.
• Mainly due to vitamin D deficiency.
• Bony pain during rest.
• Excessive perspiration in upper half of the body.
• Weakness of the proximal muscles of the LL.
• Waddling gait.
• Irritability of CNS produces convulsions, laryngismus,
spasmophilia, chvostek’s sign, opisthotonos, etc.
• Broadened forehead.
• Skull squared.
• Pigeon chest.
• Rickety rosary.
• Harrison’s sulci on the soft ribs.
• Coxa vara.
• Bowed tibia.
• Knock knee.
• Exaggerated curvature of vertebral columns.
• Anteriorly bent femur.
• Pale and flabby skin.
• Prominent abdomen.

87
 Management
• Bed rest.
• Rickets splint.
• Higher dose of vitamin D is given.

ROTATOR CUFF LESIONS

Essentials of Diagnosis
• Pain in the shoulder.
• Difficulty in carrying out the shoulder movements
especially abduction.
• More common in the sports persons.
• Commonly associated with supraspinatus tendon.
• Imaging investigation tools play a major role in diagnosis.

Management
• Rest in the sling.
• Isometric exercises to the deltoid and other shoulder
joint muscles.
• TENS.
• SWD.
• US.
• Gradual active and passive mobilization of the shoulder.
• Gravity eliminated exercises of the shoulder.
• Progressive resistive abduction exercises in the later
stage when pain has subside.
• Progressive dumbbells.
• Avoid sports activity and heavy work.
88
 SCOLIOSIS

Essentials of Diagnosis
• Lateral curvature of the spine in the upright position.
• Lateral curvature in excess of 10° is scoliosis.
• Most of the cases the visible deformity is the only
symptom.
• Sometimes pain may also be associated.
• Rib hump or abnormal paraspinal muscular promi-
nence indicates spinal rotation.
• Curvature is measured by Cobb’s angle.

Management
Special notes:
Observation—for curves < 20°
Orthosis—for curves between 20° to 40°
Operation—for curves > 40°
• Screening regularly.
• Postural correction by active and passive methods.
• Deep breathing exercises.
• Spinal mobility exercises.
• Balancing exercises.
• Active ROM exercises of the spine.
• Strengthening exercises to the abdominal and spinal
muscles.
• Passive stretching of the muscles on the concave side of
the curve.
• Regularly and repeatedly stretching of the hip flexors.
• Tilting of pelvis with knee flexed/knee straight in supine
89
lying.
 • Situps/pushups with pelvic tilt.
• Back extension exercises in prone lying.
• Bicycle exercises.
• Advice for Milwaukee or Boston brace.
• Traction.

Postoperative Physiotherapy
For first two days:
• Deep breathing exercises.
• Vibration with assisted coughing.
• Toe, ankle and upper arm movements.
• Changing the position every 2 hours.
• By the end of the 4th day, full range active and passive
movements to the hip and knee joints.

After 4th day:

• Rolling sitting and standing.
• Ambulation.

SPONDYLOLISTHESIS

Essentials of Diagnosis
• The most common sites are L5/S1 and L4/L5.
• Younger age groups are more affected. Pain is in the back.
• Females are more prone.
• Backache with muscle spasm.
• Sometimes patient feels lumbar spine is locked in
extension. Lordosis at L4/5/S1.
90
• Pain is relieved by on lying and aggravated by prolonged
standing. Sitting may at first relieve but later aggravates.
• Referred root pain in the legs.
• X-ray findings—Scottie dog’s neck sign.

Management
• Thoracolumbar-sacral molded brace.
• SWD and ultrasound.
• Weight reducing exercises.
• Correct the postural habits.
• Spinal mobility exercises.
• Active posterior tilt exercises.
• Strong abdominal isometric exercises.
• Forward bending exercises of the trunk at lumbar spine in
chair sitting position with strong abdominal contractions.
• Hamstring stretching.

Postoperative Physiotherapy
During immobilization:
• Deep breathing exercises.
• Ankle, foot and arm movements.
• Assisted movement to knee joint.
• Isometrics exercises to gluteus muscles.
• Hip flexion up to 60°.

During mobilization:
• Spinal mobilization.
• ADL.
91
 SPRAINS

Essentials of Diagnosis
First Degree
• Slight pain.
• Tenderness.
• Swelling.
• Loss of function.
• Positive stretch test.

Second Degree
• Ligament may be partially torn.
• Swelling.
• Pain.
• Tenderness.
• Loss of movement.
• Difficulty in weight bearing.

Third Degree
• Severe violence.
• Excess swelling.
• Severe pain and tenderness.
• Unstable joint.
• Unstable to weight bearing.
• Severe loss of function.

92
Management
First and Second Degree
• Cryotherapy, on first day.
• Limb elevation.
• Pressure bandaging.
• Active movements of the unaffected joints.
• On second day, thermotherapy.
• Isometric exercises to the affected muscles.
• Weight bearing.

Third Degree
• Cryotherapy.
• Compression bandage.
• Limb elevation.
• Isometrics to the affected limbs.
• Active exercises to the affected joints.

After Removal of POP Cast

• Ultrasound.
• TENS.
• SWD.
• Limb elevation.
• Transverse friction massage.
• Active exercises to the affected joints.
• Isometrics.
• Passive ROM exercises.
• Weight bearing.
• ADL.
93
 STRAINS

Essentials of Diagnosis
First Degree
• Due to blunt injury or direct trauma.
• Few muscle fibers are torn.
• Localized pain.
• Tenderness.
• Function is not impaired to a greater extent.

Second Degree
• Greater number of muscle fibers is torn.
• Bleeding.
• Hematoma.
• Severe pain.
• Severe tenderness.
• Muscle spasm.
• Unable to move limb.

Third Degree
• Greater number of muscle fibers is torn.
• More than one muscle group involved.
• More bleeding.
• Severe pain and loss of function.

Fourth Degree
• Causes severe trauma.
• Complete tear of muscle.
94 • Bleeding.
• Excess swelling.
• Severe pain.
• Tenderness.
• Snapping sound.
• Palpable gap between muscles felt.
• Total loss of function.
• Loss of active muscle contraction.
• Joint function is not lost.

Management
First and Second Degree
• Cryotherapy/20minutes.
• Gentle active muscle stretch after 50 minutes.
• Compression bandaging.
• Ultrasound.
• Gentle massage.
• Limb elevation during rest.
• Allow for light work.

Third Degree
First 24 hours:
• Cryotherapy.
• Compression bandage.
• Limb elevation.
• Limb immobilized in splints.
• Isometrics to the immobilized muscles.
• Active exercises to the unaffected joints.
• PEM.
During 24–48 hours:
• Remove bandaging. 95
• Active muscle exercises.
 • Stretching.
• SWD.
• TENS.
• Ultrasound.
• Massage.
• Nonweight bearing on crutches.
• Rest of the management same as above.

Between 48–72 hours:

• Same as above.
• Start parital weight bearing.

After 72 hours:
• Above measures are pursued in a more vigorous manner.
• Remove the pressure bandage.
• PRE.
• Start full weight bearing.
• Walking.
• Jogging.
• Full functional activity.

Fourth Degree
• Surgery is advised.
• Compression bandage.
• Active exercises to the unaffected joints.
• Slow rhythmic isometric exercises to the affected muscles.
• Nonweight bearing after 48 hours.
• Faradism current.
• Ultrasound.
96 • Rests of the management are same as for grade second
or third degree.
 SUBACROMIAL BURSITIS

Essentials of Diagnosis
• Inflammation of the subacromial bursa.
• Pain during abduction and internal rotation of the
bursa.

Management
• TENS.
• Ultrasound.
• SWD.
• Immobilization in the slings.
• Gradual mobilization of the shoulder is done by relaxed
passive movements and resistive exercises.

SUBSCAPULARIS TENDINITIS

Essentials of Diagnosis
• Pain during the terminal stages of the active resisted
international rotation movement of the shoulder.
• Passive internal rotation will be painless.

Management
• Advised to the patient for relaxed full range passive arc
of internal rotation.
• Self-assisted and later on resisted internal rotation
exercises.
97
 SUPRASPINATUS TENDINITIS

Essentials of Diagnosis
• Pain.
• Swelling.
• Limitation of shoulder movement.
• Muscle atrophy.
• Tenderness over the greater tuberosity.

Management
• Ultrasound.
• SWD.
• TENS.
• Passive mobilization.
• Gradually resisted exercises.

Physiotherapy After Surgery

• Immobilization for 3 weeks.
• Active elbow, hand, wrist movements.
• Strong isometric deltoid exercises after 10 days.

SPRENGEL’S DEFORMITY

Essentials of Diagnosis
• Scapula lies more superiorly by 2 to 10 cm.
• Hypoplastic and improperly shaped.
• Associated with other congenital anomalies like cervical
98 rib.
• No functional impairment, shoulder girdle movements
are normal.
• Sometimes torticolis may be present.

Management
• Pain relieving modalities.
• Gentle relaxed passive movements of shoulder girdle.
• Isometric and isotonic shoulder exercises.
• Postoperative physiotherapy.
• TENS/IFT.
• Passive mobilization of the scapula and shoulder with
stress on abduction and elevation.
• Strengthening exercises for upper limb.
• Posture correction.

TENNIS ELBOW

Essentials of Diagnosis
• Gradual onset present after activity disappears with rest.
• Aching or sharp pain over the wrist extensors from
elbow to wrist.
• Resisted wrist extensor is painful, while passive move-
ment is pain-free.
• Tenderness over the site and loss of mobility.
• Seen in all levels of tennis players, backhand stroke
player and may be occupational.
• Cozen’s test is positive.

99
 Management
• An above elbow POP splint with elbow in 90° flexion
and supination and the wrist in slight dorsiflexion.
• TENS.
• Ultrasound1W cm-2/continuous beam/10 minutes.
• SWD.
• Ice therapy/15–20 minutes.
• Electrical stimulation/15–20 minutes.
• Gentle massage/5–10 minutes/10 days and then fric-
tion massage/5–10 minutes/next 15 days.
• Active exercises for the shoulder, elbow, wrist and hands.
• Isometric exercises of triceps.
• Strapping-zinc oxide 2–3 cm wide, applied completely
over the forearm.
• Avoid repeated wrist extension and supination move-
ments.

THORACIC OUTLET SYNDROME

Essentials of Diagnosis
• Syndrome results from the compression of neuro-
vascular bundle comprising of subclavian artery and
vein, axillary artery and vein and brachial plexus at the
thoracic outlet.
• Numbness of the whole arm with rapid fatigue during
overhead exercises.
• Cold, cyanosis, pallor and Raynaud’s phenomenon.
• Swelling of the limb.
100 • Discoloration after exercises, which disappeared slowly
with rest.
• Klumpke’s paralysis.
• Paresthesia along the medial aspect of the arm, hand,
little and ring finger.
• Weakness of the hand.
• Ischemia and gangrene of the upper limbs are later
stage complications.
• X-ray ruled out intrinsic causes like cervical spondy-
losis, cervical rib, etc.

Management
Same as for the cervical rib.

TRAUMATIC MYOSITIS OSSIFICANS

Essentials of Diagnosis
• Trauma is the main cause.
• Pain.
• Swelling.
• Loss of movement.
• Tenderness.
• In later stage there is no pain.
• Bony hard lump may be palpated.
• Most common sites are elbow, ankle, knee, shoulder
and hip.
• In X-ray—bony growth may be seen.

Management
Acute Stage
101
• Immobilization of the part by the splints.
 • Active physiotherapy.
• Avoid the passive stretching.

Later Stage
• Active ROM exercises.
• Passive stretching.

After Surgery
• Affected part elevation.
• Active exercises to the unaffected joints.
• Isometric exercises to the elbow muscles.
• Thermotherapy.
• Elbow mobilization.
• Self-assisted exercises for the forearm.
• Passive stretching of the elbow.
• PRE.
• ADL.

TRIGGER FINGER/DE QUERVAIN’S

Essentials of Diagnosis
• Initially, the only symptom is pain at the base of the
affected finger.
• Pain is aggravated specially on trying to passively
extend the finger.
• Swelling.
• Locked finger.
• Commonly in women.
102 • Congenital trigger fingers are seen in 25% of cases and
may present as late as 2 years of the age.
Management
• Thermotherapy.
• Wax bath.
• Finger mobilization exercises.
• Friction massage to the fingers.

TUBERCULOSIS OF THE HIP JOINT

Essentials of Diagnosis
• Painful limp.
• Antalgic gait with short stance.
• Severe pain.
• Night cries.
• Cold abscess.
• Sometimes pathological subluxation of the hip.

Management
After Surgery
Management during osteotomy, THR, excision arthro-
plasty, and arthrodesis have been already discussed in
relevant topic.

TUBERCULOSIS SPINE
(KNOWN AFTER SIR PERCIVAL POTT)

Essentials of Diagnosis
• Weakness, anorexia, night sweats and cries, evening or 103
afternoon rise of temperature.
 • Loss of appetite and weight loss.
• Back pain over the site of the vertebral involvement.
• Pain is referred along with nerve course, which involved.
• Back stiffness.
• Problem in bending of the spine in day to day activity.
• If the patient complains of stiffness, weakness, awkward-
ness of lower extremities, it heralds the onset of para-
plegia.
• Muscle spasm over the spine.
• Wasting of the back muscles.
• Paravertebral swelling.
• Kyphotic deformity is most common.
• Reveals signs of anemia, debility, involvements of
lungs, lymph nodes.
• Raised ESR.
• X-ray shows osteoporosis, loss of intervertebral space,
paravertebral shadows.

Management
• Maintain good posture.
• Prevent the bedsores.
• Active exercises of the neck, UL, LL.
• Vigorous chest physiotherapy.
• Isometric exercises to the spinal flexors, extensors and
rotators.
• Spinal exercises in extension, later on to hyperexten-
sion and progressed to flexion and rotation exercises.
• Ambulation with spinal brace.

104
After Surgery
• Vigorous chest physiotherapy.
• Prevent bedsores.
• Prevent deep vein thrombosis.
• Simple resistive exercises to the neck, upper and lower
limbs.
• Ambulation with spinal corset.
• Logrolling, standing and walking.
• Strengthening exercises to the back and abdominal
muscles.

TUBERCULOSIS SPINE WITH PARAPLEGIA

Essentials of Diagnosis
• Seen within two years of onset of the disease.
• Clumsiness, twitching, increased reflexes, clonus, posi-
tive Babinski sign.
• Motor functions are affected first.
• Other clinical features are same as paraplegia.

Management
Same as paraplegia.

After Surgery
Same as tuberculosis of spine.

105
 VOLKMANN’S ISCHEMIA
(COMPARTMENT SYNDROMES)

Essentials of Diagnosis
• History of trauma.
• Severe pain.
• Swelling, redness, warm, tender and tense over the
volar aspect of the forearm.
• Flexed finger and stretched pain.
• In later, peripheral pain disappear.
• Positive passive stretch pain.
• In later stage, deformity and neurological deficits may
be seen.

Management
• Dynamic splint.
• Thermotherapy.
• Active exercises.

After Surgery
During immobilization:
• Hand elevation.
• Thermotherapy.
• Active exercises to the unaffected joints.
• Splint.

During mobilization:
• Active exercises to the shoulder, elbow and forearm
muscles.
106 • Motor and sensory reeducation.
 C H A P T E R 4

Neurological
Conditions

APHASIA

Essentials of Diagnosis
• Common communication disorder caused by brain
damage.
• Impairment of language comprehension, formulation
and use.
• Affects the sounds, vocabulary or grammar, both in
expression and reception.
• Aphasic patient may have difficulty in reading, writing
and calculation.
• Generally, aphasia is associated with visual or hearing
deficits, mental deterioration or psychiatric aberrations.
• Minneapolis test for differential diagnosis for aphasia
(MTDDA) is positive.
• The porch index of communicative ability (PICA) is the
other diagnostic criteria.
 Management
• Speech therapy.
• Movements of articulatory apparatus.
• Imitation of a small repertoire of phonemes.
• Matching identical objects, pictures, flash cards.
• Copying the letters of single noun flash cards.
• Listening the oral production of a word and attempting
to imitate it.
• Taught by alphabet board.

ALCOHOLIC NEUROPATHY

Essentials of Diagnosis
• Mainly due to vitamin B12 deficiency.
• Affect any part of the body but frequently involved
organs are the heart and peripheral nerves.
• Pain and paresthesia is felt at the feet or distal leg and
sometimes even in the hand.
• Dysthesia.
• Hyperpathia.
• Muscular imbalance, tenderness.
• Reflexes are absent or depressed.
• Excessive sweating in the palm.
• Orthostatic hypotension, dysphasia, hoarseness of the
voice.
• Diaphragmatic dysfunction, respiratory problems.
• Decreased NCV.
108
Management
• Advice for food taken which is rich in vitamin B12.
• Other management is same as that of GBS.

AMYOTROPHIC LATERAL SCLEROSIS

Essentials of Diagnosis
• Disease begins as a spastic paralysis in the fingers and
hand.
• Disease spreads up the arms, the upper limb assuming
an appearance like that seen in hemiplegic.
• Very slowly limb muscle atrophy.
• Increased reflexes but gradually decreased and finally
lost.
• Spasticity disappears and its place is taken by
flaccidity.
• Ankle clonus and the Babinski sign being present, but
they are finally lost.
• Dysarthria.
• Difficulty in swallowing.
• Respiratory problems.
• Death may occur as the result of the bulbar palsy or
because of an intercurrent infection.

Management
Same as for spinal muscular atrophy.

109
 BELL’S PALSY

Essentials of Diagnosis
• Sudden onset of lower motor facial paralysis mani-
festing as inability to close the eye, sagging angle of
mouth and poor buccinators tone.
• Pain behind the angle of the jaw and history of expo-
sure to cold.
• Loss of facial expression.
• Difficulty in eating.
• Nonverbal communication is lost like laughter, surprise,
worry.

Management
• Ultrasound over the nerve trunk just in front of the
tragus of the ear.
• Massage like stroking, kneading for 5 minutes per day.
• SWD or mild infrared radiation (1 to 2 feet away for 10
to 15 minutes).
• Taping or splinting.
• Eye care by protective goggles.
• Faradic reeducation.
• Quick stretch PNF technique.
• Icing, brushing, tapping or brisk stroking.
• Visual feed back exercises.
• Strengthening exercises.
• Chewing.
• Airing balloon.
• Suck water from a vessel through a straw.
110
• Say ‘A, E, I, O, and U.
 BRAIN TUMORS

Essentials of Diagnosis
• Increased intracranial pressure.
• Headache.
• Vomiting, usually in the morning.
• Nausea.
• Personality changes.
• Irritability.
• Drowsiness.
• Depression.
• Decreased cardiac and respiratory function and even-
tually coma if not treated.
• Visual changes.
• Seizures.
• Slurred speech.
• Uncoordinated muscle movements.
• Ataxia.

Management
• Supportive care.
• Strengthening exercises for weakend muscles.
• Speech therapy.
• Occupational therapy.
Other M/m are same as for the stroke management.

111
 CEREBRAL PALSY

Essentials of Diagnosis
• Retarted in motor development.
• Retarted abnormal development of the postural
balance mechanism or postural reflexes disturbs the
motor development.
• Appearances of certain abnormal reflexes like opistho-
tonus.
• Depending the geographical distribution, cerebral
palsy may be monoplegia, hemiplegia, paraplegia,
triplegia, quadriplegia, diplegia, double hemiplegia,
tetraplegia or total body involvement.
• Sensory deficit in hand.
• Speech problems and mental retardation.
• Audio or visual deafness.
• Seizures.
• Perceptual problems.
• Emotional problems.
• Scoliosis.
• Deformities.
• Epilepsy.

Management
• Brunnstrom Approach—motion by provoking syner-
gistic movement patterns which are observed in fetal
life.
• PNF—touch, quick stretch of muscle, traction or
112 compression of the joints, pressure and the use of voice.
• Neurodevelopmental Treatment—use of the devel-
opmental sequences of movement patterns together
with inhibition of abnormal pattern, which are present
because of the persistence of tonic reflexes.
• Rood Approach—stimulation such as stroking, brushing,
icing, heating, pressure, born pounding, slow and quick
muscle stretch, joint retraction and approximation,
muscle contraction are used to activate, facilitate or
inhibit motor responses.
• Vojata Techniques—reflex creeping patterns involving
head, trunk and limbs are facilitated at various trigger
points or reflex zones. Reflex rolling is also used with
special methods of triggering.
• Conductive Education—a fixed time-table is planned
to include getting out of bed in the morning, dressing,
feeding, toileting, movement training, speech training,
reading, writing, and other daily activity works.
• Rhythmic Intention—training the movements in rhythmic
manner.
• Biofeedback.
• Special education.
• Counseling.
• Occupational therapy.
• Deformity correction physiotherapy treatment.
• No permanent cure.
• Quadriplegics and total body involvement will never
walk but can be propped sitters.
• Most diplegics will walk by 4 years.
• All hemiplegics will walk by 12 to 16 months.
113
 DEAFNESS

Essentials of Diagnosis
• Conductive hearing loss from dysfunction of external
or middle ear.
• Sensory hearing loss results from deterioration of the
cochlea, usually due to loss of hair cells from the organ
of Corti.
• Neural hearing loss occurs with lesions involving the
eight nerve, auditory nuclei, ascending tracts or audi-
tory cortex.
• Hearing level is very low.
• Deafness is determined by tuning fork test, Weber test
and Rinne test.
• Auditory brainstem evoked studies is very helpful to
determine the loss of hearing level.

Management
• Learning to listen again.
• Assistive listening devices.
• Using visual clues.
• Managing communications.

DIABETIC NEUROPATHY

Essentials of Diagnosis
• 15% of patients with diabetes develop neuropathy
114 complications.
• Mild symmetrical, sensory, polyneuropathy giving rise
to numbness and tingling paresthesia in the toes and
feet and less often in the fingers.
• Loss of vibrations sense in the feet, depression of the
ankle jerk and mild cutaneous sensory impairment.
• Autonomic neuropathy symptoms—dysphagia, vomiting,
noctural diarrhea, sometimes constipation.
• Genitourinary symptoms—impotence, retrograde ejac-
ulation, bladder atony.
• Vascular symptoms—postural hypotension, elevating
heart rate, absence of beat to beat variation with
respiration.
• Examination of blood sugar level, urine sugar level is
confirmatory diagnosis for diabetes.

