The Pocketbook for Physiotherapists Gitesh Amrohit
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Obstetric Vasculopathies
First Edition: 2013
9789350255605
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PharmacologyCHAPTER 1

  • Drug classes in alphabetical order
  • Prescription abbreviations
2
Drug classes in alphabetical order
 
ACETAZOLAMIDE
Type: Diuretics.
Uses: Glaucoma, epilepsy, acute mountain sickness, periodic paralysis, urinary tract infection.
Side effects: Hypokalemia, drowsiness, acidosis, abdominal discomfort.
 
ACETYLCYSTEINE
Type: Mucolytic.
Uses: Reduces the viscosity of secretions, antidote for paracetamol overdose.
Side effects: Bronchoconstriction, nausea, vomiting.
 
ACICLOVIR
Type: Antiviral.
Uses: Herpes simplex and varicella zoster infection.
Side effects: Very rare.
 
ADENOSINE
Class: Antiarrhythmic.
Uses: Tachycardias.
Side effects: Nausea, bronchospasm, dyspnea, chest pain, facial flush.3
 
ADRENALINE/EPINEPHRINE
Type: Sympathomimetic agent.
Uses: During cardiopulmonary resuscitation to stimulate heart activity and raise low blood pressure, anaphylactic shock, glaucoma, in eye surgery.
Side effects: Dry mouth, anxiety, restlessness, palpitations, tremor, blurred vision, headache, hypertension, tachycardias.
 
ALBENDAZOLE
Type: Anthelmintics.
Uses: Filariasis, hydatid disease, trichinosis, tape- worms.
Side effects: Diarrhea, nausea, abdominal pain.
 
ALENDRONATE
Type: Bisphosphonate.
Uses: Postmenopausal osteoporosis, corticosteroids induced osteoporosis, Paget's disease.
Side effects: Gastrointestinal upset, esophageal irritation and ulceration.
 
ALFENTANIL
Type: Opioid analgesic.
Uses: Respiratory depressant, during surgery.4
Side effects: Drowsiness, nausea, vomiting, constipation, dizziness, dry mouth.
 
ALLOPURINOL
Type: Antigout.
Uses: Gout, kidney stones.
Side effects: Nausea, itching, rash.
 
AMIODARONE
Type: Antiarrhythmic.
Uses: Ventricular and supraventricular tachycardias.
Side effects: Liver damage, reversible corneal depositions, thyroid disorders.
 
AMINOPHYLINE
Type: Bronchodilator.
Uses: Acute severe asthma, reversible airway obstruction.
Side effects: Nausea, headache, insomnia, arrhythmias, convulsions, palpitations, tachycardias.
 
AMITRIPTYLINE
Type: Tricyclic antidepressant.
Uses: Depression, nocturnal enuresis in children.5
Side effects: Sweating, dry mouth, blurred vision, dizziness, drowsiness, fainting, palpitations, gastrointestinal upset.
 
AMLODIPINE
Type: Ca++ channel blocker.
Uses: Congestive heart failure, angina.
Side effects: Ankle edema, flushing, palpitation, headache, hypotension, gastrointestinal upset.
 
AMOXICILLIN
Please refer Ampicillin.
 
AMPICILLIN
Class: Antibiotic.
Uses: Urinary tract infection, respiratory tract infection, meningitis, gonorrhea, typhoid fever, bacillary dysentery, bacterial endocarditis, septicemias, cholecystitis.
Side effects: Diarrhea, rashes, lymphatic leukemia.
 
ALPRAZOLAM
Type: Benzodiazepines.
Uses: Anxiety, depression.
Side effects: Sedation, light headedness, vertigo, confusion, psychomotor and cognitive impairment.6
 
ALENDRONATE
Type: Bisphosphonate.
Uses: Postmenopausal osteoporosis, corticosteroids induced osteoporosis, Paget's disease.
Side effects: Esophageal irritations and ulceration, gastrointestinal upset, increased bony pain especially in Paget's disease.
 