Management
• Control of diabetes.
• Low caloric diet.
• Low carbohydrate, high protein diet.
• IFT or TENS over the painful area.
• Take immediate measures to control minor cuts or
aberrations.
• Advice for cleaning and dry for affected area.
• If excessive dryness, give moisturizing cream or oil.
• Advice for protective wears like hand gloves, shoes both
in and outside the house. Footwear should be made of
microcellular material.
• In case of postural hypotension—abdominal binders
and elastic stockings for lower limbs. Use tilt table for
erect position. 115
• If muscle weakness—strengthening exercises.
 DYSARTHRIA

Essentials of Diagnosis
• Motor speech defects results from trauma or disease of
the nuclei or fiber in tracts in and adjacent to the brain-
stem.
• Severity depends on site and severity of lesion.
• Problem in articulation, loudness, rate, phonation,
resonance, pitch, rhythm and stress pattern.
• Slurring of pronunciation.
• Slowness of speech, uneven stress on syllables.

Management
• Resistance exercises of the laryngeal muscles.
• Say pronounce “p,b,m,s,r,k,a,e,i,o,u,7,99,oh,ahh” several
times.
• Tape recording feedback.
• Ultimate option is laryngectomy.

DYSPHAGIA

Essentials of Diagnosis
• Food spillage, lack of tongue action to form bolus.
• Pooling of food in anterior and lateral sulcus.
• Lack of chewing, tongue thrust.
• Slow bolus formation, piecemeal deglutition.
• Delayed swallow, nasal regurgitation.
116 • Pooling of saliva.
Management
• Give dysphagia diets:
–– Thin liquids (fruit juice, coffee, tea).
–– Honey thick liquids (liquids are thickened to a
honey consistency).
–– Mechanical soft foods (meat loaf, casseroles).
–– Chewy foods (pizza, cheese, bagels).
–– Mixed textures.
• Postural change—swallowing maneuvers.
• Biofeedback.
• Facilitate the speech development.
• Chin tuck—patient holds the chin down, increasing
the epiglottic angles and pushes anterior laryngeal wall
backward, thereby decreasing the airway diameter.
• Head tilting.
• Head rotation—ipsilateral pharynx is closed, forcing
the food bolus to the contralateral pharynx while
cricopharyngeal pressure is decreased.
• Valsalva maneuver.
• Mendelsohn maneuver.

Different Types of Dysphagia Diets

• Thin liquids, e.g. fruit juice, coffee, tea.
• Nectar-thick liquids, e.g. cream soup, tomato juice.
• Honey thick liquids, i.e. liquids are thickened to a
honey consistency.
• Pudding thick liquids/foods, e.g. mashed bananas,
cooked cereals, purees.
• Mechanical soft items, e.g. meat loaf, baked beans,
117
casseroles.
 • Chewy foods, e.g. pizza, cheese, bagels.
• Foods that fall apart, e.g. bread, rice, muffins.
• Mixed texture.
(Thickened liquids increase oropharyngeal control. A diet
of chopped or pureed foods decreases difficulties with
mastication.

EPILEPSY

Essentials of Diagnosis
Grand Mal Attack
• No warning and the patient suddenly stiffens and falls
to the ground.
• Losing consciousness (tonic phase – lasts about 40
seconds).
• Followed by random disorganized movements (clonic
phase – lasts from a few seconds up to 30 minutes).
• Short period of coma.
• After returning consciousness position feeling of confu-
sion and restlessness.
• Blood pressure falls, pupils are dilated and there may
be incontinence of urine.
• Patient may bite his tongue with fronthing from mouth.
• Typical epileptic cry due to spasm of respiratory and
laryngeal muscles.

Petit Mal Type

• Common below 14 years of age.
118
• Momentary loss of consciousness with or without falling.
• Staring look or eyes are titled up.
• Attack may appear several times a day.
• Myoclonic jerks.

Psychomotor Type
• Emotional state of mind either with fear, horror or
outrage.
• Epigastric sensation.
• Hallucinations of smell, taste and vision.
• Memory disturbances.

Focal Fits
• Symptoms depend on location of lesion in the brain.

Management
• Keep patient in quiet room or place.
• Protect from external injury.
• Clean the airway.
• Placed in semisupine position.
• Give O2 if required.
• Require medical management.

GUILLAIN-BARRÉ SYNDROME

Essentials of Diagnosis
• Onset is acute or subacute with fever.
• Areflexia.
119
 • Progressive weakness of more than or equal to 2 limbs
due to neuropathy.
• Motor weakness, paresthesia and pain, progressing
from lower extremities to upper extremities.
• Cranial nerves are affected in 75% cases.
• Facial nerve is involved in half of those with cranial
neuropathy and of those with facial palsies. Bilateral in
75–80% cases.
• Cardiac arrhythmia, hypotension, hypertension, hyper-
pyrexia and tachycardia.
• NCV are reduced in 90% cases.

Management
• Continuous changing of position.
• Periodic suctioning.
• Nebulization.
• Percussion, shaking,
• Manual mobilization with the help of ambu bag.
• Breathing exercises.
• Postural drainage.
• External tracheal stimulation.
• Passive ROM exercises/3 times/day.
• Provide static splints especially for the foot and hand.
• If pain—TENS.
• Electrical stimulation.
• Prevention and treatment of pressure sores (see pres-
sure sores).
• Advice for erect position by help of tilt table.
• Psychological support.
120 • If ataxia—coordination exercises.
• Functional reeducation.
• Gait training.
• Respiratory and cardiovascular conditioning.

HEADACHE

Essentials of Diagnosis
• Neck pain radiates from the back to the front of head.
• Headache is worsened by neck movement or by holding
your neck in the one position.
• Eased by pressure at the base of skull.
• Sometimes headache may not always be relieved by
medications.

Management
• Mobilization of the stiff joints.
• Soft tissue release of tight muscles.
• Stretching exercises over the neck.
• Strengthening exercises for the neck.
• Heat treatment.
• Acupuncture or dry needling.
• Massage.
• Relaxation techniques.

HYDROCEPHALUS

Essentials of Diagnosis
• Increased head circumferences. 121
• Sensory impairment.
 • Disturbances in the muscle tone, reflexes and co-
ordination.
• Papilledema, abducens nerve palsy and pyramidal tract
signs are apparent in most cases.
• Tense, nonpulsatile fontanelle.
• Separation of suture—‘Crack Pot’ sign on percussion.
• Scalp vein distension.
• Inability to look upwards.
• Distended retinal veins.
• Decerebration.
• Mental retardation, vomiting, anorexia, headaches are
the other symptoms.
• In X-ray skull—‘Copper beaten appearance, separation
of suture or splayed sutures, erosion of pituitary fossa.

Management
• If spasticity is present, treatment is given following that
used for cerebral palsy.
• Full range of passive movements of toes, than tarsal
joints, ankles, knees and hip.
• Strengthening exercises for the shoulder girdle.
• Bridging.
• Resisted exercises.
• Proper positioning in sitting and sleeping.
• Pressure relief and joint protection.
• Ambulation exercises.
• If required orthotic supports are given.
• Transfers and activities of daily living.
• Self-care and family education.
122
 MIGRAINE

Essentials of Diagnosis
• May have familial history.
• It develops generally before the age of 15.
• Nausea, vomiting scintillating scotomas, photophobia,
hemianopia.
• Blurred vision.

Management
• Mobilization of the stiff joints.
• Soft tissue release of tight muscles.
• Stretching exercises over the neck.
• Strengthening exercises for the neck.
• Heat treatment.
• Acupuncture or dry needling.
• Massage.
• Relaxation techniques.

MULTIPLE SCLEROSIS

Essentials of Diagnosis
• Disease of the central nervous system largely affecting
young adults.
• Start with one focal lesion or sometimes several occur-
ring closed together.
• Weakness in one or more limbs.
• Optic neuritis. 123
• Paresthesia.
 • Nystagmus, slight intention tremor, altered reflexes.
Diminished or lost abdominal reflex. Exaggerated
tendon reflexes and extensor plantar responses are the
other early sign.
• Spastic paraplegia, if the pyramidal tracts are affected.
• Loss of cutaneous sensation, posture and vibration sense.
• Staccato or scanning speech. Dysarthria and ataxia.
• Euphoria, depression or irritability and loss of bladder
control.
• Scattered bright spots presence on an MRI.

Management
• Strengthening of the weak muscles.
• Passive movements for restricted joints.
• Spasticity reducing exercises.
• Advice the patient for avoiding the movement which
increases the spasticity.
• Frenkel’s exercises.
• Bowel and bladder training.
• Encourage sensory awareness.
• Encourage functional well-being and ADL.
• Patient and family education.
• Home modification and family care.
• Occupational therapy.

MUSCULAR DYSTROPHY

Essentials of Diagnosis
124 • Hereditary disorder characterized by progressive degen-
eration of groups of muscle without involvement of the
nervous system.
• Course is progressive.
• Muscle weakness is generally appearing in 5 years of
age.
• Difficulty in climbing stairs, difficulty in getting up from
squatting and frequent falls are the initial symptoms.
• Poor head control in infancy.
• Lordotic posture, lordotic gait, sometimes waddling
gait.
• Gower’s sign is positive.
• Pharyngeal weakness, voice may have nasal or airy
quality. Some children become wheelchair bound by
9-10 years.
• Muscle biopsy is the diagnostic criteria.

Management
• Advice for long sitting and prone lying for avoiding
contractures.
• Passive stretching/daily.
• Splint for contractured area.
• Endurance exercises, respiratory muscle strengthening
exercises.
• Postural drainage, coughing, if needed.
• Strengthening shoulder depressors and triceps.
• Occupational therapy.
• Psychological and genetic counseling.
• Advice for walking.
• Cycling or swimming.
• Blow bottles.
• Cardiac function monitoring.
• In later cases, wheelchair management. 125
• Speech therapy.
 • Genetic counseling.
• Psychological support.
• Social rehabilitation.

PARKINSON’S DISEASE

Essentials of Diagnosis
• Rigidity, akinesia.
• Pin rolling action tremors.
• Previous history of encephalitis, drug intake.
• Weaker speech and less variation in the tone.
• Flexed stooped posture.
• Festinant gait.

Management
• Relaxation techniques.
• Slow rhythmic rotational movements.
• Mat activities.
• ROM exercises.
• Pectoralis stretching.
• Isometric exercises of the quadriceps and hip extensors.
• Back flexion and extension exercises.
• Pelvic tilt.
• Postural control.
• PNF, biofeedback and NDT.
• Progressive ambulatory and gait training. (Large steps
using blocks to have patient lift legs, teaching proper
heel-toe gait pattern)
126 • Frenkel’s exercises.
• Deep breathing exercises.
• Gentle rhythmic and rocking techniques.
• Advice for assistive devices if needed.
• Music therapy with exercises is good.
• Fitness exercises for aerobic conditioning like walking,
swimming.

PERIPHERAL NERVE LESIONS

Essentials of Diagnosis
• Paralysis: Extent of the paralysis will depend on which
nerves have been damaged.
• Loss of tendon reflexes.
• Sometimes weakness of the muscles.
• Somatic sensory functions are affected.
• Loss of sensation in the affected area.
• Incomplete lesion may lead to a disturbance in sensa-
tion, resulting in numbness and tingling.
• During reinnervation there is initially a hypersensitivity,
which gradually returns to more normal sensation.
• Analgesia.
• In incomplete lesion, hyperpathia.
• Autonomic disturbances.
• Contractures of muscle.
• Diagnosis is confirmed by electromyographic tests.

Management
Neuropraxia
• Not require special treatment.
127
• Simple movements of the limbs.
 Axonotmesis and Neurotmesis
• Positioning of the limbs.
• Rest.
• Active movements of the affected limbs, if not possible
give passive movements.
• Gentle massage.
• Full range of the affected joint movements.
• Advice for functional splinting.
• Electrical stimulation.
• Care program for anesthetic area.
• Muscle reeducation.
• PNF.
• Graded weight bearing exercises.
• Muscle coordination exercises.
• Sensory reeducation.
• Functional activities.

Suturing of the Nerves

• The rehabilitation program will have to be modified
for the first 2–3 weeks following the suture as the nerve
must not be stretched. In some instances a splint may
be applied to prevent movements.

Minimal or No Recovery After the Lesions

• Try to achieve optimum function. Sometimes func-
tional splinting may help to give a reasonable level of
activity.

128
Axillary Nerve Lesions
Essentials of Diagnosis
• Inability to abduct the arm.
• Trick movement occurs when lift the arm up.
• Muscle wasting.
• Minimum sensory loss.
• Small anesthetic area over the lower part of the muscles.

Management
• Firstly treat orthopedic condition by orthopedician.
• Passive abduction of the shoulder.
• Full range of lateral movements and others, of the
shoulder.
• If the lesion is neuropraxia recovery should occur within
a few weeks.
• Axonotmesis progress will be much slower because of
the nerve degeneration.
• Full range of passive movements.

Ulnar Nerve Lesions

Essentials of Diagnosis
• Nerve may be injured in the axilla by pressure.
• Paralysis of the flexor carpi ulnaris and the medial half
of the flexor profundus digitorum.
• Weakening of ulnar deviation and the loss of flexion of
the terminal phalanges of the third and fourth fingers.
• Paralysis of the small muscles abductor digiti minimi,
flexor digiti minimi, opponens digiti minimi, the inter-
ossei, the third and fourth lumbricals, adductor pollicis 129
and usually flexor pollicis brevis.
 • Loss of the ability to abduct and adduct the fingers and to
flex the third and fourth fingers at the metacarpophalan-
geal joints while the interphalangeal joints are extended.
• Decreased power grip.
• Weaken the pinch grip.
• Sensory loss will depend on the level of the lesion.
• Anesthetic area on the ulnar side of the hand, on both
palmar and dorsal aspects, and on the little, ring and
the part of the middle fingers.
• If the lesion is at the wrist the paralysis will affect only
the muscles and in the hand and the sensory loss may
affect only the fingers.

Management
• If the scar or callus formation is present at the elbow,
referred to the surgeon.
• Functional splint.
• Guide to the patient to care of anesthetic hand.
• If the nerve has to be sutured at the elbow this will not
normally interfere with treatment to the hand.
• If the lesion at the wrist, avoid stretching the nerve.

Median Nerve Lesions

Essentials of Diagnosis
• Lacerations in the course of the median nerve are the
most common cause.
• The muscles paralyzed are thenar eminence, abductor
pollicis brevis, opponens pollicis and the first two
130 lumbricals.
• Monkey hand deformity.
• Sensory losses are present over the lateral side of the
hand and the palmar surface of the thumb, index,
middle and half the ring fingers.
• Trophic changes over the lesions.

Management
• Generally suturing may required.
• Splinting with strap.
• All passive movements of the thumb.
• Care of the anesthetic area.
• Motor and sensory reeducation.

Radial Nerve Lesions

Essentials of Diagnosis
• Compressions or more rarely wounds are more common
cause.
• Fractures specially on the midshaft of the humerus is
the other commonest cause.
• A lesion of the nerve below the axilla will result in the
paralysis of the brachioradialis, extensor digitorum,
extensor carpi radialis longus and brevis, supinator,
extensor digiti minimi, extensor carpi ulnaris, extensor
pollicis longus, extensor indicis, abductor pollicis longus
and the extensor pollicis brevis.
• Inability to extend the wrist and the fingers.
• Problem in gripping.
• If the lesion in the axilla, slight weakness of the triceps.
• Minimal disability over the lesions. 131
 Management
• If the neurotmesis is present, nerve will have to be sutured.
• Functional splint.
• All possible passive movements over the affected area.
• Reeducation.
• Brachial plexus lesion, Erb’s paralysis and Klumpke’s
paralysis are the also radial nerve lesion. All of treat as
their protocol.

Sciatic Nerve Lesions

Essentials of Diagnosis
• Mainly occurs as a result from traumatic posterior
dislocation of the hip.
• If the hole nerve is damaged the paralysis will affect the
hamstrings and all the muscles of the leg and foot.
• Sensory loss of the whole lower leg and foot except for
the medial side.
• Sciatic nerve lesions are relatively uncommon.

Management
• Avoid hard work.
• Functional positioning and splinting.
• Reeducation.
• All possible passive movements over the affected area.

Femoral Nerve Lesions

Essentials of Diagnosis
132 • Nerve is seldom damaged.
• Paralysis of quadriceps.
• Anesthesia over the anterior aspect of thigh and the
medial side of the lower leg and the foot.

Management
• Avoid hard work.
• Functional positioning and splinting.
• Reeducation.
• All possible passive movements over the affected area.

Common Peroneal Nerve Lesions

Essentials of Diagnosis
• Occurs as the result of injury round the neck of the
fibula.
• Common site is leg.
• The lesion may occur as a complications of fracture of
the neck of the fibula or lateral tibial condyle or there
may be compression by splints or pop.
• Paralysis of the tibialis anterior, extensor hallucis
longus, extensor digitorum, peroneus longus, peroneus
brevis and peroneus tertius.
• Loss of dorsiflexion, extension of the toes and eversion.
• Weak inversion.
• Foot dragging.
• High stepping gait.
• Sensory loss over the lateral side of the lower leg and
the dorsum of the foot,
• No functional disability.
• If only deep peroneal nerve will damaged the peroneus
longus and brevis are not paralyzed and eversion can 133
 occur in the plantar flexed position. Sensory loss is
much less.

Management
• Functional splint.
• Neuropraxia may not require any treatment.
• Reeducation.
• All possible passive movements over the affected area.

PERONEAL MUSCULAR ATROPHY

(CHARCOT-MARIE-TOOTH DISEASE)

Essentials of Diagnosis
• Usually becomes apparent in late childhood or adoles-
cence.
• Wasting and weakness of the peroneal muscles.
• Wasting and weakness gradually progresses to the
other muscles in the lower legs and feet.
• Muscles of the upper part of the thighs are not affected.
• Weakness of the feet often leads to pes cavus and
clawing of the toes.
• Later a symmetrical wasting and weakness occurs in
the forearm and hands.

Management
• Strengthening exercises of the weak muscles.
• Splinting.
134
• Chest physiotherapy.
• Graded ambulatory program.
• If foot deformity occurs, orthopedic surgery may be
needed.

POLYNEUROPATHIES

Essentials of Diagnosis
• Pain, tingling and numbness, which usually occur in
the hands and feet.
• Muscle weakness and/or paralysis occur mainly in the
limbs and the lower more than the upper limbs.
• Signs are more marked distally than proximally.
• Sometimes foot or wrist drop may occur.
• Contractures/fibrous adhesions.
• Loss of proprioception.
• Decreased tendon reflexes.
• Increased sweating.
• Edema.

Management
• Passive movements.
• Taught for correct positioning.
• Padded splinting.
• Reeducation of sensory and motor function.
• Coordination exercises.
• Psychotherapy.

135
 SPINA BIFIDA

Essentials of Diagnosis
• Incomplete closure of the vertebral canal, obvious
lesion over the vertebral defect on the back.
• Sometimes there may be small tuff of hair over the area.
• Enuresis or urine retention.
• Muscle paralysis and/or weakness depend on the levels
and the extent of the lesion. If the upper motor neurons
are affected there may be a spastic paraplegia; other-
wise there is a flaccid paralysis.
• Sensory impairment.
• Mental retardation.
• Secondary clinical features are vasomotor changes,
pressure ulceration, osteoporosis, soft tissue contrac-
ture and skeletal deformity.

Management
• Counseling of parents.
• Encourage for education.
• Positioning.
• Passive movements.
• Mat activities.
• Stretching of the soft tissue contractures.
• Strength and develop the arm and shoulder muscles.
• Strengthening exercises to the weight bearing muscles
like hip extensors and abductors, knee extensors, ankle
plantar and dorsiflexors.
• Proper skin care.
136
• Proper bowel and bladder care.
• Orthotic support, if required.
• Ambulation and gait training.
• Psychological rehabilitation.
• Functional activities.
• Position to be avoided with myelomeningocele-Frog-
leg in prone or supine, W-sitting, ring sitting, heel sitting,
and cross-legged sitting.

SPINAL CORD LESIONS

Essentials of Diagnosis
• Spinal shock with flaccid paralysis below the level of the
lesion.
• Flexor spasm to develop a reflex activity below the
lesion.
• Permanent paralysis of the muscles below the level.
• Sensation lost below the level of the lesion.
Clinical features will vary depending on the number of
segments involved.

COMPLETE TRANSECTION OF THE CERVICAL CORD

BELOW C5
• Tetraplegia.
• Decreased respiratory movements.
• Loss of vasomotor control, postural hypotension.
• Normal temperature regulating control is upset.
• Sensation lost below the lesion.
• Incontinence or retention of the urine and/or feces.
• Psychological problems. 137
 COMPLETE LESION OF THORACOLUMBAR SEGMENTS
If the lesion is at T12 then the muscles of the legs will be
paralyzed but the intercostal muscles and the abdominals
will be innervated, there will be a complete loss of sensa-
tion in the legs and urinary incontinence.

CAUDA EQUINA LESIONS

If the lesion below the 2nd lumbar vertebra, will affect the
peripheral nerves to the legs resulting in a flaccid paraplegia
and loss of sensation. There may be some recovery if the
conditions are favorable. However, full recovery is unlikely.

INCOMPLETE LESIONS
Some lesions may appear to be complete immediately
after the injury but once the inflammatory reaction has
subsided and the patient recovered from spinal shock
may become apparent. The psychological reactions of
the patients with incomplete lesions will vary and are not
necessarily related to the severity of the injury.

Management
Early Stage m/m
• Positioning.
• Turning.
• Passive movements, daily to all joints of the lower limbs
with a paraplegic and include the upper limbs with a
tetraplegic.
• Care must be taken with lesions in the lumbar and
lower dorsal areas that hip movements do not cause
138
 movement of the spine. Similar care may be required
with the upper limbs in relation to the cervical spine.
• Chest physiotherapy, generally paraplegics may not
require it.
• Strengthening exercises for the upper limbs in paraplegia.
• Any active movements in the upper limbs in tetraplegics.
• Psychotherapy.

Later Stage m/m

• Balance training.
• Provide wheelchairs and educate to patient to move
around and develop some independence. Patients
using hand-propelled wheelchairs can be taught to go
up and down slopes and up and down kerbs.
• Teach about transferring techniques.
• Teach about self-care.
• Strengthening exercises of the upper limbs.
• Sports activity.
• Graded ambulatory program.
• Psychotherapy.

SPINAL MUSCULAR ATROPHY

Essentials of Diagnosis
• Symmetrical muscle weakness and wasting.
• Initial problem is atrophy and weakness of the small
muscles of the hand.
• Gradually weakness spread to the forearm, shoulders
and back muscles. 139
 • Swallowing and sucking are impaired.
• Child lies with arms and legs abducted and externally
rotated.
• Contractures.
• Wasting and fasciculation gradually.
• All motor milestones are delayed.
• Dyspnea.
• Sometimes urinary retention.
• No sensory loss.
• Sometimes pain may be present.

Management
• Treatment or advice mainly depends on the particular
problems.
• Active or assisted active movements.
• If active movement is not possible passive movements
should be given.
• Maintain joint range of movement.
• Breathing exercises.
• Chest physiotherapy.
• Teach for positioning.
• Genetic counseling.
• Regular monitoring.
• Psychological support.
• Social rehabilitation.
• If required, give valuable rehabilitation aids.

140
 STROKE

Essentials of Diagnosis
• Prolonged coma is uncommon unless there is cerebral
hemorrhage or massive brain edema.
• Advanced atherosclerosis, hypertension or a source of
embolus are evident.
• Prior history of transient ischemic attacks or reversible
ischemic neurological deficit.
• Convulsions may occur at outset.
• CT scan shows the infraction or hemorrhage.
• Neurovascular syndromes according to involving
artery
a. Anterior cerebral artery—contralateral weakness and
sensory loss primarily in the lower extremity, incon-
tinence, aphasia, memory and behavioral deficits.
b. Middle cerebral artery—contralateral sensory loss
and weakness in the face and upper extremity, less
involvement in the lower extremity, homonymous
hemianopia.
c. Vertebrobasilar artery—cranial involvement (diplo-
pia, dysphasia, dysarthria, deafness, vertigo) ataxia,
equilibrium disturbance, headaches and dizziness.
d. Posterior cerebral artery—contralateral sensory loss,
thalamic pain syndrome, homonymous hemian-
opia, visual agnosia and cortical blindness.

141
 Management
• Respiratory care.
• Positioning:
– On the affected side, shoulder should be protracted
and flexed. Elbow and wrist should be extended. The
forearm should be supinated. Pelvis in protracted
position. Hip and knee in slight flexion and ankle
should be in neutral position.
– On the sound side, arm should be rested on pillow.
Shoulder girdle should be kept in protraction and
slight elevation. Shoulder in slight abduction and
flexion with elbow and wrist in extension position.
Forearm in the supine position. Pelvis should be in
the protracted position. Hip should be in the slightly
abducted and flexed. The knee should be slightly
flexed and the ankle should be in neutral position.
Finger should be kept in extension.
• Gentle passive full ROM exercises of all joints/10 repita-
tions/3–4 times/day.
• Stretching of the tendon achilles, hamstring, quadriceps,
adductors, tensor fascia lata, biceps, and wrist flexors.
• Splinting.
• Rolling.
• Scooting.
• Pelvic control exercises.
• Bridging and bridging with approximation.
• Hip extension over the edges of the mat or bed.
• Hamstring cocontraction.
• Lower trunk rotation and lower trunk rotation with
142 bridging.
• Hip flexor retraining.
• Hip and knee extension with ankle dorsiflexion.
• Scapular mobilization.
• Upper extremity elevation.
• Weight bearing activities.
• Tilt board exercises.
• Vestibular exercises.
• Gait training.
• Skillful taping over joints, which are more prone to
subluxated.
• Oropharyngeal retraining by stroking over the neck
area, ice massaging of the tongue, stimulate the lip
closures.
• Counseling.
• If required advice for mobility aids.
• Wheelchair to bed transfer techniques.
• Home modification.
• Vocational rehabilitation.

Spastic stage treatment:

• Gentle rhythmic passive movements.
• Stretching in sustained manner by manually or splint.
• Prolonged icing over the spastic muscle/15 to 20
minutes.
• Faradic stimulation to weak agonist muscle.
• Reflex inhibiting postures or pattern.
• Biofeedback.

143
 C H A P T E R 5

General Surgical
Conditions

ACUTE HEAD INJURY

Postoperative Management
• Allows the head to be raised at 30° and in side lying.
• Regular turning.
• Chest vibration on the expiratory phase of breathing.
• Tipping the patient with his head down is not advised.
• Shaking.
• Passive movements to all limbs.
• If the patient is unconscious, give stimulation in forms
of voice, voice of closed friends or relatives.

ADRENALECTOMY

Postoperative Management
• Breathing exercises are most important when the loin
incision is used.
• Mild clapping.
• Mild shaking.
• Gentle vibration.
• Resisted bilateral costal breathing.
• Active bed exercises.

ARTERIOVENOUS ANOMALIES

Postoperative Management
Same course as that for an aneurysm.

BURN

Essentials of Diagnosis
At the site of burn:
• History of burn.
• Redness.
• Blisters/ulcer.
• Pain.
• Blackened skin—later leathery in nature.
• Weeping of plasma—straw colored.
Inhalation injury:
• History of smoke, soot, and fire.
• Burnt lips and nose.
• Soot in nostrils and mouth.
• Singed nasal and facial hair.
• Voice hoarseness.
• Sore throat. 145
 During shock stage:
• Restlessness.
• Coldness and paleness of the skin.
• Thirst and sweating.
• Tachycardia.
• Reduced blood pressure.
• Cyanosis.

Later stage:
• Eschar separates.
• Scar tissues forms.
• Decreased joint ROM.
• Loss of functional capacity.

Management
• Put off the fire by:
– Falling and rolling on the floor in a blanket to put out
the flames.
– Water is used to put off the flames.
– Immersion in cold water relieves pain and mini-
mizes thermal damage.
• Sterile dressing over the wound with 1% ssd.
• In chemical burns—washed off with plenty of water.
• Except minor, all burns need hospitalization.
• Clean the wound with 1% savlon or soap water and then
put vaseline gauze and change dressing on 3rd day only.
• Respiratory care—shaking, clapping, postural drainage,
coughing, and suction by the use a piece of foam under
the physiotherapist hands.
146 • Avoid tipping in facial burn.
• Positioning—by the use of towels or pillows:
– Head and Neck—patient may be lying in chest and
leg burns or in half-lying with facial burns. Towel
under the neck and/or a pillow under the shoulders.
– Upper limbs—shoulder in abduction and slight
flexion, elbows and wrist in extension, MCP joints
in flexion, IP joints in extension and thumb in
abduction.
– Lower limbs—hips in abduction and extension,
knees in extension and ankle in 90° dorsiflexion.
Foot end of bed is elevated but not by the pillows
under the legs which would put the hips into the
flexion.
• Splinting.
• Full ROM active exercises/hourly.
• Strengthening exercises.
• Passive stretching.
• Cycling.
• Skipping.
• Jumping.
• Walking.
• Kneading over the scar tissues.
• Pressure garments.
• Occupational therapy.

CHOLECYSTECTOMY

Postoperative Management
• Deep breathing exercises. 147
 • In this operation, danger of atelectasis is to the right lower
lobe and so the emphasis must be to the right lower lobe.
• Leg exercises.

COLOSTOMY

Postoperative Management
• Leg exercises regularly.
• Deep breathing exercises.
• When patient is able to sit, regular leg exercises in inter-
vals and leg care.
• Teaching the patient how to lift correctly and avoid
excessive strain.
• Fitness exercises.

CYSTECTOMY

Postoperative Management
• Chest physiotherapy.
• Teach about lifting.
• Fitness exercises.

CEREBRAL ABSCESS

Postoperative Management
Same as for the cranial surgery.
148
 CAROTID ARTERY STENOSIS

Postoperative Management
• Early mobilization.
• Reeducation of hemiplegic limbs.

CLEFT LIP AND PALATE

Postoperative Management
If required:
• Postural drainage.
• Turning.
• Vibration.

COMPOUND FRACTURES

Postoperative Management
• Regular exercises of the affected limb without distur-
bance to fracture site or skin graft/flap.
• In compound fractures of the tibia and fibula mobiliza-
tion of the ankle and knee and strengths the quadri-
ceps.
• In case of rib fracture, sternum and mandible, breathing
exercises are must.
• After formation of the callus, allowed weight bearing
exercises.
149
 COSMETIC SURGERY

Postoperative Management
• Chest physiotherapy.
• Ultrasound.
• Pulsed electromagnetic energy.

CRANIAL SURGERY

Postoperative Management
• Deep breathing exercises.
• Relaxation exercises.
• Coughing.
• Active exercises of all the joints.
• Ankle foot pump exercises.
• Postural drainage regularly, but contraindicated just
after operation.
• Turning and lying to sitting exercises but continue after
few days of operation.
• Respiratory facilitation techniques suitable for the
unconscious adult patient.
• Preoral stimulation.

CRUSH INJURIES OF THE HAND

Postoperative Management
• Shoulder and elbow exercises.
150 • Hand movements.
• Elevation massage.
• Low dose of pulsed ultrasound.
• Pressure bandage.
• Active/passive exercises.

If scar adherent:
• Ultrasound.
• Pulsed electromagnetic energy.

EPILEPSY

Postoperative Management
• Rehabilitation follows general principles with deficits
being treated accordingly.

FACIAL FRACTURES

Postoperative Management
• Breathing exercises.
• Suctioning.
• SWD to the temporomandibular joint/low dosage.

FACIAL PALSY

Postoperative Management
• Determine the type of nerve lesion by SD curves.
• Movement activity. 151
 • PNF technique.
• Spatula is placed inside the cheek and the patient is
asked to pull the cheek in.
• Infrared/ice/ultrasonic therapy.
• Electrical stimulation.

GASTRECTOMY

Postoperative Management
• Deep breathing exercises specially on lower costal.
• Coughing with support.
• Leg exercises.
• If the patient has been ill before operation for some-
time or long time bedridden, general mobilizing and
strengthening exercises.

HEAD AND NECK SURGERY

Postoperative Management
• Advice for half lying position.
• Breathing exercises.
• Regular suctioning.
• Leg exercises.
• If required, postural drainage.

After 7th day of operation:

• Shoulder girdle exercises.
152 • Facial exercises.
• Intensive exercises to the lips with finger assistance or
resistance.
• Reassured him.
• If required, speech therapy.

HERNIA

Postoperative Management
• Active leg exercises.
• Breathing exercises.
• Static contractions of the abdominal muscles.
• Teach the patient for correct lifting.

HYDROCEPHALUS

Postoperative Management
• Patients are nursed flat in bed for two to three days.
• Gradually set up after third day of operation.
• Maintain upright position on 5th day.
• Ambulation.

ILEOSTOMY

Postoperative Management
• Similar to a colostomy.

153
 INTRACTABLE PAIN

Postoperative Management
• Encouraged to get up on the 2nd day postsurgery.
• Chest care.
• Static muscles contraction exercises.
• Active extension exercises.
• Gentle neck mobilization.
• Stimulation of periaqueductal gray matter.
• Chronic thalamic stimulation.

INTERVERTEBRAL DISk LESIONS

Postoperative Management
• Gentle active movements for the lower limbs in the side
lying position.
• Static work for the back extensors and abdominals.
• Strengthening exercises for the back and abdominals.
• Full range of movement of all the affected joints but
avoid flexion of spine.
• Postural correction.
• Social rehabilitation program.

JAW OSTEOTOMIES

Postoperative Management
Same as for the facial fractures.
154
 LYMPHEDEMA

Postoperative Management
• Leg is immobilized until the wound is healed.
• Gentle active movements after 7 to 10 days.
• After 10 to 12 days, weight bearing is allowed with a
double layer of tubigrip.

MALIGNANT MELANOMA

Postoperative Management
Upper Limb
• Breathing exercises.
• Active-assisted exercises for digital joints.
• Elevation.
• Flowtron compression.

Lower Limb
• Immobilization of the grafted area.
• Movements over the distal joints.
• After 10 to 14 days, hip mobilization exercises.
• Ambulation with double layer of tubigrip.

MASTECTOMY

Postoperative Management
• In lumpectomy or wedge resection—no treatment 155
required.
 • In local or simple mastectomy without axillary clear-
ance—no treatment required.
• In extended or radial mastectomy:
- Pendular type shoulder exercises.
- Hand and wrist movement.
- Static contraction of the deltoid.
- Mobilizing exercise of the shoulder.
- Shoulder shrugging exercises.
- Lifting the affected hand by pillows in resting position.
- Posture correction.
- Teach the patient, how to lift without strain on the
shoulder.
- Psychological support.
- Advice for breast prosthesis.

MOVEMENT DISORDERS

Postoperative Management
• Chest care.
• Functional reeducation.
• Stabilizing exercises.
• Full range joint mobility exercises.

NEPHRECTOMY

Postoperative Management
• Posterior basal and lower costal breathing exercises.
156 • Posture correction.
• Leg exercises.
• Elevating of the leg in resting position.

POLICIZATION

Postoperative Management
After removal of plaster cast:
• Active exercises.
• Re-education.

PROSTATECTOMY

Postoperative Management
• Early ambulation is essential.
• Ambulatory exercises.
• Deep breathing exercises.
• If required, chest physiotherapy.
• If incontinence is present, interferential therapy or
Faradism.

REPLANTATION

Postoperative Management
After 5th day of the operation:
• Movement of the replanted part.
• Passive movements of the individual joints.
157
 In later stage:
• Passive stretching.
• Ultrasound.
• Massage.
• If necessary—splinting.

SKIN GRAFTS

Postoperative Management
• Generally after 14 days later, finger kneading round the
edges with lanolin.
• After 3–5 days of operation, E1 dosage of UVR is given
over the donor area. Air cooled mercury vapor burner
is used at a distance of 45 cm for 3–5 days.
• After 5–7 days, full range movement exercises pro-
grammed over the joint and muscles, which is nearly to
grafting area for 10 times/hour.
• After releasing of flap or pedicle, kneading, hold-relax
and mobilization exercises.
• Coughing.
• Huffing.
• Fitness exercises.

SPINAL TUMORS

Postoperative Management
• Breathing exercises.
158 • Assisted coughing.
• General fitness exercises.
• Gentle static exercises for the back extensors.
• Gradual mobilizing and strengthening for the trunk.
• General care of the back.
• Graded strengthening exercises and reeducation of
function in a case of temporary paralysis of the muscles.
• In case of any type of paralysis, provide rehabilitation
appliances.

SUBARACHNOID HEMORRHAGE

Postoperative Management
Same as for intracranial tumors.

SYNDACTYLY

Postoperative Management
• Active movements.
• Massage over the scar.

THYROIDECTOMY

Postoperative Management
• Chest physiotherapy specially on upper lobes.
• Splitting of the upper part of the sternum.
• Mobilized rapidly.
• Head and neck movements. 159
 TOE TO THUMB TRANSFER

Postoperative Management
After removal of plaster cast:
• Active exercises specially flexion and extension of
terminal joint.
• Apposition activity at carpometacarpal joint.
• Avoid movement at the point of arthrodesis.

TUMORS (BRAIN)

Postoperative Management
• Retraining of orofacial dysfunction.
• Correct positioning of head.
• Slowly and carefully diet progression both to more
liquid to more solid.
• Sometimes required shoulder girdle reeducation.
• Chest physiotherapy.
• Breathing exercises.
• Active movements, if not possible give passive move-
ments.
• Keep regular watching for physical conditions.

ULCERS AND LACERATIONS WITH SKIN NECROSIS

Postoperative Management
• Active/assisted exercises but not to disturb the skin grafts.
160
• After 5th day, pulsed electromagnetic energy therapy.
• After 10 days, leg swing exercises.
• After 11th to 12th day, ambulation with double layer of
tubigrip.

VASCULAR LESIONS

Postoperative Management
Same as for the cranial surgery.

161
 C H A P T E R 6

Pulmonary/Cardiac
Surgery

CARDIAC SURGERY

Following points and charts should be noted or looked at:

• Type of operation.
• Incision with leg wounds, if present.
• Central and peripheral temperature.
• Arterial trace.
• Blood pressure.
• Pulse rate.
• ECG.
• Respiration—artificial/spontaneous, with rate/depth.
• Color.
• Blood pH.
• PCV.
• Hb.
• Electrolytes.
• Fluid chart.
• Drug chart.
• Drains and tubes.
Management
This will vary from patient to patient and surgeon to surgeon.

On the Day of Operation:

• Help to patient for sit forward in half lying.
• Three deep breaths and to try one or two huffs, with
incision supported.

Day 1:
• Diaphragmatic and bilateral basal breathing exercises
are practiced with huffing/four times a day.
• Thoracic expansion exercises.
• Position sense training.
• Assisted exercises of the arm, if the lateral thoracotomy
done.
• Foot movements.
• Hip/knee bending exercises.
• Stretching of hip and knee.

Day 2:
• Same as for 1st day.
• Arm movements should be in full range in case of
lateral thoracotomy.
• Start bilateral shoulder movement, if median ster-
notomy done.
• Advice to patient for sitting beside his bed.

Day 3:
• Same as for day 2.
• General arm and trunk exercises. 163
• Short walking.
 • Posture correction.
• Arm swinging exercises.

Day 4:
• Same as for the day 3.
• Allowed to go to toilet on his own.
• Group exercises with other cases.

Day 5–14:
• Same as for the day 4.
• Independent light ADL.
• Walking upstairs.
• Advice for home exercises.
• Patient will be advised that he should not drive for
6 weeks and that sexual relation should be avoided
for 4 weeks after leaving hospital. Patient will be able
to resume light or part-time work after 2 months and
heavy work after 3 months.

DECORTICATION OF THE LUNG

Management
Same as for the pleurectomy.

LOBECTOMY

Management
164 On the day of operation:
• Advice for half lying position.
• Breathing exercises.
• Vibrations over the unoperated side.
• Huffing with support.
• Foot and ankle exercises.

On the 1st day of operation:

• Half lying position.
• Inhalation therapy.
• Breathing exercises with inspiratory holding.
• Vibrations to operated side.
• Percussion.
• Arm exercises on the operated side.
• Foot and ankle movements.
• Quadriceps contractions.
• Alternate hip and knee bending and stretching.
• Side lying on the unoperated side.

On the 2nd day of operation:

• As first day.
• Self-supported huffing.
• Abdominal contractions exercise.
• Trunk exercises.
• Arm exercises.
• Avoid crossed-leg sitting position.

On the 3rd and 4th day of operation:

• As first and second day.
• Walking exercises.
• Promote for ADL.
165
 PECTUS CARINATUM/EXCAVATUM

Management
• Maintaining airways.
• Lung expansion exercises.
• Preventing lung collapse/consolidation.
• Advice lying position.
• Avoid side lying.
• Bilateral shoulder girdle and arm exercises.
• Posture correction during walking and sitting.

PLEURODESIS

Management
Same as for the pleurectomy.

PLEURECTOMY

Management
• Care of the drainage tube.
• Side lying position, affected lung uppermost.
• Breathing exercises.
• Coughing.
• Elevation of the foot end of the bed.
• On 1st day of operation, sitting position advised.
• Postural drainage until all excess secretions is removed.
• Walking.
166
• Stair climbing.
• General exercises.

PNEUMONECTOMY

Management
On the day of operation (surgery am-treat pm):
• Positioning with half lying by pillows arranged behind
the neck and back .
• Expansion breathing exercise.
• Foot and ankle exercises.

On the 1st day of operation:

• Half lying position advised.
• Segmental expansion exercises.
• Unilateral shaking on the good side during expiration.
• Vibrations.
• Huffing and expectoration with wound support.
• Active leg, ankle and foot exercises.
• Posture correction.
• Full range active/assisted shoulder exercises.
• Advice for rope ladder for moving around in bed and sit
up.

On the 2nd day of operation:

• Trunk turning and bending exercises.
• Trunk stretching exercises.
• Bilateral breathing exercises in sitting position.
• Shoulder girdle exercises. 167
• Walking with arm swinging.
 On the 3rd day of operation:
• Breathing exercises.
• Huffing.
• Early mobilization with controlled breathing.

On the 4th day of operation to discharge:

• Walking.
• Stair climbing with breathing control.
• Bilateral breathing exercises.
• Trunk and arm exercises.
• Thoracic mobility exercises.

THORACOPLASTY

Management
On the day of the operation:
• Half lying position.
• Breathing exercises.
• Coughing and huffing (applies firm pressure over the
apical areas of the thorax).

On the 1st day of the operation:

• Posture correction exercises.
• Active assisted arm movements.

On the 2nd day of the operation:

• Same as for the 1st and 2nd day.

168 On the 3rd day of the operation:

• Sitting up.
• Resisted exercises for the shoulder girdle.
• Resisted arm exercises.

On the 4th day of the operation:

• Trunk exercises in sitting.

On the 5th day onwards:

• Trunk exercises in standing.
• Walking with posture correction.

On the 8th day onwards:

• Trunk and thoracic cage mobility exercises.
• Posture correction for 3 months.
(If paradoxical movement of upper chest is present, it
should be prevented by the application of a firm ‘paradox-
ical pad’ which should extend from below the clavicle and
into the axilla).

THORACOTOMY

Management
On the day of the operation:
• Oxygen therapy.
• Active/assisted shoulder movements.
• Breathing exercises.
• Coughing with support.

On the 1st day of the operation:

• Side lying position. 169
• Advice for the sit out of the bed.
 • Breathing exercises.
• Coughing.
• Limb and shoulder girdle exercises.
• Posture correction exercises.

On the 2nd day of the operation:

• Same as for the 1st day.
• Advice for sitting.
• Trunk exercises.
• Stair climbing.

On the 3rd day to discharge:

• Same as for the 2nd day.
• General activities.

170
 C H A P T E R 7

Psychiatric Conditions

ANXIETY

Essentials of Diagnosis
• Normal reaction experienced in daily life in mild form,
when it becomes excessive and pervasive it is an illness.
• Occur alone or as often happens in combination with
other psychiatric illness.
• Dyspnea, dizziness, paresthesia.
• Abdominal pain, constipation, diarrhea.
• Tachycardia, transient systolic hypertension, fainting.
• Dysuria, impotence, frigidity, urinary frequency.
• Cold clammy palms.
• Inability to swallow.

Management
• Kindly attention to the root problem of the patient.
• Reassure him.
• Relaxation exercises.
 • Psychotherapy.
• Fitness exercises.
• Specially instance running upstairs, doing step-ups.

ANOREXIA NERVOSA

Essentials of Diagnosis
• Disturbed body image.
• Low body weight.
• Onset is usually adolescence.
• More common in women.

Management
• Bed rest.
• Regulated food intake with careful observation.
• Isometric exercises.
• Active exercises.
• Weight lifting exercises.

DEPRESSION

Essentials of Diagnosis
• Anorexia and weight loss continuing until the patient
begins to recover.
• Sleep disturbances and insomnia.
• Early morning wakening and suicidal thoughts will
often occur at this time.
172 • Sexual disturbances and incapacity.
• Spontaneity is gone.
• Loss of pleasurable interest.
• Slower thinking and speech procedure.
• Mild depressive patient feels physically fit and does his
usual work.
• Agitated depressed patient feels aches, pains, fatigues
of unworthiness or guilty fears.
• In severe cases, total motor retardation.