ASPIRIN
Type: NSAIDs and antipyretic.
Uses: As analgesic, antipyretic, acute rheumatic fever, RA, OA, postmyocardial infarction and post-stroke.
Side effects: Nausea, vomiting, epigastric distress, rhinorrhea.
 
ATENOLOL
Type: B-antiadrenergic.
Uses: Arrhythmias, angina, hypertension, myocardial infarction, congestive heart failure.
Side effects: Cold hand and feet, bradycardia, hypotension, fatigue.
 
ATRACURIUM
Type: Nondepolarizing muscle relaxant.
Uses: As a muscle relaxant.
Side effects: Hypotension, flushing, skin rashes.7
 
ATROPINE
Type: Antimuscarinic.
Uses: Corneal ulcers, peptic ulcers, pulmonary embolism, preanesthetic medication, bradycardia, motion sickness.
Side effects: Dry mouth, difficulty in swallowing and talking, blurring of near vision, constipation, flushing, dry skin.
 
AZATHIOPRINE
Type: Immunosuppressant.
Uses: Autoimmune and collagen disease including rheumatoid arthritis, polymyositis, systemic lupus erythematosus.
Side effects: Nausea, vomiting, loss of hair, loss of appetite, bone marrow suppression.
 
BACLOFEN
Type: Skeletal muscle relaxant.
Uses: For reducing spasticity.
Side effects: Nausea, urinary disturbances, drowsiness.
 
BECLOMETHASONE
Type: Corticosteroid.
Uses: Asthma, allergic rhinitis, in vasomotor symptoms.8
Side effects: Nasal discomfort, irritation, horse voice, cough, nosebleed, sore throat.
 
BENDROFLUMETHIAZIDE/BENDROFLUAZIDE
Type: Thiazide diuretic.
Uses: Hypertension, cardiac failure, resistant edema, for reducing urinary calcium excretion.
Side effects: Hypokalemia, dehydration, postural hypotension, gout, hyperglycemia.
 
BUDESONIDE
Type: Corticosteroid.
Uses: Asthma, COPD.
Side effects: Nasal discomfort, cough, sore throat.
 
CALCITONIN
Type: Hormone.
Uses: Hypercalcemia, bone pain, osteoporosis.
Side effects: Vomiting, nausea.
 
CAPTOPRIL
Type: ACE inhibitor.
Uses: Hypertension, congestive heart failure, post- myocardial infarction, diabetic nephropathy.
Side effects: Persistent dry cough, rashes, loss of taste sensation, reduces kidney function, postural hypotension.9
 
CARBAMAZEPINE
Type: Antiepileptic.
Uses: Partial and tonic–clonic seizures, trigeminal neuralgia.
Side effects: Drowsiness, epigastric pain, nausea, confusion, blurred vision.
 
CELECOXIB
Type: NSAID.
Uses: Osteoarthritis, rheumatoid arthritis.
Side effects: Fluid retention, dizziness, hypertension, headache, itching, insomnia.
 
CHLORAMPHENICOL
Type: Broad spectrum antibiotics.
Uses: Enteric fever, anerobic infections, intraocular infections, H. influenzae, meningitis.
Side effects: Nausea, vomiting, diarrhea, gray baby syndrome, bone marrow depression.
 
CHLORPROMAZINE
Type: Antipsychotic.
Uses: Schizophrenia, mania, organic brain syndrome, alcoholic hallucinosis.
Side effects: Dry mouth, blurring vision, constipation, parkinsonian symptoms, dystonic, 10jaundice, akathisia, malignant neuroleptic syndrome symptoms.
 
CHLOROQUINE
Type: Antimalarial drug.
Uses: Malaria.
Side effects: Hypotension, vision loss, hearing deficit, nausea, vomiting, anorexia, itching.
 
CICLOSPORIN
Type: Immunosuppressant.
Uses: Used to prevent rejection of organ and tissue transplantation. Rheumatoid arthritis, severe resistant psoriasis, severe dermatitis when other treatments have failed.
Side effects: Nephrotoxicity, hypertension, increased body hair, nausea, tremors, swelling of gums.
 