Management
• Give kind attention and reassurances.
• Suicide risk is to be evaluated.
• Aerobic an anaerobic exercises.
• If patient is depressed due to long-term physical disa-
bility, give specific treatment to the person to gain/
maintain functional independence.

HYSTERIA

Essentials of Diagnosis
• Psychic symptoms without any basis.
• Symptoms seldom occur when the patient is alone and
are exaggerated in presence of a sympathetic audience.
• Symptoms serve the primary or secondary gain.

Management
• Isolation of the patient.
• Placebo therapy.
173
 • Psychotherapy.
• If the patient has been paralyzed for a long time,
reeducate the limb and restore function.
• Family or marital therapy.

OBSESSIVE COMPULSIVE STATES

Essentials of Diagnosis
• Repetitions of certain ideas or actions like continual
washing of the hands, doubt about whether doors are
locked or gas turned off, etc.
• Often troublesome, when they interfere with ADL.

Management
• Psychotherapy.
• Relaxation exercises.
• Exercise therapy.

PHOBIA

Essentials of Diagnosis
• Excessive fear attached to an object or a situation such
as eating out, open spaces (agoraphobia), enclosed
spaces (claustrophobia), animals, fire and many others.
• Tremor, pallor, tachycardia, rapid breathing, diarrhea,
vomiting and tightness in the chest.
• Attack to panic lasts as long as patients face the phobic
174 subject or situation.
Management
• Psychoanalysis.
• General fitness exercises.
• Relaxation technique.
• Group therapy.
• Environmental manipulation.

SCHIZOPHRENIA

Essentials of Diagnosis
• Impaired thinking.
• Alteration in the behavior.
• Preoccupation with ideas derived from day-dreams
and fantasies, hallucinations and delusions.
• Mood is inconsistent or exaggerated.
• Develops contradictory feelings, attitudes, wishes or
ideas towards a given object, situation or object.
• False, troubling impression that others are talking about
him.

Management
• Psychotherapy.
• Industrial therapy.
• Recreational therapy.
• Social skills training.
• Regular physical activity.
• Avoid competitive activities.
• Care for each movement, because of drug regimes
175
patients may possible lead to tradive dyskinesia.
 STRESS

Essentials of Diagnosis
• Excessive sweating.
• Skeletal muscle tension—tension headache, backache.
• Increased rate of respiration.
• Functional gastrointestinal disorders.
• Increases of heart action and blood pressure.
• Decreased genitourinary dysfunction.
• Fatigueness.
• Hyperventilation syndrome.
• Leisureness.

Management
• Give attention to the root cause of the patient.
• Reassure him.
• Mitchell method of relaxation.
• Advice for rest.
• Relaxation position.
• Massage.
• Music therapy.
• Hydrotherapy.

Obstetric Patients
Antenatal
• Rest during pregnancy.
• Reassure her.
• Relaxation therapy.
176
• Relaxed position—kneeling forward on to one’s arms
on a cushion placed on the seat of a chair, the knee and
hip joints are at right angle. Another useful position for
a rest after activity is kneeling forward on to one’s arms
on a cushion on the floor, with the buttocks high.

Delivery
• Positioning.
• Sustained relaxation.
• In final dilation of the cervix total relaxation.
• Breathing high in the chest pain.
• In second stage of labor whole body massage.

SUBSTANCE ABUSE

ALCOHOL
Management
• Coordination exercises.
• Regular exercises.
• Relaxation exercises.
• Endurance exercises.

PRESCRIBED DRUGS
Management
• Support and encouragement.
• Regular exercises.
• Relaxation exercises.
• If musculoskeletal problems are present, treat properly. 177
 STREET DRUGS
Management
• Regular exercises.
• Promote for ADL.

178
 C H A P T E R 8

Obstetrics/Gynecology

Routine Antenatal Check-up

To be done each month, till 7 months, then every 15 days
in last 2 months.
• Record the weight.
• Record the blood pressure.
• Always check the edematous feet and uterus.
• In late months, palpate the position of the fetus and
auscultate fetal heart sounds.
• Assess the general body fitness.
• Proper check the psychological status.
• Obstetrician’s notes should keep in mind.

Routine Antenatal Investigations

Most essential routine antenatal investigations are:
1. Hemoglobin, blood group and Rh.
2. Urine albumin—mostly every month.
3. In 5th and 9th month, ultrasonography.
 Antenatal Attentions
• Assess the physical health properly; if not good, try to
manage it in proper way.
• Always try to prevent the problem, which produces
during pregnancy.
• Advice for continued exercises of walking, swimming
and cycling accordingly their physical status.
• Take well-balanced food with extra protein and irons.
• Take adequate rest, with sleep at least for 8 hours at
night and 2 hours at noon.
• Avoid long journey in 1st trimester and last 2 months. If
unavoidable always prefer the train.
• Give special attention to the cleanliness of whole body
specially vulva and nipples.
• Avoid sexual intercourse specially in last 6 weeks.
• Maintain regular bowel habits. Avoid constipation.

Sequence for Exercises

• Warm up.
• Stretching.
• Aerobic activity.
• Postural exercises.
• Cool-down activities.
• Pelvic floor exercises.
• Relaxation techniques.
• Labor and delivery education.
• Educational information.
• Postpartum exercises instruction.
180
Pregnancy and Postpartum
M/M Guidelines
• Postural awareness training.
• Stretching.
• Strengthening exercises.
• Ergonomics consideration in ADL.
• Resistive exercises to appropriate muscles.
• Pelvic floor exercises.
• Diastasis recti exercises.
• Aerobics exercises.
• Relaxation techniques.
• Postpartum exercises instruction.
• Comprehensive approach for prolapsed, incontinence
or hypertonus.

Postcesarean Section
M/M Guidelines
• Breathing instruction.
• Coughing and huffing with support of pillow.
• Postoperative TENS.
• Active leg exercises.
• Early ambulation.
• Gentle abdominal exercises with incision support.
• Scar mobilization and friction massage.
• Supportive exercises.
• Posture instruction.
• Instruction for incisional splinting.
• Pelvic floor exercises.
181
 • Abdominal exercises.
• Corrective exercises for diastasis recti.

High-risk Pregnancy
M/M Guidelines
• Positioning.
• Facilitation of the joint motion in available ROM.
• Stretching.
• Strengthening exercises.
• Ankle pumping exercises.
• Movement activities.
• Postural instructions.
• Bed mobility and transfer technique if able to avoid
Valsalva.
• Stress m/m.
• Relaxation technique.
• Breathing training.
• Childbirth education.

ABDOMINAL ADHESIONS

Essentials of Diagnosis
• Abdominal or pelvic pain.

Management
• Warmth therapy.
• Abdominal support.
182 • TENS.
 AFTER PAINS

Essentials of Diagnosis
• Postpartum lower abdominal pain.

Management
• Sleep.
• Urine passing.
• TENS, over the nerve roots innervating the uterus and
perineum (T10-L1 and S2-S4).

Back Pain

Essentials of Diagnosis
• Stabbing pain over the posterior pelvis, deep into the
buttocks, distal and lateral to L5/S1.
• Radiating pain into the posterior thigh or knee but not
into the foot.
• Pain aggravates with prolonged sitting, standing or
walking.
• Symptoms are relieved with rest or change of position.

Management
• Use external stabilization—belts or corsets.
• Deep heating agents, electrical stimulation and traction
are contraindicated.
• Manipulation and mobilization.
• Advice for keeping the legs together, then pivoting 183
during ADL such as getting in or out of the bed or car.
 • During sexual activity, avoid full range of hip abduction.
• During climbing, avoid more than one step.
• Rest.
• Pelvic tilting with crook lying.
• Massage over the back.
• TENS, if indicated.
• Postural correction.

CERVICITIS

Essentials of Diagnosis
Acute Cervicitis
• Mainly gonococcal or puerperal in origin.
• Cervix is congested, enlarged, swollen, mucous mem­­
brane pouting at the external OS.
• Cervix is tender with profuse purulent discharge.

Chronic Cervicitis
• Histological diagnosis.
• Mucopurulent discharge.
• Low back pain relieved by rest.
• Aching in low abdomen and pelvis.
• Deep-seated dyspareunia.
• Congestive dysmenorrhea, menorrhagia and bleeding.

Management
• SWD in coplanner method/15 minutes.
184
 COCCYDYNIA

Essentials of Diagnosis
• Pain in coccygeal region.
• Occasionally, a coccyx may spontaneously fracture
during the second stage of labor.

Management
• Rubber ring over coccygeal region in sitting.
• Gentle mobilization—grasping the coccyx using a gloved
index finger in the anus and the thumb posteriorly.
• Ice packs.
• Heat.
• Ultrasound.
• TENS.

COMPRESSION SYNDROME

Essentials of Diagnosis
• Thoracic outlet syndrome or carpal tunnel syndrome
may be produced in pregnancy.
• Women are three times as likely as men to experience
carpal tunnel syndrome.
• Compression may also occur in the lower extremi-
ties because of the weight of the fetus, fluid retention,
hormonal changes or circulatory compromise.

Management
• Postural correction exercises. 185
• Manual techniques.
 • Ergonomics assessment.
• Heat therapy.
• Icing.
• Consideration of splints for carpal tunnel syndrome.

COSTAL MARGIN PAIN

Essentials of Diagnosis
• Common in final trimester.
• Pain along the anterior margin of the lower limbs.
• Sometimes unilateral thoracic back pain.
• The diameter of the chest is increased.
• In some cases patient complains lateral abdominal wall
pain.

Management
• Rib lifting technique.
• Raising both arms over the head with the hands clasped
or side flexion.
• Put hot water bottle over the painful area.
• Ice pack.

CRAMP

Essentials of Diagnosis
• Common at night.
• Common site is calf, feet and thighs.
• Reduced activity.
186 • Calf cramp is almost always triggered by the woman
stretching in bed and plantar flexing her feet.
Management
• Stretching of the calf muscle.
• Positioning—knee extension and dorsiflexion.
• Vigorous foot exercises.
• Deep kneading massage.
• Bed time walk.
• Warm bath.
• Foot exercises before sleeping.

Diastasis Recti

Essentials of Diagnosis
• Looks highly stretched abdominal wall from the bottom
of the breast bone to the belly button and increases
with muscle strained.
• Most common in the multiple pregnancies.
• Extra skin and soft tissues in the front of the abdominal
wall may be seen.
• In later part of the pregnancies, the top of the pregnant
uterus is bulging out of the abdominal wall.
• In severe cases, an outline parts of the unborn baby
may be seen.

Management
• Advice the patient to perform the self-diastasis test on
or after third postpartum day for optimal accuracy.
• Monitored the integrity of the linea alba to make sure
the separation continues decreases. 187
 • Head lift exercises—allow the hook lying position with
her hand crossed over the midline at the diastasis. Ask
the patient for exhale and lift only her head off the floor
or until the point just before the bulge appears. Her
hands should pull the rectus muscle towards midline.
After then lower her head very slowly and relax.
• Head lift with pelvic tilt exercises—position is main-
tained as above. Ask the patient to slowly lift her head
off the floor while performing the posterior pelvic tilt
and then slowly lower her head and relax.

DISPLACEMENT AND GENITAL PROLAPSE

Essentials of Diagnosis
• Feeling of something coming down per vaginam specially
during moving.
• Discomfort on walking when the mass comes outside
the introitus.
• Backache or dragging pain in the pelvis.
• Symptoms are usually relieved on lying down.
• Difficulty in passing urine.
• Difficulty in passing stool. The patient has to push back
the posterior vaginal wall in position to complete the
evacuation of feces.
• Excessive white or blood stained discharge per vaginam.

Management
• Nutritional supplement.
188 • Relaxation exercises.
• Antenatal hygiene.
• Adequate postnatal care.
• Pelvic floor exercises.

DYSMENORRHEA

Essentials of Diagnosis
• Painful menstruation.
• Sex fear, unsatisfied sex urge.
• Anxiety and depression.
• Sensation of pain arises in uterus and is related to
muscle contraction.
• Starts just before and after menstruation and lasts about
12 hours.
• Pain radiates to inner side of thigh.

Management
• Teach young girl to menstruation, sex and health.
• Relaxation exercises.
• Breathing exercises.
• TENS.
• SWD.

DYSPAREUNIA

Essentials of Diagnosis
• Painful or difficult sexual intercourse.
• Due to infection or allergy. 189
• Sometimes due to trauma such as after operation.
 Management
• Counseling.
• Education.
• Ultrasound to soften scar.
• Self-massage.
• Pelvic floor exercise.

FIBROIDS

Essentials of Diagnosis
• Pain as a result of red degeneration.
• Sometimes they are actually visible and palpable
through the abdominal wall.

Management
• TENS.

HYSTERECTOMY

Management
• Deep breathing exercises.
• Frequent foot and leg pump exercises.
• Coughing with support.
• Pelvic tilting exercises.
• Pelvic floor exercises.
• Posture correction.
190 • Graded ambulatory exercises.
 INCONTINENCE

Essentials of Diagnosis
• Involuntary small leak of the urine.
• Patients need to void frequently through the day and
more than twice at night.
• Digital evaluation of vagina test is ‘o’ or ‘1’.
• Perimeter reading is very high.
• Pad test is positive.

Management
• Pelvic floor exercises perform twice a day.
• Abdominal stress exercises.
• Faradism stimulation of the pelvic floor muscles.
• IFT—a frequency sweep of 10–5 Hz is used for genuine
stress incontinence and 5–10 Hz for urge incontinence.
• Reeducation of the pelvic floor muscles.

JOINT LAXITY

Essentials of Diagnosis
• All joint structures are at risk of injury during preg-
nancy and immediate postpartum period.
• Tensile quality of the ligamentous support is decreased.

Management
• Advice for the safe exercises.
• Nonweight bearing aerobics. 191
• Less stressful aerobics.
 MORNING SICKNESS

Essentials of Diagnosis
• Nausea and vomiting during the first trimester of preg-
nancy.
• More severe in multiple pregnancies.

Management
• Pressure is applied by the flexor surface of the index,
middle and ring fingers to the distal 5 cm of the forearm.
The thumb gives counter pressure underneath.
Acupressure point that is stimulated is P6. Pressure
is applied for 30 seconds at a time.
• A rounded button stitched to a 2 cm wide elastic bracelet
and worn so that the button pressure on the acupunc-
ture point.

Osteitis Pubis/Diastasis (Separation) of

Symphysis Pubis

Essentials of Diagnosis
• Increase width of pubic symphysis in pregnancy from
about 4 to 9 mm.
• Sometimes joint separates completely.
• Transient sometimes incapacitating pain in and around
the joint and radiating down the medial aspect of thighs.
• Pain in hip abduction and turning in the bed.
192 • Walking may be impossible except with a walking aid.
Management
• Bed rest with legs adducted and flexed.
• Binding the hips with a long roller towel.
• Trochanteric belt.
• Walking aids, if necessary.
• Ice packs over the painful area.

PAINFUL PERINEUM

Essentials of Diagnosis
• Visible problem can include bruising, edema, labial
tear, hematoma, tight stitches, infection and breakdown
of suturing.
• Hemorrhoids.
• Vaginal hematoma will not be visible but may be
intensely painful.
• Immediate postnatal problem.

Management
• Ultrasound/3MHz/0.5W/cm2/2 minutes.
• Pulsed electromagnetic energy, pulse width of 40–65
µs pulses with a repetitions rate of 10–220 pulses per
seconds.
• Pelvic floor exercises.
• Comfortable position for feeding, relaxation and sleep,
using pillows and a foam rubber ring.
• Crushed ice can be wrapped in damp disposable gauze
or a disposable wash cloth/surgical wipe and, with the 193
 woman reclining, the resulting pad applied lightly to
the painful, possibly edematous area for 5–10 minutes.
Alternatively, crushed ice may be put into a plastic bag.
• Massage with an ice cube over painful area.
• Warm saline can also poured over the perineum from a
jug.
• IR/nonluminous/side or crook lying position with her
legs apart and well-supported on pillows/50–70 cm
distance/20 minutes.

PELVIC FLOOR DYSFUNCTION

Essentials of Diagnosis
• Descent of any of the pelvic viscera out of their align-
ment.
• Involuntary loss of bladder or bowel contents.
• Dyspareunia.
• Difficulty with elimination.

Management
• Control and relaxation of the pelvic floor muscles.
• Neuromuscular reeducation in the pelvic floor muscles.
• Manual stretch facilitation to the levator ani.
• Lumbar stabilization exercises.
• EMG biofeedback.
• TENS.
• Superficial heat.
• Icing.
194
 PRURITUS

Essentials of Diagnosis
• Distressing skin irritation.
• Sometimes presents during the third trimester.

Management
• Discontinuing the use of perfumed soaps, talc and bath
oils, taking cold baths.
• Weaning light cotton clothes.

RESTLESS LEG SYNDROME

Essentials of Diagnosis
• Unpleasant creeping sensation deep in the lower legs.
• Fatigue.
• Stress.
• Anxiety.

Management
• Bed rest.
• Reduce the activity.
• General fitness exercises.

RETENTION OF URINE

Essentials of Diagnosis
• Main problem in newly delivered woman. 195
• Experiencing in initiating and completing maturation.
 • Bladder over distension can produce chronic changes
by irreversible damage to detrusor muscle.

Management
• Gentle pelvic floor contraction exercises.
• Running taps, whistling and calm breathing with relax-
ation on expiration, while sitting on the toilet.
• Sitting in warm bath.

SORE AND CRACKED NIPPLES

Essentials of Diagnosis
• Redness over nipple and areola.
• Swelling.
• Cracks are present.

Management
• Washing the breasts before and after each feed with
gentle soap.
• Teach mother to feeding techniques.
• Expose the nipple in sunlight and air.
• Avoid weight bra.
• Use padded brassiere.

SYMPHYSIS PUBIS PAIN

Essentials of Diagnosis
196 • Pain in the region of the symphysis pubis is present in a
small proportion of postpartum women.
• Follow a traumatic delivery.
• Pain aggravate on movement.
• Swelling.

Management
• Bed rest.
• Gradual mobilization on crutches or a Zimmer frame.
• Standing should be avoided.
• Ultrasound.
• Strengthening exercises of the abdominal muscles.
• Ice massage over painful area.

UTERINE LIGAMENT PAIN

Essentials of Diagnosis
• Sudden, sharp stabs of lower abdominal pain or the
constant dull ache, often unilateral.

Management
• Warmth or cold therapy.
• Massage over the site of pain.
• Stroking the skin over pain area.

VULVITIS

Essentials of Diagnosis
• Continuous moist discharge from glands in the vulva.
• Irritation at some parts of the perineum. 197
 • Rawness and a curdy, white discharge.
• Little boils in root of perineum.

Management
• Continuous or pulsed SWD.
• Ultrasound.
• IR.
• Laser.

198
 C H A P T E R 9

ENT

ACUTE OTITIS MEDIA

Essentials of Diagnosis
• Inflammation of the mucous membrane lining the
middle ear.
• Causes are follows upper respiratory infection and
sometimes it follows in influenza, scarlet fever, measles
and diphtheria.
• A serous exudates is formed which often becomes
purulent.
• Persistent discharge from ear.
• Varying degrees of deafness.
• Fever, vomiting and convulsion.
• Mastoid tenderness, often edema.
• Signs of facial nerve paralysis, meningitis, even brain
abscess may be seen in fulminating cases.
 Management
• Bed rest.
• Take plenty of fluids.
• Zinc solution—special aural electrode or by means
careful packing of external auditory meatus with ribbon
gauze soaked in 2% solution of zinc sulfate. 3 milliam-
peres given for ten minutes.

NASAL BLEEDING

Essentials of Diagnosis
• Bleeding from nose.
• Caused by trauma, ulceration, polyp or new growth in
the nose, impacted foreign body, hypertension, rheu-
matic fever, typhoid and other hemorrhagic diseases.
• Most common in summer seasons.
• Mainly faced by children.

Management
• Pinching the lower part of the nose between forefinger
and thumb. Keep pressure on for ten minutes.
• Sit down.
• Lean forward.
• Breathe through mouth.
• Allow any blood that comes down the back of the nose
to trickle out of the mouth, into a bowl, a towel or what-
ever is to hand.
• Do not let go of the nose for at least ten minutes, timed
200
on a clock or watch.
• If the bleeding restarts on releasing the pressure, repeat
the steps.

SINUSITIS

Essentials of Diagnosis
• Inflammation of the mucous membrane of the sinuses.
• May be acute or chronic.
• May involve one sinus only or all the sinus of one side or
both sides.
• Spread of inflammation from nasal mucous membrane.
• Due to virus causing the common cold.
• Maxillary sinusitis arises from infection of roots of teeth
of upper jaw.
• Deflected nasal septum.
• Hypertrophy of nasal mucous membrane.
• Swollen nasal mucous membrane blocks the opening
from the sinus into the nose.
• The stagnant mucus is converted into pus.
• Retention of temperature.
• Pulse and R/R increases.
• Headache.
• Nasal discharge is mucous at first but after few days
purulent materials appears in the nasal cavity.
• Pain and tenderness on pressure.

Management
• SWD/15 minutes/daily.
• Maintain general health. 201
• General fitness exercises.
 TONSILlITIS

Essentials of Diagnosis
• May become acutely inflamed or chronic inflamed.
• Fever and general illness.
• The crypts of tonsil become filled with pus and toxic
absorption may be continuous, thus causing trouble
elsewhere.
• Pain in throat.
• Pain aggravates during taking the cold liquids.

Management
• Rest.
• Start with fairly bland foods like butter toast.
• Don’t have hot spices, vinegar or sharp citrus fruits, but
do eat that need chewing.
• Chewing gum, preferably sugar-free.
• Gentle fitness exercises.
• Keep away from crowds or anyone with a cold, flu or
other infection.
• Keep strictly away from cigarette smoke.
• Avoid dusty or dirty environment.
• Brush teeth twice daily.
• Taught to blow the nose with the head bent forward and
holding the bridge of the nose and not the nostrils.
• Taught to breathe in with mouth closed and out with
mouth open.
• Correct use of chest concentrate on basal and lateral
regions of the lungs, manual pressure and use of straps
202
are of value.
• A good habit is acquired by carrying on the good
breathing while performing simple exercises, games
and ADL are ideal.
• Cooperation of patients is essential.

VERTIGO

Essentials of Diagnosis
• Hearing loss, tinnitus, aural fullness, otalgia or otor-
rhea.
• Facial weakness.
• Impaired facial sensation, clumsiness, dysarthria,
dysphasia, cranial nerve palsy, hemisensory loss, and
hemiparesis or memory disturbances.
• Loss of consciousness, olfactory or gustatory hallucina-
tions.
• Peripheral vertigo is usually paroxysmal, severe with
short duration.
• Central vertigo is usually seldom paroxysmal with long
duration.
• Otoscopy, tuning fork test, audiometry or brainstem
auditory evoked tests are confirmatory.
• Vestibular assessment is also helpful.

Management
• Eye exercises—follow pencil end with eyes only by side
to side, up and down, obliquely up to the right down
to the left and obliquely up to the left and down to the
right. Progress is done by increasing repetitions, speed 203
 and altering distance. Objects at different positions and
distances are identified by number then the numbers
are called out in random order for the patient to focus
on. Exercises to be carried out 15 minutes twice a day
increasing to 30 minutes.
• Head and neck exercises—in sitting position bend head
forward, then backward with eyes open. Slowly first,
then quickly 20 times. Followed by rotation of the head
to the side and back.
Turn head from left to right and vice versa. Gently
first, then quickly 20 times.
 As dizziness improves exercises should carried out
with eyes closed.
• Shoulder and trunk exercises—in sitting position,
shoulder girdle raising, pushing down and resting
slowly first and then 20 times.
Turn shoulders to right and then left. Slowly first,
then quickly 20 times.
Bend forward and pick up objects from the ground
and sit up 20 times.
• Standing exercises—standing up and sitting down with
eyes open 20 times. Repeat with eye closed.
 Pass ball from hand to hand, in front then overhead,
stretching the arms and watching the ball throughout
the movement.
Stand up, turn round and then sit down.
• Moving exercises—walk across room with eyes open
and then closed 10 times.
 Walk up and down a slope with eyes open and then
204 closed 10 times.
 Walk up and down steps with eyes open and then
closed 10 times.
Go into the darkened room walk around feeling for
objects with hands and feet.
Go outdoors walk and cross street with friend or
physiotherapist and then alone.
Any game involving stooping or turning is good.
• Avoid excessive salt and water, jerky movements, driving,
under water swimming, working at heights or accident
prone work when under influences of drugs.

VERTIGO DUE TO MENIERE’S DISEASE

Essentials of Diagnosis
• Sudden onset of vertigo, nausea and vomiting in middle
age.
• Tinnitus prior to and during attack.
• Progressive sensory neural deafness.
• Frequent remission and exacerbations.

Management
• Bed rest in dark and quiet room.
• Restriction on fluid intake to 3 cups a day.
• Avoid smoking.
• Avoid mental stress and heavy work.
• Exercises—same as for the vertigo.

205
 VaSOMOTOR RHINORRHEA

Essentials of Diagnosis
• Undue sensitivity of sympathetic nerve fibers of nasal
mucous membrane.
• Irritation may be by definite irritants (may be with
sudden changes in temperature) or not known irritants.
• Pricking in the nose.
• Violent bout of sneeze.
• A profuse, watery discharge accompanied by intense
lacrimation.

Management
• Decrease sensitivity of nasal mucous membrane by the
use of zinc ionization for five minutes.
• Progressed from five to seven and up to ten minutes.
• Care is necessary to not to produce a hemorrhage.
• UVR to nasal mucosa.
• Rest.
• General fitness exercises.

206
 C H A P T E R 10

Miscellaneous

ARTERIOSCLEROSIS OBLITERanS

Essentials of Diagnosis
• Disease of the large and medium-sized arteries, particu-
larly of the lower extremities, characterized by occlusive
lesions.
• Intermittent claudicating pain.
• Changes in the skin color and temperature.
• Sensory disturbances.
• Absence of pulses.
• Gangrene.
• Ulceration.
• Paralysis.

Management
Buerger’s exercises/5 times/sessions/5 times per day.
• Patient in supine lying, legs elevated to 45°.
• Observe time taken for blanching.
 • Patient is asked to remain in the same position for 2
minutes.
• He then is made to sit in high sitting position.
• Pooling is allowed in the superficial veins due to gravity.
• Patient continued in the same position for 3 minutes.
• He then lies flat for 5 minutes.

CONSTIPATION

Essentials of Diagnosis
• Defecation is delayed.
• Stools are hard, dry and difficult to expel.
• Causes are—highly refined or low fiber foods, inade-
quate fluids, physical inactivity, prolonged bed rest, lack
of exercises, pregnancy and antacids, ganglion blocking
agents, iron salts, opiates types of drugs.

Management
• Foods with high fiber content like bran and raw fruits,
salads of lettuce and vegetables.
• Drink at least 10 glasses of water in a day.
• Regular exercises.
• Develop regular bowel habit. Natural reflex should not
be suppressed.
• Massage over the colon with hand or fist moving from
cecum along ascending and transverse colon down to
descending colon.

208
 DEEP VEIN THROMBOSIS

Essentials of Diagnosis
• Common in those who are confined to bed for a
prolonged period.
• Pain, swelling and cyanotic discoloration of affected
limbs.
• Warm skin.
• Pulmonary embolism.
• Low grade pyrexia.
• Hoffmann sign.
• Phlegmasia alba dolens—arterial spasm may accom-
pany extensive DVT and causes a swollen white leg.
• Phlegmasia cerulea dolens—cyanosed and swollen
legs.

Management
• Ambulation and leg exercises. (not to be done if there is
DVT).
• Inpatients confined to bed with a cradle under the
bedclothes and the bed end elevated 15–22 cm.
• General breathing exercises.
• Stop contraceptive pills before planned surgery.
• Graduated compression stocking.
• External pneumatic compression.
• Continuous rotation beds.
• Elastic stockings.
• All type of physical exercises.
209
 DIABETES

Essentials of Diagnosis
• Gradual in adults but acute in children.
• Polyuria, intense thirst.
• Nocturia.
• Polyphagia.
• Weight loss, weakness and lassitude.
• Leg cramps, crops of boils, loss of libido and impotence
in middle age.
• Blurring of vision.
• High fasting blood sugar >120 mg%.
• Urine may be positive for sugar.
• Pruritus vulvae in females and balanitis in males.

Stress Test is Indicated in Case of

• Suspected CAD.
• Type 1 diabetes of more than 15 years duration.
• Type 2 diabetes of more than 10 years duration.
• Patient over 35 years of age.
• Past history of microvascular complications.

Management
• Walking or cycling for 30 minutes/three times a week.
• Resistance training for 15 minutes/ twice a week.
• Aerobic activity involving large muscle group.
• Stretching exercises.
• Wash the feet daily.
210 • Dry between your toes after bathing.
• Wear clean socks.
• Test the temperature of the bath water with a part of your
body that feels things properly. If that is not possible,
use a thermometer. Temperature should be 85°–90°.
• Inspect feet for cuts, scratches, redness, swelling, discol-
oration, bruises and cuts.

Don’ts
• Sit with crossed legs.
• Walking barefoot.
• Wear stockings with elastic tops.
• Wear round elastic graters.
• Smoking.
• Expose to cold climate.
• Use of hot water bottle or heating pad.
• Sun exposure.
• Put medicine on corns or cut them without supervision.
• Wear run down shoes.
• Wear worn out stocks.
• Dig into corners of toes.
• Low calorie diet.
• Low carbohydrate, high protein diet.
• Lots of green vegetables to be consumed.

FILARIA

Essentials of Diagnosis
• High fever with rigors.
• During attack nausea and vomiting.
• Tender inflamed lymphatic are seen as red streaks. 211
 • Lymph gland swollen, firm, and tender, generally of
groins.
• Itching, irregular erythematous swelling of skin scat-
tered over the body.
• Secondary gram-positive bacterial infection in breast.
• Microfilariae in peripheral blood collected about mid-
night.
• Gland biopsy to identify adult worm.

Management
• Rest.
• Elevation of the limb.
• Elastrocrepe bandage during daytime.
• Hot fomentations.
• Infrared rays.
• SWD.
• Twice daily washing of affected parts with soap and
water.
• Regularly working the foot up and down.
• Keeping the nails clean.

HEMOPHILIA

Essentials of Diagnosis
• Inherited, life-long, sex-linked disorders occurring
predominantly in males.
• Hemorrhages into joints, muscles and other tissues
either spontaneously of following minor trauma.
212 • In an untreated case, crippling deformity.
Management
• Full range of motion exercises of all joints.
• Muscle strengthening exercises.
• Prevent deformity by exercises or the help of orthotic
support.
• ADL.
• Psychological rehabilitation.

HEMORRHOIDS/PILES

Essentials of Diagnosis
• Slowing of fecal material through gut.
• Increased fluid absorption and harder stools.
• Constipation.
• Straining to move the bowels can cause ballooning of
the veins in and around the anus.
• Difficulty in stool passing.

Management
• Take plenty of fiber and fluid.
• Pelvic floor contractions.
• Ice packs over affected region.
• Rubber ring.

HEARTBURN

Essentials of Diagnosis
• Anorexia, epigastric fullness, nausea. 213
• Epigastric tenderness.
 • Diarrhea, colic, hematemesis, fever, chills, headache,
malaise.

Management
• Bed rest.
• Bland soft diet.
• Raising the head of the bed on two bricks and using
extra pillows can give night time relief.

HEMOPHILIC ARTHROPATHY

Essentials of Diagnosis
Similar to hemophilia.

Management
• Short-term immobilization.
• Isometric exercises.
• Braces and splints.
• Active assistive, active and finally to resistive exercises.
• Heat or cold application.
• Electrical stimulation.
• Hydrotherapy.

HICCUP

Transient phenomenon may occur as manifestation of

many diseases such as neuroses, CNS disorders, GIT disor-
214 ders, etc. It may be only symptom of peptic esophagitis.
Management
• Rebreathing deeply into a paper bag.
• Deep breathing.
• Swallowing dry bread or crushed ice.
• Drink a small quantity of cold milk and hot milk alter-
nately.
• Juice of white radish.
• Take a glass of water and hold it in the mouth. Press middle
fingers in both ears and swallow the water, removing the
fingers after moment or two. Repeat till relief.

INSOMNIA AND NIGHTMARES

Essentials of Diagnosis
• Difficulty to get to sleep at night.
• Uncomfortable feeling.
• Unsatisfactory sleeping position.
• Someone, initially fall asleep easily but are unable to
drop off again after one of their many night time visits
to the toilet.
• Anxiety.
• Fear and worries.
• Sometimes frightening dreams are also common.
• Tense feeling.
• Will not be able to deal with the coming day.

Management
• Use the pillows, bean bags.
215
• Alternative sleeping position.
 • Support the abdomen and top leg with pillows in side
lying.
• Supporting position.
• Relaxation exercises.
• Instead of tossing and turning in desperation, they get
out of bed, eat something light and have a warm drink
and go back.

LYMPHEDEMA

Essentials of Diagnosis
• Swelling of an extremity or other body part secondary to
a malformation or obstruction of lymphatic channels.
• Edema pits, on pressure but later it becomes solid.
• Enlargement of secondary lymph glands in secondary
lymphedema.

Management
• Effleurage massage.
• Graded pressure pumps.
• Gradient elastic stockings.
• Muscles strengthening exercises.
• Soft tissue manipulation.
• Full joint range of motion exercises.
• Mechanized sequential compression from distal to
proximal segments.

Advice to Patient
216 • Use the limb as normally as possible.
• Avoid minor injuries.
• Avoid injection on the affected side.
• Do not wear tight bands or jewelry on the swollen
limbs.
• Do not take hot baths since the limb will swell further-
cool baths are allowable.
• Elevate the limb by putting the lower limb on a chair
during the day and raising the foot of the bed at night.
Support the upper limb in a sling or sit for short periods
with the hand on the head.
• Do not carry heavy objects with affected limb.
• Wear footwear.
• Wear a thimble when sewing.

OBESITY

Essentials of Diagnosis
• Body weight that exceeds the normal or standard weight
for a particular person based on height and frame size.
• Increased BMI.
Classification BMI (Kg/m2)
Underweight < 18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity 30.0-39.9
Extreme obesity > 40
• Waist to hip ratio—values more than 0.8 for women and
0.95 for men are indicative of excessive visceral adipose
tissue accumulation.
217
 Abdominal girth (cm)
WHR =
Hip girth (cm)
• Waist circumferences:
< 40 year—100 cm or more
> 40 year—90 cm or more.
• Health problem associated with obesity are heart disease,
hypertension, diabetes, and certain type of cancer.

Management
• Aerobic activity, walking or stationary cycling/30 minutes/
three times a week.
• Gradually increase duration of exercise to 60 minutes
per day.
• Resistance training.
• Jogging.
• Swimming.
• Rope skipping.
• Calisthenics.
• Encouraged to increase general activity level. Instead of
using lift take stairs, go on bicycle to market, get down
at one bus stop earlier and walk to office, do gardening
on weekends, do stationary bicycle while watching
television, go out with family swimming on holidays, go
for a stroll after dinner.
• Advice for low caloric diet.
• Decrease mode of eating.
• Take liquid diet frequently, but low in calorie.
• Suggest diet chart.

218
 RHEUMATIC FEVER

Essentials of Diagnosis
• Carditis.
• Sydenham’s chorea.
• Subcutaneous nodules.
• Erythema marginatum.
• Fleeting polyarthritis.
• Fever.
• Polyarthralgia.
• Prolongation of PR interval.
• Increased ESR.
• Increased antistreptolysin O titer.
• Disease develops in some people following infection
with group A hemolytic streptococcus, but the inflam-
mation is aseptic.

Management
• Avoid exposure of streptococcal throat infection.
• Bed rest.
• Ice therapy, applied in towels round the affected joints.
• Radiant heat, prior to exercises.
• Wax to the wrist, hand, ankle, and feet.
• Free active exercises to all joints.
• Pool therapy.
• Walking re-education.
• Restoration of confidence.
• Group exercises.
219
 SCAR TISSUE

Essentials of Diagnosis
• Pain.
• Traction on the neighboring structures, when the scar
is adherent.
• Limitation of movement which arises when the scar is
over a joint line.
• Impaired blood supply when the scar constricts blood
vessels.

Management
• Stroking round and towards the scar with thumb.
• Thumb kneading on one side of the scar while the other
side is supported avoiding stretching.
• Wax bath.
• Active exercises with full range.
• Ultrasound/frequency 3MHz/intensity 1 W/cm2/4 minutes.
• Passive stretching.
• Serial splinting.
• Whirlpool bath.

SEXUAL DYSFUNCTION

Essentials of Diagnosis
• Premature or delayed ejaculation in men.
• Erectile dysfunction.
220 • Pain during sex.
• Lack or loss of sexual desire.
• Lower urinary tract symptoms.
• Difficulty having an orgasm.
• Vaginal dryness.

Management
• Contrast bath for men and women/hot water for 3
minutes/cold water for 1 minutes/ 3 times/ 2 sets per
day/5 weeks.
• Do not use this technique in prostate cancer or other
malignancies.
• Therapeutic massage.
• Kegel’s exercises for women.
• Proper education about sex.
• Joint counseling.
• Psychotherapy.

TEMPOROMANDIBULAR DISORDERS

Essentials of Diagnosis
• Affect jaw muscle, teeth, joints, and nerves.
• Chronic facial pain.
• Symptoms may occur one or both side of the face, head
or jaw or develop after an injury.
• Most common nondental related chronic orofacial pain.
• Sensitive teeth without dental pain.
• Locked or stiffed jaw when you talk, yawn or eat.
• Difficulty in opening or closing your mouth.
• Clicking when opening and closing the mouth. 221
 Management
• Practicing good posture.
• Give liquid diet.
• Eating soft food.
• Stress management.
• Jaw exercises.
• Mobilization.
• Jaw ROM exercises.
• Occlusal splint.
• Ultrasound.
• Muscle stimulation.

ULCERS

Same as for pressure sores.

Varicose Veins

Essentials of Diagnosis
• Superficial veins appear as tortuous ‘knotted’ struc-
tures.
• Occasionally, severe pain in the lower extremities.
• Calf muscle cramp, generally at night.
• Fatigue specially during walking.
• Weakened calf muscle, pigmented and indurate skin
over the site.
• Congestion and edema over the ankle.
222 • In later cases, bleeding from the ruptured vein, venous
ulcer or venous thrombosis may be seen.
Management
• Apply elastic stockings or elastic bandages.
• Advice regular walking but avoid long periods standing.
• Elevations of the lower legs for 10–12 minutes/3 times/
day.
• Ankle and foot exercises in elevated condition.
• Faradic current under pressure.
• Air compression.
• Exercises in the pressure support bandage or elasti-
cized support stockings.
• Elevation of lower limbs.
• Effleurage.
• Bandaging.
• Control of infection.
• Mobilization of skin and connective tissue.
• Stimulation of the ulcer floor and edges—ultrasound/
laser.
• Joint mobilization.
• Muscle strengthening.

223
 Appendix

NATIONAL IMMUNIZATION SCHEDULE

TIME VACCINE
Birth BCG and OPV zero dose (for
institutional deliveries)
6 weeks BCG (if not given at birth)
DPT-1 and OPV-1
10 weeks DPT-2 and OPV-2
14 weeks DPT-3 and OPV-3
9 month Measles
18–24 months DPT and OPV (1 booster)
5 year DT
10 year and 16 yrs TT
For pregnant women Early in pregnancy TT-1, after
1 month TT-2
Because of smallpox has been eradicated from the world,
there is no need of smallpox vaccination.
 ELECTROTHERAPY

Principles of Electrotherapy Application

Receiving the Patient
• Good morning sir/madam.
• Please be seated (Please take your seat).
• I am your therapist who is going to treat you.
• Don’t worry; I will do my best for you.

Case Sheet Reading

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

Checking General Contraindications

• Hyperpyrexia.
• Epilepsy.
• Severe renal and cardiac problems.
• Cardiac pacemakers.
• Severe hypotension and hypertension.
• Infections.
• Pregnant women.
• Metal implants.
• Mentally retarded patients.
• Mentally upset patients.
• Malignancy.
• Eyes.
• Anterior aspect of neck and carotid sinus.

225
 Tray Preparation
Patient tray or skin resistance lowering tray and skin
sensation testing tray:
1. Pillows.
2. Cotton.
3. Soap.
4. Towel.
5. Mackintosh.
6. Kidney tray.
7. Petroleum jelly or Vaseline.
8. Test Tubes (hot and cold).
9. U-pin (sharp and blunt).
10. Clips.
11. Bowel of water.
12. IR lamp.
13. Hot and cold packs.

Treatment tray:
1. Pillow.
2. Towel.
3. Bed sheet.
4. Cotton.
5. Adhesive tapes.
6. Straps.
7. Salt.
8. Powder.
9. Scissor.
10. Inch tape.
11. Paper.
226
12. Graph paper.
13. Pencil.
14. Eraser.
15. Scale.
16. Goggles.
17. Machine and accessories.
18. Sand bags.
19. Crepe bandages.

Checking Local Contraindications

• Open wounds.
• Scars.
• Local skin infections.
• Cuts.
• Abrasions.
• Eczema.
• Localized hemorrhagic spots.
• Skin sensitivity (testing).

Apparatus Preparation
• The apparatus and accessories needed should be
assembled and suitably positioned.
• Visually check the electrodes, leads, cables, plugs, power
outlets, switches, controls, dials and indicator lights for
cracks and breaks.

Apparatus Checking
• Check the apparatus in front of the patient.
• Demonstrate the treatment to the patient. 227
 • Give an explanation of the treatment to the patient.
• Explained about the type of sensation, which will be
experienced by the patient.

Positioning the Patient

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

Placement of Electrodes
• Place electrodes properly.
• Use adhesive tapes or straps for placing the electrodes.
• Apply electrode gel evenly on entire electrode.
• Maintain good contact between the skin and the elec-
trode.
• Tie the electrodes with even pressure.
• Wires or leads should not cross each other during the
treatment.
• Again check all the connections.
228
Instructions and Warnings
Instructions
• Don’t move during the treatment.
• Don’t sleep while the treatment is going on.
• Don’t touch the cables, apparatus, therapist and any
other metal nearby you.

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

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

Termination of Treatment
• Switch off the machine and the main supply.
• Inspect the treated part for any adverse reactions.
229
 • If there is any mild erythema, apply powder.
• If it is too severe, advise him/her to go to the physician.
• An accurate record of all parameters of treatment
including region treated, technique, dosage and the
resultant effect must be made.

INTERFERENTIAL

Contraindications
• Cardiac diseases.
• Hemorrhage.
• Pregnant uterus.
• Artificial pacemakers.
• During menstruation over the abdomen only.
• Dermatological conditions.
• Febrile conditions.

Skin Sensation Test

Pinprick test.

Prescription Writing
• Electrode type—small/medium/large.
• Site of application.
• Type of current—dipole/isoplanar vector filed.
• Frequency.
• Base frequency.
• Spectrum.
• Spectrum mode—rectangular/triangular/trapezoidal.
230
• Treatment time.
• Intensity.
• Sessions.
• Specific precautions.
• Remarks.

SHORT-WAVE DIATHERMY

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

Skin Sensation Test

Hot and cold.

Prescription Writing
• Patient position.
• Site of application.
• Electrode type—pad/pisk/wire coil.
231
• Electrode placement—coplanar/contro­planar/crossfire.
 • Spacing—medium/narrow.
• Dosage:
Acute - Subthermal
Subacute - Mild thermal
Chronic - Thermal
• Duration:
Acute 10–15 min
Subacute 15–20 min
Chronic 20–30 min
• Session.
• Specific precautions.
• Supplementary therapy.
• Remarks.

Ultraviolet Radiation

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

Skin Sensation Test

Hot and cold.
232
Prescription Writing
• Patient position.
• Spectrum.
• Distance.
• Dosage:
Base 
Wall  
 For infected ulcers
Floor 
• Focusing point.
• Duration.
• Session.
• Specific precautions.
• Remarks.

LASER THERAPY

Contraindications
• Cardiac conditions.
• Pregnancy.
• Over the eye.
• Hemorrhage.
• Cancers.
• Photosensitized patients.

Skin Sensation Test

Hot and cold.

233
 Prescription Writing
• Patient position.
• Therapist position.
• Site of application.
• Dosage.
• Duration.
• Session.
• Specific precautions.
• Remarks.

ULTRASOUND

Contraindications
• Thrombophlebitis.
• Hemorrhage.
• Ischemic tissue.
• Pregnant uterus.
• Malignancy.
• Anesthetic area.
• All intratissue prosthetic and metallic substances.
• Recent grafts.
• Defective skin sensation.
• Deep X-ray therapy.
• Acute infection.
• Over cardiac area (in advanced cardiac diseases).