CIPROFLOXACIN
Type: Prototype antibacterial.
Uses: UTI, gonorrhea, bacterial gastroenteritis, typhoid, gynecological disease, tuberculosis, meningitis, respiratory infections.
Side effects: Nausea, vomiting, anorexia, bad taste dizziness, headache, rashes, urticaria.11
 
CLOFAZIMINE
Please refer Dapsone.
 
CLOMIPRAMINE
Type: Tricyclic antidepressant.
Uses: Depression.
Side effects: Sweating, drowsiness, dryness of mouth, blurring of vision, dizziness, fainting, palpitations, gastrointestinal upset.
 
CLONIDINE
Type: Alpha 2 adrenoceptor agonist.
Uses: Migraine, menopausal flushing, hypertension.
Side effects: Dryness of mouth, gastrointestinal upset, headache, dizziness, rashes, sedation, depression, bradycardia, retention of fluid, nocturnal unrest.
 
CODEINE PHOSPHATE
Please refer Morphine.
 
DAPSONE
Type: Antileprotic drug.
Uses: Leprosy.
12Side effects: Hemolytic anemia, gastric intolerance, rashes, headache, lepra reactions, nausea, vomiting.
 
DEXAMETHASONE
Please refer Prednisolone.
 
DIAZEPAM
Type: Benzodiazepines.
Uses: Anxiety, sleep disturbances, alcoholism and as muscle relaxants.
Side effects: Unsteadiness, drowsiness, dizziness, confusion in elderly. Dependence develops with prolonged use.
 
DICLOFENAC
Type: NSAIDs and antipyretic.
Uses: Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, post-traumatic and postoperative inflammatory conditions.
Side effects: Epigastric pain, nausea, rashes, headache, dizziness.
 
DIDANOSINE
Please refer Zalcitabine.13
 
DIGOXIN
Type: Cardiac glycoside.
Uses: Heart failure, supraventricular arrhythmias.
Side effects: Nausea, anorexia, vomiting, diarrhea, visual disturbances, headache, tiredness, palpitations.
 
DIHYDROCODEINE/DF 118
Please refer Morphine.
 
DILTIAZEM
Please refer Amlodipine.
 
DOBUTAMINE
Type: Inotropic sympathomimetic.
Uses: Heart failure.
Side effects: Tachycardias.
 
DONEPEZIL
Type: Anticholinesterase.
Uses: Dementia especially due to Alzheimer's disease.
Side effects: Insomnia, muscle cramps, fatigue, gastrointestinal upset. 14
 
DOPAMINE
Type: Inotropic sympathomimetic.
Uses: Shock, heart failure.
Side effects: Nausea, vomiting, peripheral vasoconstriction, hypotension, hypertension tachycardia.
 
DORNASE ALFA
Type: Mucolytic.
Uses: Used by inhalation in cystic fibrosis to facilitate expectoration.
Side effects: Laryngitis, pharyngitis, pain in chest.
 
DOSULEPIN/DOTHIEPIN
Please refer Clomipramine.
 
DOXAPRAM
Type: Respiratory stimulant.
Uses: COPD with type-II respiratory failure.
Side effects: Hypertension, cerebral edema, hyperthyroidism, dizziness, sweating, confusion, seizures, nausea, vomiting, tachycardia, perineal warmth.
 
DOXYCYCLINE
Please refer Tetracyclines. 15
 
ENALAPRIL
Type: ACE inhibitor.
Uses: Hypertension, chronic heart failure.
Side effects: Rashes, dry cough, loss of taste, postural hypotension, dizziness, headache, reduce kidney function.
 
EFAVIRENZ
Please refer Zalcitabine.
 
ERYTHROMYCIN
Type: Macrolide antibiotic.
Uses: Inflammation, diphtheria, syphilis, gonorrhea.
Side effects: Gastrointestinal discomfort, rashes, fever.
 
ETIDRONATE
Type: Bisphosphonate.
Uses: Postmenopausal osteoporosis, corticosteroid induced osteoporosis, Paget's disease, bone metastases in breast cancer.
Side effects: Ulceration and esophageal irritation, gastrointestinal upset, increased bony pain in Paget's disease.16
 
FENTANYL
Type: Opioid analgesic.
Uses: Mainly used to depress respiration in patients needing prolonged assisted ventilation.
Side effects: Drowsiness, nausea, vomiting, constipation, dizziness, dry mouth.
 
FERROUS SULPHATE
Type: Iron salt.
Uses: Iron deficiency anemia.
Side effects: Constipation, epigastric discomfort, darkening of feces.
 
FLUCLOXACILLIN
Please refer Penicillin.
 
FUROSEMIDE/FRUSEMIDE
Type: Loop diuretic.
Uses: For reducing acute pulmonary edema secondary to left ventricular failure.
Side effects: Hypokalemia, postural hypotension, hyponatremia, hyperuricemia, gout, dizziness, nausea.
 
GABAPENTIN
Type: Anticonvulsant. 17
Uses: Epileptic seizures, neuropathic pain, trigeminal neuralgia.
Side effects: Dizziness, drowsiness, ataxia, nystagmus, tremor, diplopia, gastrointestinal upset, peripheral edema, amnesia, paresthesia.
 
GATIFLOXACIN
Please refer Ciprofloxacin.
 
GENTAMICIN
Type: Aminoglycoside antibiotics.
Uses: Pseudomonas, Proteus, Klebsiella infections, respiratory infection's meningitis.
Side effects: Vestibular disturbances, auditory loss, nausea, vomiting.
 
GLICLAZIDE
Type: Sulphonylurea.
Uses: Type-II diabetes mellitus.
Side effects: Hypoglycemia, weight gain.
 
HALOPERIDOL
Type: Antipsychotic.
Uses: Used for controlling violent and dangerously impulsive behavior associated with psychotic disorders like as schizophrenia, dementia and mania.
18Side effects: Acute dystonia, akathisia, drowsiness, postural hypotension, parkinsonism.
 
HEPARIN
Type: Anticoagulant.
Uses: Pulmonary embolism, DVT.
Side effects: Thrombocytopenia, hemorrhage.
 
HYDROCORTISONE
Please refer Prednisolone.
 
IBUPROFEN
Class: Nonsteroidal anti-inflammatory/NSAID.
Uses: For reducing pain, stiffness, swelling. Osteoarthritis, rheumatoid arthritis, soft tissue injuries, headache, dental pain, operative pain.
Side effects: Indigestion, heart burn.
 
INSULIN
Type: Peptide hormone.
Uses: Insulin dependent and maturity onset diabetes mellitus.
Side effects: Irritation over injection site, hypoglycemia, weakness, weight gain, sweating.19
 
INTERFERON
Type: Antiviral and anticancer.
Uses: Leukemia, multiple sclerosis, granulomatous disease.
Side effects: Lethargy, chills, myalgia, fatigue, rashes, fever, headache, anorexia, irritation.
 
IPRATROPIUM
Type: Antimuscarinic.
Uses: COPD.
Side effects: Dry mouth and throat.
 
ISONIAZID
Type: Antitubercular drug.
Uses: Tuberculosis.
Side effects: Paresthesia, numbness, convulsions, mental disturbances, hepatitis.
 
ISOSORBIDE MONONITRATE
Type: Organic nitrate.
Uses: Congestive heart failure, angina.
Side effects: Throbbing headache, flushing, sweating, palpitation, dizziness, fainting.20
 
KETAMINE
Type: Intravenous anesthetic.
Uses: As anesthetics agent (not use in head and neck surgery).
Side effects: Tachycardia, hallucinations, increased blood pressure, increased muscle tone, apnea, hypotension, other transient psychotic sequelae.
 
LACTULOSE
Type: Osmotic laxative.
Uses: Constipation, hepatic encephalopathy.
Side effects: Diarrhea, stomach cramps, flatulence, belching.
 
LEVODOPA/L-DOPA
Type: Dopamine precursor.
Uses: Parkinson's disease.
Side effects: Nausea, vomiting, postural hypotension, cardiac arrhythmias, alteration in taste sensation, behavioral changes, abnormal movements, abdominal pain, dizziness, discoloration of urine and other body fluids.
 