Skin Sensation Test

Hot and cold.
234
Prescription Writing
• Patient position.
• Mode.
• Method—direct/water bag/under water bath.
• Site of application.
• Duration.
• Intensity.
• Pulsed ratio.
• Attenuation.
• Field.
• Coupling media: Water/oil/liquid paraffin/aqua sonic
gel.
• Size of head.
• Frequency.
• Phonophoretic agent (if used).
• Session.
• Specific precautions.
• Remarks.

TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS)

Contraindications
• Cardiac pacemakers.
• First trimester of pregnancy.
• Hemorrhagic conditions.
• Open wounds.
• Over carotid sinus, mouth and near eyes.
• Epilepsy. 235
 Skin Sensation Test
Pinprick test.

Prescription Writing
• Type—high/low.
• Frequency.
• Pulse width.
• Intensity.
• Site of application.
• Duration.
• Session.
• Specific precautions.
• Remarks.

IONTOPHORESIS

Contraindications
• Cardiac pacemakers.
• Uncontrolled hypertension.
• Pregnancy.
• Osteoporosis.
• Epilepsy.
• Cancer.
• Over the pharyngeal area.

Skin Sensation Test

Pinprick test.
236
Prescription Writing
• Patient position.
• Drug/solutions.
• Type of electrode—small/medium/large.
• Electrode placement.
• Site of application.
• Intensity.
• Duration.
• Session.
• Specific precautions.
• Remarks.

INFRARED RADIATION

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

Skin Sensation Test

Hot and cold.

237
 Prescription Writing
• Patient position.
• Apparatus type—luminous/nonluminous.
• Generator type—lamp/tunnel bath.
• Distance.
• Focus point.
• Wavelength.
• Frequency.
• Duration.
• Session.
• Specific precautions.
• Remarks.

PARAFFIN WAX BATH

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

Skin Sensation Test

Hot and cold.
238
Prescription Writing
• Patient position.
• Temperature.
• Method—pouring/brushing/dipping/bandaging.
• Site of application.
• Duration.
• Session.
• Specific precautions
• Remarks.

NEUROMUSCULAR ELECTRICAL STIMULATION

(NMES)

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

Skin Sensation Test

239
Pinprick test.
 Prescription Writing
• Patient position.
• Instruction for patient.
• Site of application.
• Current type—faradic/galvanic/others.
• Pulse.
• Frequency.
• Duration.
• Session.
• Specific precautions.
• Remarks.

MICROWAVE DIATHERMY

Contraindications
• Malignancy.
• Tuberculosis.
• Deep X-ray therapy.
• Nonpitable edema.
• Hypersensitive areas.
• Anesthetic areas.
• Psychic patients.
• Paralytic patients.
• Recent injury.

Skin Sensation Test

Hot and cold.
240
Prescription Writing
• Patient position.
• Type of applicator—small/large circular/rectangular.
• Site of application.
• Distance.
• Frequency.
• Intensity.
• Duration.
• Session.
• Specific precautions.
• Remarks.

CRYOTHERAPY (COLD THERAPY)

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

Skin Sensation Test

Hot and cold.

Prescription Writing
• Patient position. 241
 • Types of application—ice massage/towels/immersion/
cold packs/evaporative cooling/excitatory cold/cold
gel/cold compression.
• Site of application.
• Duration.
• Session.
• Special precautions.
• Remarks.

HOT PACKS (HYDROCOLLATOR PACKS)/

ELECTRIC HEATING PADS

Contraindications
• Impaired skin sensation.
• Open wounds.
• Allergic conditions.
• Hemorrhage.
• Impaired circulation.

Skin Sensation Test

Hot and cold.

Prescription Writing
• Patient position.
• Layers of towel.
• Types of packs—small/large/contoured.
• Site of application.
242 • Duration.
• Session.
• Specific precautions.
• Remarks.

WHIRLPOOL BATH

Contraindications
• Skin allergy.
• Skin infections.
• Open wounds
• Hemorrhage.

Skin Sensation Test

Hot and cold.

Prescription Writing
• Patient position.
• Temperature.
• Duration.
• Session.
• Specific precautions.
• Remarks.

CONTRAST BATH

Contraindications
• Skin infections. 243
• Open wounds.
 • Hemorrhage.
• Skin allergy.
• Diabetes.

Skin Sensation Test

Hot and cold.

Prescription Writing
• Temperature
– Warm
– Cold
• Timing in
– Warm
– Cold
• Repetition.
• Session.
• Specific precautions.
• Remarks.

SAUNA BATH

Contraindications
• Psychic conditions.
• Loss of skin sensations.
• Dehydration.

Skin Sensation Test

244 Hot and cold.
Prescription Writing
• Temperature of hot chamber.
• Expanded time in:
– Sweating phase
– Cooling phase
• Pause between two phases.
• Duration (total).
• Session.
• Specific precautions.
• Remarks.

ELECTROMYOGRAPHIC BIOFEEDBACK

Contraindication
• Psychic conditions.

Skin Sensation Test

Hot and cold and pinprick test.

Prescription Writing
• Patient position.
• Types of biofeedback devices—myoelectrical/postural/
goniometric/force/pressure/orofacial control/toilet
training/cardiovascular/stress/temperature.
• Treatment duration.
• Types of electrode—surface/needle.
• Session.
• Specific precautions. 245
• Remarks.
 FLUIDO THERAPY

Contraindications
• Psychic conditions.
• Loss of skin sensations.
• Dehydration.

Skin Sensation Test

Hot and cold.

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

INTERMITTENT PNEUMATIC COMPRESSION

Contraindications
• Acute pulmonary edema.
• Congestive heart failure.
• Recent DVT.
246 • Acute fracture.
• Acute skin allergy.
Skin Sensation Test
Pinprick test.

Prescription Writing
• Patient position.
• Area of treatment.
• Pressure.
• Inflation time.
• Deflation time.
• Duration.
• Session.
• Specific precautions.
• Remarks.

CONTINUOUS PASSIVE MOTION

Contraindications
• Large wound.
• Excess pain.

Prescription Writing
• Patient position.
• Area of treatment—knee/shoulder/elbow/ankle.
• Movement and range.
– Shoulder
- Abduction/adduction with synchronized rotation
- Abduction/adduction with fixed rotation
- Rotation with fixed abduction/adduction 247
- Flexion/extension
 – Elbow
- Extension/flexion
- Extension/flexion with synchronized pronation-
supination.
– Knee
- Flexion/extension
– Ankle
- Dorsiflexion/plantar flexion
• Duration.
• Session.
• Specific precautions.
• Remarks.

TRACTION

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

Prescription Writing
• Position of the patient.
248 • Position of the spine—neutral/flexion/extension.
• Methods—mechanical/manual/positional/gravity/
inversion
• Type—static/intermittent.
• Magnitude of force.
• Total treatment duration.
• Duration of hold.
• Rest (if intermittent).
• Specific precautions.
• Remarks.

EXERCISE PRESCRIPTION

Name:
Age:
Sex:
Address:
Resting heart rate:
Blood pressure:
Body fat percentage:
Resistance exercise frequency:
Warm up period:
Performing exercises:
Initial resistance:
Repetitions:
Number of sets:
Rest intervals:
Overall intensity of the exercises:
Speed of muscles contractions:
Cool down time: 249
 Stretching:
Progression:
Modifications:

NORMAL RANGE OF MOTION FOR

VARIOUS JOINTS

Shoulder
Flexion 0–180° (150°–180°)
Extension 0–45° (40°–60°)
Abduction 0–180° (150°–180°)
Adduction 0
Internal rotation 0–90° (70°–90°)
External rotation 0–90° (70°–90°)

Elbow
Flexion 0–130° (120°–150°)
Extension 135°–0

Forearm
Supination 0–90°
Pronation 0–90°

Wrist
Flexion 0–90° (10°–90°)
Extension 0–70° (50°–70°)
Ulnar deviation 0–40° (25°–40°)
250 Radial deviation 0–20° (15°–25°)
MCP
Flexion 0–90°
Extension 0–20° (15°–30°)
Abduction 0–20°
Adduction 0

PIP
Flexion 0–110° (90°–120°)
Extension 0

DIP
Flexion 0–90°
Extension 0

Thumb
MCP flexion 0–45°

Hip
Flexion 0–120° (110°–130°)
Extension 0–35° (25°–40°)
Abduction 0–55°
Adduction 0
External rotation 0–45° (35°–50°)
Internal rotation 0–35° (30°–45°)

Knee
Flexion 0–120°
Extension 0 251
 Ankle
Plantar flexion 0–45°
Dorsiflexion 0–20°
Inversion 0–45°
Eversion 0–15°

MTP
Flexion 0–40°
Extension 0–80° (10°–90°)
Abduction 0–15°

Interphalangeal
Flexion 0–60° (50°–70°)
Extension 0

Cervical Spine
Flexion 0–45°
Extension 0–45°
Lateral flexion 0–45°
Rotation 0–60°

Thoracic and Lumbar Spine

Flexion 0–80°
Extension 0–25°
Lateral flexion 0–35°
Rotation 0–45°

252
Note:
MCP—metacarpophalangeal joint, PIP—proximal inter-
phalangeal joint, DIP—distal interphalangeal joint.

COMMON MUSCULOSKELETAL TESTS

Cervical Spine
Distraction Test
Tests: Nerve root compression.
Patient position: Sitting.
Procedure: Put one hand under chin and other hand under
occiput and then, gently lift patients head.
Positive sign: Relief or decrease in pain.

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

Romberg’s Test
Tests: Cervical neuropathy, UMNL.
Patient position: Standing.
253
 Procedure: Asked to the patient close his eyes and hold the
position for 20–30 seconds.
Positive sign: Body sways, patient’s looses balance.

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

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

Upper Limb Tension Test

Tests: Brachial plexus tension.
Procedure: Test should be done in sequence given below.
254
ULTT 1
• Depress and abduct (110°) shoulder.
• Elbow extension.
• Forearm supination.
• Wrist extension.
• Finger and thumb extension.
• Contralateral side flexion of cervical spine.

ULTT 2
• Depress and abduct (10°) shoulder.
• Elbow extension.
• Forearm supination.
• Wrist extension.
• Finger and thumb extension.
• Shoulder lateral rotation.
• Contralateral side flexion of cervical spine.

ULTT 3
• Depress and abduct (10°) shoulder.
• Elbow extension.
• Forearm pronation.
• Wrist flexion and ulnar deviation.
• Finger and thumb flexion.
• Shoulder medial rotation.
• Contralateral side flexion of cervical spine.

ULTT 4
• Depress and abduct (10°–90°) shoulder
• Elbow extension.
• Forearm supination. 255
 • Wrist extension and radial deviation.
• Finger and thumb extension.
• Shoulder lateral rotation.
• Contralateral side flexion of cervical spine.
Positive sign: Radiculating pain and stress over the nerve
of brachial plexus.

THORACIC SPINE
Slump Test
Tests: Dural stretch.
Patient positions: Sitting.
Procedure:
1. Patient sits on table, slump so that spine flexes, shoulder
sags forward examiner hold the chin and head erect. If
no symptoms then in continuation.
2. Examine flexes patients neck and held the head down,
if again no symptom their in continuation.
3. Examiner passively extends patients knee and dorsiflex
the foot.
Positive sign: Sciatic pain, impingement of dura and spinal
cord or nerve roots.

LUMBAR SPINE
Brudzinski–Kernig Test
Tests: Neurodynamic dysfunction.
Patient position: Supine.
Procedure: Hands cupped behind the head. Patient actively
256
flex the head onto chest. Patient raises the extended leg
with hip flexion until pain is felt, patient then flexes the
knee.
Positive sign: Pain disappears.

Farfan Torsion Test

Tests: Lumbar instability.
Patient position: Prone.
Procedure: Examiner stabilizes ribs and spine by a hand
and other hand on ilium. Anteriorly pulls the ilium back-
ward result in rotation of spine on opposite side.
Positive sign: Reproduce all the symptoms in patient.

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

Slump Test
Tests: Neurodynamic dysfunction.
Procedure:
ST 1: Supine lying
• Cervical spine flexion. 257
• Thoracic and lumbar spine flexion.
 • Hip flexion (90°).
• Knee extension.
• Ankle dorsiflexion.

ST 2: Supine lying
• Cervical spine flexion.
• Thoracic and lumbar flexion.
• Hip (90°), abduction.
• Knee extension.
• Ankle dorsiflexion.

ST 3: Side lying
• Cervical spine flexion.
• Thoracic and lumbar spine flexion.
• Hip flexion (20°).
• Knee flexion.
• Ankle plantar flexion.

ST4: Long sitting

• Cervical spine flexion, rotation.
• Thoracic and lumbar spine flexion.
• Hip flexion (90°).
• Knee extension.
• Ankle dorsiflexion.
Positive sign: Reproduce the patient’s symptoms, cause
discomfort or pain on neurological tissues.

Straight Leg Raise Test

Tests: Neurodynamic dysfunction.
258
Patient position: Supine lying.
Procedure: Stabilize the unaffected leg, patient actively
raise the leg (hip flexion, with knee extension and ankle in
neutral position).
Positive sign: Pain and stretch below the range of 65°–70°.

SHOULDER JOINT
Anterior Drawer Test
Tests: Anterior shoulder stability.
Patient position: Supine.
Procedure: Hold shoulder in 80°–120° abduction, 0°–20°
forward flexion and 0°–30° lateral rotation. Stabilize scapula.
Draw humerus anteriorly.
Positive sign: Click sound or/and apprehension.

Clunk Test
Tests:Ligament injury/ tear of glenoid labrum.
Patient position: Supine.
Procedure: Abduct shoulder over patient’s head. Apply
anterior force to posterior aspect of humeral head, while
rotating humerus laterally.
Positive sign: Clunk or grinding sound and/or apprehen-
sion of instability present anteriorly.

Crank (Anterior Apprehension Test)

Tests: Anterior shoulder instability.
Patient position: Supine. 259
 Procedure: Slowly abduct the shoulder to 90° with lateral
rotation.
Positive sign: Apprehension.

Droparm Test/Codman’s Test

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

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

Empty Can Test

Test: Pathology of supraspinatus tendon.
Patient position: Sitting or standing.
Procedure: Shoulder abduction 90°; horizontal flexion 30°
and medially rotate the thumb pointing downwards.
Positive sign: Weakness or reappearance of symptoms.
260
Hamilton Ruler Test
Tests:Inferior shoulder instability.
Patient position: Standing.
Procedure: Examiner places straight ruler over affected
arm and check whether the acromion process and lateral
epicondyle are touched by the ruler at the same or not.
Positive sign: If the ruler does not touch both at the same
time, indicates instability.

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

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

261
 Neer Impingement Test
Tests: Biceps or supraspinatus tendon impingement.
Patient position: Sitting or standing.
Procedure: Forward flex arm and medially rotate it passively.
Positive sign: Reappearance of symptoms.

Posterior Drawer Test

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

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

Sulcus Sign
262 Tests: Inferior shoulder stability.
Patient position: Standing or sitting.
Procedure: Arm by side. Hold arm below elbow and pull
distally.
Positive sign: Reappearance of symptoms and/or appre-
hension of sulcus under acromion.

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

Elbow Flexion Test

Tests: Cubital tunnel syndrome.
Patient position: Sitting or standing.
Procedure: Elbow full flexion with extended wrist. Hold it
for 5 minutes.
Positive sign: Tingling or paresthesia in ulner nerve distri-
bution.

Jug Test
Test: Lateral epicondylitis.
Patient position: Standing.
263
 Procedure: Ask him to lift a jug full of water holding it from
its mouth.
Positive sign: Pain and reappearance of symptoms.

Lateral Epicondylitis Test (Tennis Elbow)

Tests: Lateral epicondylitis.
Patient position: Sitting or standing.
Procedure:
Method 1: Passive elbow extension, forearm pronation and
flexes fingers and wrist while palpating lateral epicondyle.
Method 2: Resist extension of middle finger distal to PIP
joint.
Positive sign: Pain over lateral epicondyle and reappear-
ance of symptoms.

Pinch Grip Test

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

Valgus Stress Test

Tests: Stability of medial collateral ligament.
Patient position: Sitting.
264
Procedure: Stabilize upper arm with elbow flexion in
20°–30° and lateral rotation of humerus in full range. Apply
force while abducting forearm.
Positive sign: Reappearance of symptoms or increased
laxity.

Varus Stress Test

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

WRIST JOINT AND HAND

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

Liniburg’s Test
Test: Tendon pathology between flexor pollicis longus and
flexor indices. 265
 Patient position: Sitting.
Procedure: Flex thumb towards hypothenar eminence and
extend index finger.
Positive sign: Limited extension and reappearance of
symptoms.

Lunotriquetral Ballottement (Reagan’s) Test

Tests: Stability of lunotriquetral ligament.
Patient position: Sitting.
Procedure: Stabilize the triquetrum and lunate. Apply
posterior and anterior glide.
Positive sign: Reappearance of symptoms, cripitus or laxity.

Murphy’s Sign
Tests: Lunate dislocation.
Patient position: Sitting.
Procedure: Patient makes a fist.
Positive sign: 3rd metacarpal lines up with 2nd and 5th
metacarpal.

Phalen’s (Wrist flexion) Test

Tests: Median nerve pathology, carpal tunnel syndrome.
Patient position: Sitting.
Procedure: Place the hands together from its dorsal aspect
with wrist in flexion. Hold it for 1 minute.
266
Positive sign: Tingling sensation in distribution of median
nerve.

Reverse Phalen’s Test

Tests: Median nerve pathology.
Patient position: Sitting.
Procedure: Place the palm of both hands together with
wrist extension for 1 minute.
Positive sign: Tingling sensation over median nerve distri-
bution.

Sweater Finger Sign

Tests: Rupture of flexor profundus tendon.
Patient position: Sitting.
Procedure: Patient makes a fist.
Positive sign: Loss of flexion of DIP joint of one of the
fingers.

Thoment’s Sign
Tests: Ulnar nerve paralysis.
Patient position: Sitting or standing.
Procedure: Hold piece of paper between thumb and index
finger. Pull the paper away.
Positive sign: As the paper is pulled away, the IP joint of
thumb flexes.
267
 Tinel’s Sign
Tests: Median nerve pathology, carpal tunnel syndrome.
Patient position: Sitting.
Procedure: Tap over carpal tunnel.
Positive sign: Tingling sensation or paresthesia over
median nerve distribution.

Watson (Scaphoid Shift) Test

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

PELVIS
Anterior Gapping Test
Tests: Sprain of anterior sacroiliac joint or ligaments.
Patient position: Supine.
Procedure: Push right and left ASIS apart.
Positive sign: Reappearance of symptoms.

Gaenslen’s Test
268 Tests: Sacroiliac joint involvement, hip pathology or L4
nerve root lesion.
Patient position: Side lying on normal side, with leg flexed
against chest.
Procedure: Affected leg is hyperextended at hip and pelvis
is stabilized by examiner.
Positive sign: Pain on SI joint, while performing movement.

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

Hibb’s Test
Tests: Movement of sacroiliac joint, stress of posterior
sacroiliac ligament.
Patient position: Prone.
Procedure: Pelvis is stabilized and a patient performs 90°
flexion on the knee, hip is medially rotated, while palpating
sacroiliac joint on that side. Repeat the test and compare it
with other side.
Positive sign: Range of opening and quality of movement at
each sacroiliac joint differ.
269
 Laguere’s Sign
Tests: Sacroiliac joint involvement, hip pathology.
Patient position: Supine.
Procedure: Examiner flexes, abducts and laterally rotate
the patient’s hip to be tested. Over pressure is applied at
end range. Pelvis is stabilized. Repeat the test on others
side and compare both sides.
Positive sign: Pain on SI joint or hip.

Piedallu’s Sign (Sitting Flexion)

Tests: Movement of sacrum on ilia.
Patient position: Sitting.
Procedure: As the patient forward flexes, palpate the right
and left PSIS.
Positive sign: Normal side moves higher than other, indi-
cates hypomobility on that side.

Posterior Gapping Test

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

Standing Flexion
Tests: Movement of ilia on sacrum.
270
Patient position: Standing.
Procedure: Palpate PSIS of both sides, while patient
forward flexes the hip.
Positive sign: Normal side moves higher than affected side,
indicates hypomobility on affected side.

Supine to Sit (Long Sitting) Test

Tests: Pelvic torsion or rotation.
Patient position: Supine.
Procedure: Note the level of inferior border of medial
malleoli. Patient is asked to sit of the changing position of
malleoli is noted.
Positive sign: One leg moves up more than other.

HIP/JOINT
Anterior Labral Tear Test
Tests: Ligament or labrum tear or injury.
Patient position: Supine.
Procedure: Full flexion at hip, lateral rotation and full
abduction. Examiners extend, medially rotate and adduct
the hip.
Positive sign: Pain, reappearance of symptom with/without
click.

Ober’s Sign
Tests: Tensor fascia lata and iliotibial band contractures.
Patient position: Side lying with lower leg flexed. 271
 Procedure: Pelvis stabilized. Abduct and extend upper leg
with knee extension or flexion to 90° passively and allow it
to drop towards plinth.
Positive sign: Upper leg remains abducted and does not
lower to plinth.

Patrick’s (Faber’s) Test

Tests: Hip joints and SI joint dysfunction, spasm of iliop-
soas muscle.
Patient position: Supine.
Procedure: Foot of test leg is placed on opposite knee.
Slowly lower knee of test leg.
Positive sign: Pain or spasm, knee remains above the oppo-
site leg.

Posterior Labral Tear Test

Tests: Ligament injury or labrum tears.
Patient position: Supine.
Procedure: Full flexion at hip, adduction and lateral rota-
tion. Examiner extends, abduct and laterally rotate the hip.
Positive sign: Resist extension of middle finger distal to PIP
joint.

Rectus Femoris Contracture Test

Tests: Ractus femoris contracture.
272 Patient position: Supine.
Procedure: Knee flexed to 90° over edge of plinth. Patient
takes other knee to chest.
Positive sign: Knee extends over edge of plinth.

Thomas Test
Tests: Hip flexion contracture.
Patient position: Supine.
Procedure: Patient takes knee on to chest.
Positive sign: Opposite leg lifts off plinth.

Trendelenburg’s Sign
Tests: Strength of hip abductors, stability of hip.
Patient position: Standing.
Procedure: Patient is made to stand on one leg.
Positive sign: Pelvis on opposite side drops.

KNEE JOINT
Abduction (Valgus) Stress Test
Test: Full knee extension ligament injury (ACL, MCL, POL,
PCL), quadriceps and semimembranosus expansion.
Patient position: Supine.
Procedure: Ankle is stabilized and medial pressure is applied
on knee joint at 0° and then at extension in 20°–30° .
Positive sign: Excessive movement is seen as compare to
opposite knee. 273
 Adduction (Varus) Stress Test
Tests: Full extension ligament injury (LCL), iliotibial band,
biceps femoris tendon.
Patient position: Supine.
Procedure: Ankle is stabilized, lateral pressure is applied
on knee joint at 20° and then extension at 20°–30°.
Positive sign: Excessive movement is seen as compare to
opposite knee.

Anterior Drawer Test

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

Apley’s Test
Tests: Compress for meniscus injury and distraction for
ligamentous injury.
Patient position: Prone with 90° knee flexion.
Procedure: Medial and lateral rotation of tibia, first with
distraction and then with compression.
Positive sign: Pain.
274
Brush Test
Tests: Mild effusion.
Patient position: Long sitting.
Procedure: Stroke the patella on medial side, below joint
line up to suprapatellar pouch two to three times and
stroke down lateral side of patella by using opposite hand.
Positive sign: Fluid travels to medial side and bulge appears.

External Rotation Recurvatum Test

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

Fairbank’s Apprehension Test

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

Hughston Plica Test

275
Tests: Inflammation of suprapatellar plica.
Patient position: Supine.
 Procedure: Knee is medially rotated and flexed. Applying
medial glide on patella and medial femoral condyle is
palpated. Extend and flex knee passively.
Positive sign: Popping of plica band over femoral condyle,
tenderness.

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

Mc Murray Test
Tests: Medial meniscus and lateral meniscus injury.
Patient position: Supine.
Procedure: Complete knee flexion.
Test medial meniscus: Knee lateral rotation and 90° exten-
sions passively, while palpating joint line.
Test lateral meniscus: Test is repeated with medial rotation
at knee.
Positive sign: Click or a snap.

Posterior Drawer Test

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

Posterior Sag Sign

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

Slocum Test for Anterolateral Rotatory Instability

Tests: Ligament injury (ACL, PCL, LCL and cruciate), ilioti-
bial band.
Patient position: Supine.
Procedure: 45° flexion at hip and 90° flexion at knee, foot is
placed in 30° medial rotations and stabilized; posteroante-
rior force is applied on tibia.
Positive sign: Excessive movement on lateral side, when
compared with other knee.

Slocum Test for Anteromedial Rotatory Instability

Tests: Ligament injury (MLC, POL, ACL).
Patient position: Supine.
277
 Procedure: 45° hip flexion, 90° knee flexion, foot is placed
in 15° lateral rotation and stabilize it and then posteroante-
rior force is applied on tibia.
Positive sign: Excessive movement on medial side, when
compared with other knee.

ANKLE JOINT AND FOOT

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

Squeeze Test of Leg

Tests: Syndesmosis injury (fracture, contusion or compart-
ment syndrome).
Patient position: Supine.
Procedure: Examiner grasps leg at midcalf level and
squeeze the tibia and fibula together.
Positive sign: Pain in the lower leg.

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

Thompson’s Test
Test: Achilles tendon ruptures.
Patient position: Prone.
Procedure: Feet are placed overedge of plinth and then calf
muscle is squeezed.
Positive sign: Absence of plantar flexion.

NORMAL CARDIAC/RESPIRATORY VALUES

Age group Heart rate Respiratory Blood pressure
means (range) rate range systolic/diastolic
(beats/min.) (breaths/min.) (mm Hg)
Preterm 150 (100–200) 40–60 39–59/16–36
Newborn 140 (80–200) 30–50 50–70/25–45
< 2 years 130 (100–190) 20–40 87–105/53–66
> 2 years 80 (60–140) 20–40 95–105/53–66
> 6 years 75 (60–90) 15–30 97–112/57–71
Adults 70 (50–100) 12–16 95–140/60–90

279
 Arterial Blood
pH – 7.35–7.45 [H­+] 45–35 nmol/l
PaO2 – 10.7–13.3 kPa (80–100 mm Hg)
PaCO2 – 4.7–6.0 kPa (35–45 mm Hg)
HCO­3–­­ – 22–26 mmol/l
Base excess – 2 to +2

Venous Blood
pH – 7.31–7.41 [H+] 46–38 nmol/l
PO2 – 5.0–5.6 kPa (37–42 mm Hg)
PCO2­ – 5.6–6.7 kPa (42–50 mm Hg)

Ventilation/Perfusion
Alveolar – Arterial oxygen gradient A–aPO2
Breathing air – 0.7–2.7 kPa (5–20 mm Hg)
Breathing oxygen – 100% 3.3–8.6 kPa (25–65 mm Hg)

Pressures
mm Hg kPa
Right atrial (RA) Mean —1 to +7 0.13–0.93
pressure
Right ventricular (RV) Systolic 15–25 2.0–3.3
pressure diastolic 0–8 0–1.0
Pulmonary artery (PA) Systolic 15–25 2.0–3.3
pressure diastolic 8–15 1.0–2.0
mean 10–20 1.3–2.7
Pulmonary capillary Mean 6–15 0.8–2.0
wedge pressure (PCWP)

280
Contd...
Contd...
Central venous pressure 3–15 cmH2O
Intracranial pressure <10mmHg (<1.3kPa)
(ICP)
Peak inspiratory mouth Male 103–124 cmH2O
pressure (Pi max)
Female 65–87 cmH2O
(Case
dependent)
Peak expiratory mouth Male 185–233 cmH2O
pressure (Pe max)
Female 128–152 cmH2O
(Case
dependent)

NORMAL REFERENCE/LAB VALUES

HEMATOLOGY
Male Female Units
Activated partial 35–45 35–45 Seconds
thromboplastics
time
APTT(PTTK)
ESR
Westergren 0–10 0–20 mm/lst hr
Wintrobe 0–7 0–14 mm/lst hr
Eosinophil count 40–450 40–450 Cells/cumm
Hemoglobin Hb 13–18 11–16 G/dl
Hematocrit PCV 40–55 35–48 %
Contd... 281
 Contd...
Mean corpuscular MCH 28–32 28–32 Pg
hemoglobin
Mean corpuscular MCHC 31–36 31–36 G/dl or %
hemoglobin
concentration
Mean corpuscular MCV 78–98 78–98 FL
volume
Platelet count 1.5–4.0 1.5–4.0 Lakhs/cumm

Prothrombin time 11–14 11–14 Seconds

(PT)

RBC count 4.5–5.5 3.8–5.2 Million/cumm

Reticulocyte 0.5–2.0 0.5–2.0 %

count
Serum iron 80–180 60–160 Ug/dl
Serum ferritin 16–300 12–160 Ug/ml
(mean (mean
50) 18)
Total iron binding Tibc 250–450 250–450 Ug/dl
capacity
Total leukocyte TLC 4000– 4000– Million/cumm
count 11000 11000
Transferring 30–35 30–35 %
282 saturation
CHEMICAL PATHOLOGY
S—Serum, B—Blood, P—Plasma
Investigation Reference value Units
S. alanine ALAT 5–35 U/l
Aminotransferase SGPT

P. ammonia 47–65 Umol/l

S. amylase 30–170 U/l
S. aspartate ASAT
aminotransferase SGOT 5–40 U/l

P. bicarbonate 21–28 mmol/l

S. bilirubin Total 0.2–1.0 mg/dl

S. bilirubin conjugated 0.1–0.2 mg/dl

S. calcium Total 9.0–11.0 mg/dl

P. calcium 2.3–2.7 mmol/l
B. CO2 content 19–24 mmol/l
S. chloride 95–105 mEq/l
S. cholesterol 150–230 mg/dl
S. copper 11–12 Umol /l
S. creatinine 0.6–1.2 mg/dl
283
Contd...
 Contd...
Creatinine clearance 70–120 ml/min
S. fatty acid Total 9–15 mmol/l
B. glucose fasting 65–100 mg/dl
B. glucose PP (postprandial <140 mg/dl
2 hours)
S. actate dehydrogenase 50–150 Units/l
LDH
S. lipids total 400–800 mg/dl
S. phosphatase acid 1–5 Ka units/dl
2–10 Units/l

Prostatic fraction Up to 4 Units/l

S. phosphatase alkaline 40–100 Units/l
4–12 Ka units/dl

S. proteins total 5.5–8 gm/dl

Albumin 3.5–6.0 gm/dl
Globulin 2.0–3.5 gm/dl
A/g ratio 1.5:1–3:1

S. phosphorus 1.0–1.4 mmol/l

S. potassium 3.8–4.8 mEq/l
S. sodium 135–145 mEq/l
B. urea 20–40 mg/dl
B. urea nitrogen (BUN) 10–20 mg/dl

S. uric acid 2–6 mg/dl

284 Values are only for adults and depending on testing

methods used.
 OTHER BODY FLUIDS

 Reference value
Urine examination 24 hrs volume 600–1800 ml.
Specific gravity urine (random) 1.003–1.030
Protein excretion 24 hrs urine <150 mg/day
Protein, qualitative urine negative
Glucose excretion 24 hrs urine 50–300 mg/day
Glucose qualitative urine (random) negative
Porphobilinogen urine (random) negative
Urobilinogen 24 hrs urine 1.0–3.5 mg/day

Stool Examination
Coproporphyrin 400–1000 mg/day
Fecal fat excretion <6.0 g/day
Occult blood negative (<2ml blood /day)
Urobilinogen 40–200 mg/day

Cerebrospinal Fluid (CSF)

Normally, cerebrospinal fluid is clear, colorless and faintly
alkaline.
Production 100 ml/day
CSF volume 120–150ml
CSF pressure 60–150 mm of water in horizontal
position
200–250 mm of water in sitting
position
Leukocytes 0–4 lymphocytes/ul
pH 7.31–7.34 285
 Glucose 50–80 mg/dl
Proteins 15–45 mg/dl
Calcium 5.7–6.8 mg%

Body Volume
Total 50–70%
Intracellular 33%
Extracellular 27%

CALORIC CONTENTS OF DIET

1 Chapati–80
1 slice bread–601
1dosa–100
1 idly–70
1 masala dosa–250
2 vada–112
1 poori–150
1 roti–86
1 cup pongal–200
1 cup rice–70
1 cup dal–100
1 pizza–300
1 plate French fries–218
1 cup green leaves–20
1 cup potato–56
1 cup raddish–8
1 cup curd–62
286 1 cup coconut water–48
1 biscuit sweet marie–24
1 salt biscuit–15
1 cup coffee/tea–40
1 cup horlicks–41
100 gm meat–194
100 gm chicken–109
100 gm fish–87
1 piece sandwich–70
1 piece somosa–140
Veg biriyani–200
50 gm plain cake–135
1 cup cow milk–134
1 egg–86
1 cup butter milk–90
1 pappad–45
I piece mango pickle–65
1 glass beer (240 ml)–115
Veg burger–225
Nonveg burger–260
Chocolates (50gm)–250
Soft drinks (300 ml)–180

SAMPLE DIET CHART

Obese Diabetic
• Early morning Light tea without sugar.
• Breakfast Tonned milk 1 cup.
Papaya 2 slices.
• Lunch Fulka 2–3 small and thin. 287
 Rice 1/2 medium bowl.
Dal 1 medium bowl.
Salad.
Leafy vegetables.
• 4 PM Light tea without sugar 1 cup/1
bread slice.
• Dinner Fulka 3 small
rice 1/2 medium bowl
vegetables 3/4 bowl.
Oil for cooking 1 teaspoonful.

Underweight Diabetic
• Early morning Light tea with little sugar.
• Breakfast Bread 2 slice.
One fruit.
• Lunch Fulka 2–3 small and thin.
Rice 1 medium bowl.
Dal 3/4 medium bowl.
Or fish 2 pieces.
Or lean meat 2 pieces.
Leafy vegetables 1 medium bowl.
Salad 1 medium bowl.
Oil for cooking 1 teaspoonful.
• 4 PM Light tea 1 cup/1 bread 1 slice/
1 biscuit.
• Dinner Fulka 3 small
Rice 1 medium bowl.
Dal 1 medium bowl.
Vegetables 1 bowl.
288 Oil for cooking 1 teaspoonful.
Obesity
• Early morning Light tea – 1 cup
• Breakfast Butter milk 1 cup without sugar,
papaya 2–3 slices/ bread 2 slices.
• Lunch Fulka 2–3 small and thin.
Rice 1/2 medium bowl.
Dal 1 medium bowl.
• 4 PM Light tea without sugar 1 cup.
1 biscuit/1 bread slice/ 1 idly/ a
fruit.
• Dinner Thin soup and fresh salad or boil
vegetables.
Fulka 3 small.
Pulses 1/2 medium bowl.
Thin buttermilk.

BURNING OF THE CALORIES

• ½ hour of walking 130 calories

• ½ hour of jogging 300–350 calories
• ½ hour of light activity like
writing, driving 50 calories
• ½ hour of swimming 250 calories
• ½ hour of cycling 150 calories
• ½ hour aerobic exercises 250 calories
• 1 hour of no exercises or sleep 60 calories

289
 KEY DEVELOPMENT MILESTONES

Age Milestones
Gross motor
3 months Neck holding
5 months Sitting with support
8 months Sitting without support
9 months Standing with support
10 months Standing without support
11 months Creeping
12 months Walking with support
13 months Walking without support
18 months Running
24 months Walking upstairs
36 months Riding tricycle.

Fine motors
4 months Grasp a ring when placed in hand
5 months Reaches out to an object an holds it
with both hands
7 months Holding objects with crude grasp from
palm
9 months Holding small object, like a pellet
between index finger and thumb.

Language
1 month Turns head to sound
3 months Cooing
6 months Monosyllables
290 9 months Bisyllables
12 months Two words with meaning
18 months Ten words with meaning
24 months Sentences
36 months Telling a story.

Personal social
2 months Social smile
3 months Recognizing mother
6 months Smiles at mirror image
9 months Waves bye-bye
12 months Plays a simple ball game
36 months Knows gender.

List of pharmacology abbreviations

Abbreviation Meaning
a.c. Before bed
ad lib As desired
b.d. Twice daily
cap Capsule
i.m. Intermuscular
i.v. Intravenous
LA Local anesthetic
liq Liquid
OC Oral contraceptive
o.d. Once daily
o.m. In the morning
o.n. At night
opv Oral poliomyelitis vaccine 291
 ORS Oral rehydration salt
ORT Oral rehydration therapy
p.c. After food
p.r.n. When required
q.i.d. Four times a day
q.q.h. Every four hours
s.i. Sublingual
s.o.s. As required
stat. Immediately
susp Suspension
syr Syrup
tab Tablet
t.d.s. Three times a day.

ABBreVIATIONS

AAA Abdominal aortic aneurysm

Ab Antibody
ABG Arterial blood gases
ABPA Allergic bronchopulmonary aspergillosis
ACBT Active cycle of breathing technique
ACE Angiotesin converting enzyme
ACT Activated clotting time
ACTH Adrenocorticotrophic hormone
AD Autogenic drainage
ADH Antidiuretic hormone
ADL Activities of daily living
ADO2 Alveolar–arterial oxygen gradient
292 ADR Adverse drug reaction
AE air entry
AEA above elbow amputation
AF atrial fibrillation
AFB acid fast bacillus
AFO ankle foot orthosis
Ag antigen
AGN acute glomerulonephritis
AHRF acute hypoxemic respiratory failure
Ai aortic insufficiency
AIDS acquired immune deficiency syndrome
AKA above knee amputation
AL acute leukemia
ALD alcoholic liver disease
ALI acute lung injury
AMBER advance multiple beam equalization radio­
graphy
AML acute myeloid leukemia
AP anterior posterior/Anteroposterior
APACHE acute physiology and chronic health evalu-
ation
APo2 alveolar–arterial oxygen gradient
ARDS acute respiratory distress syndrome
ARF acute renal failure
AROM active range of movement
AS ankylosing spondylitis
ASD atrial septal defect
ATN acute tubular necrosis
ATPS ambient temperature and pressure satu-
rated
293
 AVAS absolute visual analogue scale
AVF arteriovenous fistula
AVR aortic valve replacement
AVSD atrioventricular septal defect
AXR abdominal X–ray
B/slab back slab
BCG bacille Calmette–Guérin
BDI Baseline and transition dyspnea index
BE bacterial endocarditis/barium enema/base
excess
BEA below elbow amputation
BiPAP bilevel positive airway pressure
BIVAD biventricular device
BKA below knee amputation
BM blood glucose monitoring
BMI body mass index
BO bowels open
BP blood pressure
BPD bronchopulmonary dysplasia
BPF bronchopleural fistula
Bpm beats per minute
BS bowel sound/breath sound
BSA body surface area
BSO bilateral salpingo oophorectomy
BVHF bi ventricular heart failure
C/O complains of
C/W consistant with
Ca carcinoma
CABG coronary artery bypasses graft
294 CAD coronary artery disease
CAH chronic active hepatitis
CAL chronic airflow limitation
CAO chronic airways obstruction
CAPD continuous arterial venous hemofiltration
CBC complete blood cell count
CBD common bile duct
CBF cerebral blood flow
CCF congestive cardiac failure
CCU coronary care unit
CDH congenital dislocation of the hip
CF cystic fibrosis
CFA cryptogenic fibrosing alveolitis
CFMS cerebral function monitors
CHD coronary heart disease
CHF chronic heart failure
Ci chest infection
CK creating kinase
CL lung compliance
CLD chronic lung disease
CML chronic myeloid leukemia
CMV controlled mandatory ventilation /cytomega­
lovirus
CNS central nervous system
CO cardiac output
COAD chronic obstructive airways disease
CoP completion of plaster
COPD chronic obstructive pulmonary disease
CP cerebral palsy
CPAP continuous positive airway pressure
CPM continuous passive movement 295
 CPN community psychiatric nurse
CPP cerebral perfusion pressure
CPR cardiopulmonary resuscitation
Crash team cardiac arrest team
CRF chronic renal failure
CRP C-reactive protein
CRP conditioning rehabilitation program
CRQ chronic respiratory disease questionnaire
C-section cesarean section
CSF cerebrospinal fluid
CT computed tomography
CVA cerebrovascular system
CVI cerebrovascular incident
CVP central venous pressure
CVS cardiovascular system
CVVHF continuous venovenous hemofiltration
CXR chest X -rays
D and C dilation and curettage
D/C discharge
D/W discussed with
DBE deep breathing exercises
DDD degenerative disk disease
DDH developmental dysplasia of the hips
DH drug history
DHS dynamic hip screw
DIB difficulty in breathing
DIC ` disseminated intravascular coagulopathy
DIOS distal intestinal obstruction syndrome
Dish diffuse idiopathic skeletal hyperostosis
296 Dl deciliter
DLCO diffusing capacity for carbon monoxide
DM diabetes mellitus
DMARD Disease modifying antirheumatic drug
DMD Duchenne’s muscular dystrophy
DNA deoxyribonucleic acid / did not attend
DOA dead on arrival / date of admission
DSA digital subtraction angiography
DU duodenal ulcer
DVT deep vein thrombosis
DXT deep X- ray therapy
EBV Epstein–Barr virus
ECCO2R extracorporeal carbon dioxide removal
ECG electrocardiogram
ECMO extracorporeal membrane oxygenation
EECP enhanced external counter pulsation
EEG electroencephalogram
EIA exercise induced asthma
EIT exercise tolerance test
EMG electromyography
ENT ear, nose and throat
EOR end of range
Ep epilepsy
EPAP expiratory positive airway pressure
EPP equal pressure points
ERCP endoscopic retrograde, cholangiopancreato­
graphy
ERV expiratory reserve volume
ESR erythrocyte sedimentation rate
ESRF end stage renal failure
ETCO2 endtidal carbon dioxide 297
 ETT endotracheal tube
EUA examination under anesthetic
FB foreign body
FBC full blood count
FDP fibrin degradation product
FET forced expiration product
FEV1 forced expiratory volume in 1 second
FFD fixed flexion deformity
FG French gauge
FGF fibroblast growth factor
FH family history
FHF fulminating hepatic failure
FiO2 fractional inspired oxygen concentration
FRC functional residual capacity
FROM full range of movement
FVC forced vital capacity
FWB full weight bearing
GA general anesthetic
GAW airway conductance
GBS Guillain–Barré syndrome
GCS Glasgow coma scale
GH general health
GI gastrointestinal
GIT gastrointestinal tract
GOR gastroesophageal reflux
GPB glossopharyngeal breathing
GTN glycerol trinitrate
GU gastric ulcer / genitourinary
HASO hip abduction spinal orthosis
298 Hb hemoglobin
HC head circumference
Hct hematocrit
HD hemodialysis
HDU high dependency unit
HF heart failure
HFCWO high frequency chest wall oscillation
HFJV high frequency jet ventilation
HFO high frequency oscillation
HFOV high frequency oscillatory ventilation
HFPPV high frequency positive pressure ventilation
HFV high frequency ventilation
HH hiatus hernia / home help
HI head injury
HIV human immunodeficiency virus
HLA human leukocyte antigen
HLT heart–lung transplantation
HME heat and moisture exchanger
HPC history of presenting condition
HPOA hypertrophic pulmonary osteoarthropathy
HR heart rate
HRR heart rates reserve
HT hypertension
IABP intraaortic balloon pump
IBS irritable bowel syndrome
IC inspiratory capacity
ICC intercostal catheter
ICD intercostal drain
ICP intracranial pressure
ICU intensive care unit
IDC indwelling catheter 299
 IDDM insulin dependent diabetes mellitus
IF interferential therapy
Ig immunoglobulin
IHD ischemic heart disease
ILD interstitial lung disease
IM intramedullary
IM/i.m. intramuscular
IMA interanal mammary artery
IMV intermittent mandatory ventilation
INH inhalation
INR international normalized ratio
IPAP inspiratory positive airway pressure
IPPB intermittent positive pressure breathing
IPPV intermittent positive pressure ventilation
IPS inspiratory pressure support
IRQ inner range quadriceps
IRV inspiratory reverse volume
IS incentive spirometry
ITU intensive therapy unit
IV/i.v. intravenous
IVB intervertebral block
IVC inferior vena cava
IVH intraventricular hemorrhage
IVI intravenous infusion
IVOX intravenacaval oxygenation
IVUS intravenacaval ultrasound
JVP jugular venous pressure
KAFO knee ankle foot orthosis
KCO transfer coefficient
300 KO knee orthosis
LA local anesthetic
LAP left atrial pressure
LBBB left bundle branch block
LBP low back pain
LCL lateral collateral ligament
LDL low density lipoprotein
LED light–emitting diode
LFA low friction arthroplasty
LFT liver function test / lung function test
LFT x 2 lung or liver function test
LL lower limb / lower lobe
LOC level of consciousness
LP lumbar puncture
LRTD lower respiratory tract disease
LSCS lower segment cesarean section
LTOT long-term oxygen therapy
LVAD left ventricular assist device
LVEF left ventricular ejection fraction
LVF left ventricular failure
LVRS lung volume reduction surgery
MAOI monoamine oxidase inhibitor
MAP mean airway pressure/mean arterial pressure
MAS minimal access surgery
MC and s microbiology, culture and sensitivity
MCH mean corpuscular hemoglobin
MCL Medial collateral ligament
MCV mean corpuscular volume
MDI multidisciplinary team
MDI metered dose inhaler
301
 ME metabolic equivalents / myalgic encephalo­
myelitis
MEFV maximum expiratory flow volume
METs metabolic equivalents
MHz megahertz
MI myocardial infarction
MIFV maximum inspiratory flow volume
ML middle lobe
MM muscle
MMAD mass median aerodynamic diameter
MMV mandatory minute volume
MND motor neuron disease
Mph miles per hour
MRI magnetic resonance imaging
MRSA methicillin – resistant Staphylococcus aureus
MS mitral stenosis / multiple sclerosis
MSU midstream urine
MUA manipulation under anesthetic
MV minute volume
MVO2 myocardial oxygen consumption
MVR mitral valve replacement
MVV maximum voluntary ventilation
MWM mobilization with movement
N/S nursing staff
NAD nothing abnormal detected
NAG natural apophyseal glide
NAI nonaccidental injury
NBI no bony injury
NBL nondirected bronchial lavage
302 NBM nil by mouth
NCPAP nasal continuous positive airway pressure
NEEP negative end expiratory pressure
NEPV negative extrathoracic pressure ventilation
NFR note for resuscitation
NG nasogastric
NICU neonatal intensive care unit
NIDDM noninsulin dependent diabetes mellitus
NIPPV noninvasive intermittent positive pressure
ventilation
NITU neonatal intensive care unit
NIV noninvasive ventilation
NMR nuclear magnetic resonance
NOF neck of femur
NOH neck of humerus
NP nasopharyngeal
NPA nasopharyngeal airway
NPV negative pressure ventilation
NR nodal rhythm
NREM nonrapid eye movement
NSAID nonsteroidal antiinflammatory drug
NSR normal sinus rhythm
NWB nonweight bearing
O/E on examination
OA oral airway/ osteoarthritis
OB obliterative bronchiolitis
Occ occasional
OD over dose
Oe objective examination
OGD esophagogastroduodenoscopy
OHFO oral high–frequency oscillation 303
 OI oxygen index
oJACCOL No jaundice, anemia, clubbing, cyanosis,
edema
oLKKS no liver, kidney, kidney, spleen
OLT orthotopic liver transplantation
OPD outpatient department
ORIF open reduction and internal fixation
PR per rectum
PA pernicious anemia/posteroanterior/pulmo-
nary artery
PACO2 partial pressure of carbon dioxide in alve-
olar gas
PaCO2 partial pressure of carbon dioxide in arterial
blood
PADL personal activities of daily living
PAIVM passive accessory intervertebral movement
PAO2 partial pressure of oxygen in alveolar gas
PaO2 partial pressure of oxygen in arterial blood
PAP pulmonary artery pressure
PAWP pulmonary artery wedge pressure
PBC primary biliary cirrhosis
PC presenting condition / pressure control
PCA patient–controlled analgesia
PCD primary ciliary dyskinesia
PCIRV pressured–controlled inverse ratio ventila-
tion
PCP pneumocystis carinii pneumonia
PCPAP periodic continuous positive airway pres-
sure
304 PCV packed cell volume
PCWP pulmonary capillary wedge pressure
PD parkinson’s disease/peritoneal dialysis/
postural drainage
PDA patent ductus arteriosus
PE pulmonary embolus
PEEP positive end–expiratory pressure
PEF peak expiratory flow
PEFR peak expiratory flow rate
PEG percutaneous endoscopic gastrostomy
PeMAX peak expiratory mouth pressure
PEME pulsed electromagnetic energy
PEP positive expiratory pressure
PERLA pupils equal reacting to light and accommo­
dating
PFC persistnt fetal circulation
PFO persistent foramen ovale
PFY patellofemral joint
PHC pulmonary hypertension crisis
PID pelvic inflammatory disease
PIE pulmonary interstitial emphysema
PIF peak inspiratory flow
PIFR peak inspiratory flow rate
Pimax peak inspiratory mouth pressure
PIP peak inspiratory pressure
PMH previous medical history
PMR percutaneous myocardial revascularization
PN percussion note
PND paroxysmal nocturnal dyspnea
POMR problem oriented medical records
POP plaster of Paris 305
 PPIVM passive physiological intervertebral move-
ment
PROM passive range of movement
PS pressure support/pulmonary stenosis
PTB pulmonary tuberculosis
PTCA percutaneous transluminal coronary angio-
plasty
PTFE polytetrafluoroethylene
PTT partial thromboplastin time
PU passed urine
PVC polyvinyl chloride
PVD peripheral vascular disease
PVH periventricular hemorrhage
PVL periventricular leukomalacia
PVR pulmonary vascular resistance
PWB partial weight bearing
Px prescribing
QOL quality of life
R/O removal of
RA rheumatoid arthritis
RAP right atrial pressure
Raw right arterial pressure
RAW airway resistance
RBBB right bundle branch block
RBC red blood cell
RDS respiratory distress syndrome
REM rapid eye movement
RFT respiratory function test
RH residential home
306 RhF rheumatic home
RIP rest in peace
RMT respiratory muscle training
ROM range of movement
ROP retinopathy of prematurity
RPE rating of perceived exertion
RPP rate pressure product
RR respiratory rate
RSV respiratory syncytial virus
RTA road traffic accident
RV residual volume
RVF right ventricular failure
S.C. Subcuticular
SA sinoatrial
SAB Subacromial bursa
SAH subarachnoid hemorrhage
SALT speech and language therapist
SaO2 arterial oxygen saturation
SB sinus bradycardia
SBE subacute bacterial endocarditis
SCI spinal cord injury
SDH subdural hematoma
SFL/SFR side flex left/right
SGAW specific airway conductance
SGAW specific airway conductance
SH social history
SHO senior house officer
SIG sacroiliac joint
SIMV synchronized intermittent mandatory
ventilation
SL sublingual
SLAP superior labrum, anterior and posterior 307
 SLE systemic lupus erythematosus
SMA spinal muscular atrophy
SN swedish nose
SNAG sustained natural apophyseal glide
SOA swelling of ankles
SOB shortness of breath
SOBAR short of breath at rest
SOBOE short of breath on exertion
SOOB sit out of bed
SPO2 pulse oximetry arterial oxygen saturation
SpR special registrar
SPS single point stick
SR sinus rhythm
SRAW specific airway resistance
ST sinus tachycardia
SUF (c) E slipped upper femoral (capital) epiphysis
SV self-ventilating
SVC superior vena cava
SVD spontaneous vaginal delivery
SVG saphenous vein graft
SVO2 mixed venous oxygen saturation
SVR systemic vascular resistance
SVT supraventricular tachycardia
SWT shuttle walk test
T21 trisomy 21 (Down’s syndrome)
TA – tendoachilles
TAA thoracic aortic aneurysm
TAH total abdominal hysterectomy
TAR total ankle replacement
308 TATT tired all the time
TAVR tissue atrial valve repair
TB tuberculosis
TBI traumatic brain injury
TCCO2 transcutaneous carbon dioxide
TCO2 transcutaneous oxygen
TED thromboembolic deterrent
TEE thoracic expansion exercises
TENS transcutaneous electrical nerve stimulation
TFA transfemoral arteriogram
TFT thyroid function test
TGA transposition of the great arteries
TGV thoracic gas volume
THR total hip replacement
TIA transient ischemic attack
TKA through knee amputation
TKR total knee replacement
TLC total lung capacity
TLCO carbon monoxide transfer factor
TLCO transfer factor in lung of carbon monoxide
TLSO thoracolumbar spinal orthosis
TM tracheostomy mask
TMR transmyocardial revascularization
TMVR tissue mitral valve repair
TOP termination of pregnancy
TPN total parenteral nutrition
TPR temperature, pulse and respiration
TTO to take out
TURBT transurethral resection of bladder tumor
TURP transurethral resection of prostate
TV tidal volume 309
 TWB touch weight bearing
Tx transplant
U and E urea and electrolytes
UAO upper airway obstruction
UAS upper abdominal surgery
UL upper limb/upper lobe
URTI upper respiratory tract infection
USS ultrasound scan
UTI urinary tract infection
V ventilation
V/p shunt ventricular perfusional shunt
V/Q ventilation/perfusion ratio
VA alveolar ventilation / alveolar volume
VAD ventricular assist device
VAS visual analogue scale
VATS video–assisted thoracoscopy surgery
VBG venous blood gas
VC vital capacity/volume control
Vd dead space
VE minute ventilation
VE ventricular ectopics
VEGF vascular endothelial growth factor
VER visual evoked response
VF ventricular fibrillation / vocal fremitus
VR vocal response
VRE vancomycin – resistance Enterococcus
VSD ventricular septal defect
VT ventricular tachycardia
Vt tidal volume
310 W/R ward round
WBC white blood count
WCC white cell count
WOB work of breathing
ZEEP zero end expiratory pressure.

Important Terminologies

acr – across o – outward

med – medial tow – towards
Hor – horizontal lat – lateral
Incl – inclined obl – oblique
Betw– between und – under
l – left beh – behind
b – backward movt. – Movement
d – downward sup – support
w/c – with tog – together
alt – alternate j – jump
rhythm – rhythmically spr – spring
pend – pendulum ass – assited
stat – stationary pass – passive
opp. – opposite wd – wide
foll – Followed rev – reverse
cont – continuously reb – rebound
rep – repeat bal. – balance
res – resisted < – less than
> – more than o – no
# – Fracture – diagnosis
– circumduction
311
  – parallel – abdomen

H – head Frh – forehead

N – neck B – back
T – trunk S – side
Abd. – Abdomen P. – pelvis
Sh.bl. – shoulder blades Sh – shoulders
A – arms Elb – elbows
Wr – wrists Hnd – hands
Fing – fingers L – legs
K – knees Hl – heels
F – feet Ank – ankles
Fra – forearm St – standing
Ly – lying wg – wing
Yd – yards Kn – kneeling
Gr – grasp Hg – hanging
Wlk – walk Bd – bend
Pr – prone Rst – rest
X – cross Cl. – close
Crk – crook Lax – relaxed
Crch – crough Sitt – sitting
Pos – position Rch. – reach
Str – stretch Std – stride
Stp – stoop Lg – long
Flex – flexion Rot – rotation
Abd – abduction Ev – eversion
Inv – inversion Supin – supination
Pron – pronation R – right
Ext – extension f – forward
312 Add – adduction U – upward
S – sideways
NOTES
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------- 313
 ------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------------------------------------
------------------------------------------------------------------
-------------------------------------------------------------------
-------------------------------------------------------------------
314 -------------------------------------------------------------------
 Index

A drawer test 259, 274, 278

gapping test 268
Abdominal adhesions 182
labral tear test 271
Abduction stress test 273
Anxiety 171
Acne vulgaris 1
Aphasia 107
Activated partial
Apley’s test 274
thromboplastin time 281
Arterial blood 280
Acute
Arteriosclerosis obliterans 207
bronchitis 12
Arthrodesis 30
cervicitis 184
Arthroplasty 30
head injury 144
Atelectasis 13
otitis media 199
Axillary nerve lesions 129
Addison’s disease 2, 11
Axonotmesis 128
Adduction stress test 274
Adhesive capsulitis 56
Adrenalectomy 144 B
Alcoholic neuropathy 108 Babinski sign 105
Alopecia 2 Back pain 183
Amyotrophic lateral Baker’s cyst 81
sclerosis 109 Bell’s palsy 110
Anemia 74 Bicipital tendinitis 36
Ankle Body fluids 285
joint and foot 278 Bow legs 59
varus deformity 53 Brachial plexus lesion 132
Ankylosing spondylitis 28, 68 Brain tumors 111
Anorexia nervosa 172 Bronchial asthma 14
Anterior Brudzinski-Kernig test 256
apprehension test 259 Brush test 275
cerebral artery 141 Burning of calories 289
 C Coccydynia 185
Codman’s test 260
Calcaneal spur 37
Cold therapy 241
Calcaneovalgus deformity 37
Colostomy 148
Caloric contents of diet 286
Common
Cardiac surgery 162
musculoskeletal tests 253
Carotid artery stenosis 149
peroneal nerve lesions 133
Carpal Tunnel syndrome 38
Compartment syndromes 106
Cauda equina lesions 138
Complete
Central venous pressure 281
lesion of thoracolumbar
Cerebral
segments 138
abscess 148 transection of cervical cord
palsy 112 below c5 137
Cerebrospinal fluid 285 Compound
Cervical fractures 149
disk syndrome 39 palmar ganglion 42
rib 40 Compression
spine 252, 253 bandage 66
Cervicitis 184 syndrome 185
Charcot-Marie-tooth Congenital
disease 134 dislocation of hip 44
Cholecystectomy 147 flat foot 45
Chondromalacia patellae 43 radioulnar synostosis 46
Chronic short femur 46
bronchitis 17 talipes equino varus 47
cervicitis 184 torticolis 48
Chvostek’s sign 87 Constipation 208
Claw Continuous passive motion 247
hand 5 Contracted fingers 49
toes 5 Contrast bath 243
Cleft lip and palate 149 Control of pelvic tilt and
Cleidocranial dysostosis 41 rocking 68
Club hand 42 Copper beaten appearance 122
316 Clunk test 259 Cosmetic surgery 150
Costal margin pain 186 Dysmenorrhea 189
Coxa Dyspareunia 189
plana 51 Dysphagia 116
vara 50
Cozen’s test 263 E
Crack pot’ sign 122 Elbow
Cramp 186 arthroplasty 35
Cranial surgery 150 flexion test 263
Crush injuries of hand 150 joint 263
Cryotherapy 66, 241 Electric heating pads 242
Cystectomy 148 Emphysema 18
Cystic fibrosis 17 Empyema 20
Eosinophil count 281
D Epilepsy 118, 151
De Quervain’s disease 52 Erb’s paralysis 132
Deafness 114 Excision arthroplasty of hip 30
Decortication of lung 164 External rotation recurvatum
Deep test 275
breathing exercises 13
diaphragmatic breathing 68 F
vein thrombosis 209 Facial
Deformity 53 fractures 151
Dehydration 74 palsy 151
Depression 172 Fairbank’s apprehension
Diabetes mellitus 11 test 275
Diabetic neuropathy 114 Farfan torsion test 257
Diastasis recti 187 Femoral nerve lesions 132
Distraction test 253 Fever 12
Drop Arm test 260 Filaria 211
Duga’s test 260 Finkelstein test 265
Dupuytren’s contracture 54 First degree kyphosis 68
Dysarthria 116 Fluido therapy 246
317
 Foot drop 5 Hemireplacement of hip 31
Forced expiratory Hemoglobin 281
techniques 15 Hemophilia 212
Frozen shoulder 56 Hemophilic arthropathy 214
Hemorrhoids 213
G Hernia 153
Gaenslen’s test 268 Hibb’s test 269
Ganglia 57 Hot packs 242
Gastrectomy 152 Hughston plica test 275
Genu Hydrocephalus 121, 153
recurvatum 60 Hydrocollator packs 242
valgum 58 Hydrotherapy 74
varum 59 Hyperhidrosis 4
Gillets test 269 Hysterectomy 190
Gluteal and abdominal Hysteria 173
contraction 68
Golfer’s elbow 60 I
Grand mal attack 118
Ileostomy 153
Guillain-Barré syndrome 119
Incentive spirometry 13
Infrared radiation 237
H Infraspinatus tendinitis 65
Hallux Insomnia and nightmares 215
rigidus 63 Intermittent pneumatic
valgus 63 compression 246
Hamilton ruler test 261 Intervertebral disk lesions 154
Hammer toe 64 Intracranial pressure 281
Hamstring stretching 77 Intractable pain 154
Hand Iontophoresis 236
arthroplasty 36
infections 62
Hawkins-Kennedy test 261
J
Headache 121 Jaw osteotomies 154
318 Heartburn 213 Jerk test 261
Joint laxity 191 Lung
Jug test 263 abscess 20
tumor 15
K Lunotriquetral ballottement
test 266
Key development
Lymphedema 155, 216
milestones 290
Klippel-Feil syndrome 67
Klumpke’s paralysis 101, 132 M
Knee Madelung’s deformity 69
flexion deformity 53 Malignant melanoma 155
joint 273 Manual hyperinflation 13
rehabilitation 77 Mastectomy 155
Knock knee 58 McMurray test 276
Kyphosis 67 Mean corpuscular
hemoglobin
L concentration 282
Lachman’s test 276 volume 282
Laguerre’s sign 270 Median nerve lesions 130
Laser therapy 233 Meniere’s disease 205
Lateral epicondylitis test 264 Metatarsalgia 70
Legg-Calve-Perthes disease 51 Microwave diathermy 240
Leprosy 5 Middle cerebral artery 141
Limb elevation 66 Migraine 123
Liniburg’s test 265 Milwaukee brace 68
Lobectomy 164 Morning sickness 192
Long sitting test 271 Morton’s metatarsalgia 71
Lordosis 69 Movement disorders 156
Loss of fingers 5 Multiple sclerosis 123
Lower limb 155 Murphy’s sign 266
Lumbar spine 256 Muscle atrophy 66

319
 Muscular dystrophy 124 Parkinson’s disease 126
Mycosis fungoides 6 Patrick’s test 272
Peak
N expiratory mouth
Nasal pressure 281
bleeding 200 inspiratory mouth
bridge collapse 5 pressure 281
National Immunization Pectus carinatum 166
Schedule 224 Pelvic floor dysfunction 194
Nephrectomy 156 Periarthritis 56
Neuromuscular electrical Peripheral nerve lesions 127
stimulation 239 Pernicious anemia 11
Neurotmesis 128 Peroneal muscular atrophy 134
Pes cavus 76
O Phalen’s test 266
Ober’s sign 271 Phobia 174
Obese diabetic 287 Piedallu’s sign 270
Obesity 217, 289 Pinch grip test 264
Obsessive compulsive Pityriasis rosea 6
states 174 Placement of electrodes 228
Olecranon bursitis 72 Plantar fasciitis 78
Osteitis pubis 192 Platelet count 282
Osteoarthritis 73 Pleurectomy 166
Osteochondritis deformans Pleurodesis 166
juvenilis 51 Plica syndrome 77
Osteomyelitis 74 Pneumonectomy 167
Osteoporosis 75 Pneumonia 23
Osteotomy 75 Pneumothorax 23
Policization 157
Oxygen inhalation 13
Poliomyelitis 78
Polymorphic light eruption 7
P Popliteal cyst 81
Painful perineum 193 Positive stretch test 92
320 Paraffin wax bath 238 Postcesarean section 181
Posterior Relaxation exercises 68
cerebral artery 141 Respiratory
drawer test 262, 276 diseases 12
gapping test 270 exercises 68
labral tear test 272 failure 26
sag sign 277 Restless leg syndrome 195
Postinjection contractures Retention of urine 195
in infancy 82 Reticulocyte count 282
Pressure sores 7 Reverse Phalen’s test 267
Principles of electrotherapy Rheumatic fever 219
application 225 Rheumatoid arthritis 84
Prostatectomy 157 Rickets 87
Prothrombin time 282 Right
Pruritus 195 atrial pressure 280
Psoriasis 9 ventricular pressure 280
Pulmonary Romberg’s test 253
artery pressure 280 Rotator cuff lesions 88
capillary wedge pressure 280
edema 25
S
embolism 24
tuberculosis 25 Sample diet chart 287
Sarcoidosis 27
Q Sauna bath 244
Scar tissue 220
Quadrant test 253, 257 Scheuermann’s disease 68
Schizophrenia 175
R Sciatic nerve lesions 132
Radial nerve lesions 131 Scoliosis 89
RBC count 282 Senile osteoporosis 68
Rectus femoris contracture Serum
test 272 ferritin 282
Recurrent dislocation of iron 282
patella 82 Severe pain 106
321
Redness of joint 66 Sexual dysfunction 220
 Short-wave diathermy 231 Student’s elbow 72
Shoulder Subacromial bursitis 97
arthroplasty 35 Subarachnoid hemorrhage 159
joint 259 Subscapularis tendinitis 97
Sinusitis 201 Substance abuse 177
Sitting flexion 270 Sulcus sign 262
Skin grafts 158 Supraspinatus tendinitis 98
Slight pain 92 Suturing of nerves 128
Slocum test for Sweater finger sign 267
anterolateral rotatory Swelling of joint 66
instability 277 Symphysis pubis 192
anteromedial rotatory pain 196
instability 277
Slump test 256, 257 T
Sore and cracked nipples 196 Talar tilt 278
Speed’s test 262 Temporomandibular
Spina bifida 136 disorders 221
Spinal Tennis elbow 99, 264
cord lesions 137 Thomas test 273
mobilization exercises 68 Thoment’s sign 267
muscular atrophy 139 Thompson’s test 279
orthosis 75 Thoracic
tumor 158 and lumbar spine 252
Spondylolisthesis 90 outlet syndrome 100
Sprains 92 spine 256
Sprengel’s deformity 98 Thoracoplasty 168
Spurling’s test 254 Thoracotomy 169
Squeeze test of leg 278 Thyroidectomy 159
Standing flexion 270 Tinel’s sign 268
Staphylococcus aureus 3 Tonsillitis 202
Straight leg raise test 258 Total
Street drugs 178 ankle arthroplasty 34
322 Stretching of hamstrings 68 hip replacement 32
 iron binding capacity 282 V
knee replacement 33
Valgus stress test 264
leukocyte count 282 Varicose veins 222
wrist arthroplasty 36 Varus stress test 265
Transcutaneous electrical Vasomotor rhinorrhea 206
nerve stimulation 235 Venous blood 280
Transferring saturation 282 Vertebrobasilar artery 141
Transverse friction massage 77 Vertigo 203
Traumatic myositis Vojata techniques 113
ossificans 101 Volkmann’s ischemia 106
Trendelenburg’s sign 273 Vulvitis 197
Trigger finger 102
Tropic ulcers 5
Tuberculosis
W
of hip joint 103 Watson test 268
spine 103, 105 Westergren wintrobe 281
Whirlpool bath 243
U Wrist
flexion test 266
Ulcers 222
joint and hand 265
Ulnar nerve lesions 129
Ultraviolet radiation 232
Underweight diabetic 288 Z
Upper limb 155 Zinc
tension test 254 solution 200
Uterine ligament pain 197 sulfate 200

323