LIGNOCAINE/LIDOCAINE
Type: Na+ channel blocker.
Uses: As anesthetic and antiarrhythmic.
Side effects: Dizziness, drowsiness, nausea, vomiting.21
 
LIQUID PARAFFIN
Type: Laxatives.
Uses: Constipation, before surgery night.
Side effects: Dehydration, lipid pneumonia.
 
LISINOPRIL
Type: ACE inhibitor.
Uses: Hypertension, congestive heart failure, following myocardial infarction.
Side effects: Nausea, vomiting, cough, taste alteration, hypotension.
 
MANNITOL
Type: Osmotic diuretic.
Uses: Glaucoma, head injury, stroke.
Side effects: Nausea, diarrhea, headache, fever.
 
MELOXIAM
Type: NSAID.
Uses: Rheumatoid arthritis, ankylosing spondylitis, osteoarthritis.
Side effects: Headache, gastrointestinal upset, dizziness, vertigo, rashes.
 
METFORMIN
Type: Biguanide.22
Uses: Type-II diabetes mellitus.
Side effects: Anorexia, nausea, vomiting, diarrhea.
 
METHOTREXATE
Type: Cytotoxic and immunosuppressive.
Uses: Leukemia, lymphoma, rheumatoid arthritis, psoriatic arthritis.
Side effects: Diarrhea, bone marrow suppression, vomiting, inflammation.
 
METHYLDOPA
Type: Antihypertensive.
Uses: High blood pressure.
Side effects: Sedation, lethargy, disturbed mental capacity, impotence, postural hypotension.
 
METRONIDAZOLE
Type: Antiamebic.
Uses: Giardiasis, amebiasis, trichomonas vaginitis, enterocolitis, gingivitis bacterial infections.
Side effects: Nausea, vomiting, anorexia, headache, glossitis, rashes, dizziness.
 
MIDAZOLAM
Type: Benzodiazepine.
23Uses: Anxiety, mainly used during small procedures under local anesthetic and in ITU units for those on ventilator support.
Side effects: Hypotension, apnea, drowsiness, headache, confusion, ataxia, amnesia, muscular weakness.
 
MORPHINE
Type: Opioid analgesic.
Uses: Ventricular failure, pain.
Side effects: Nausea, vomiting, constipation, dizziness, drowsiness, respiratory depression, dry mouth.
 
NAPROXEN
Type: NSAID.
Uses: Rheumatoid arthritis, musculoskeletal disorders in acute stage, gout, menstrual cramps.
Side effects: Gastrointestinal upset.
 
NORFLOXACIN
Please refer Ciprofloxacin.
 
OMEPRAZOLE
Type: Proton pumps inhibitor.
Uses/Side effects: Please refer Ranitidine.24
 
ONDANSETRON
Type: Serotonin antagonist.
Uses: Used to treat nausea and vomiting associated with anticancer drug therapy, radiotherapy and following surgery.
Side effects: Headache, constipation.
 
ORPHENADRINE
Type: Antimuscarinic.
Uses: For reducing rigidity and tremor in younger patients with parkinsonism.
Side effects: Dry mouth, dry skin, constipation, blurred vision, retention of urine.
 
OXYBUTININ
Type: Antimuscarinic.
Uses: Urinary frequency, urgency and incontinence, nocturnal enuresis, neurogenic bladder instability.
Side effects: Dry mouth, dry eye, gastrointestinal upset, difficulty in micturation, skin reaction, blurring of vision.
 
OXYTETRACYCLINE
Please refer Tetracycline. 25
 
PANCURONIUM
Please refer Vecuronium.
 
PARACETAMOL
Type: Nonopioid analgesic.
Uses: Pain, fever.
Side effects: Very rare. Overdose is dangerous causing liver failure.
 
PENICILLIN-G
Type: Benzyl penicillin.
Uses: Streptococcal, pneumococcal, meningococcal infections, gonorrhea, syphilis, diphtheria.
Side effects: Pain at inj. Site, nausea, rash, itching, urticaria, shock, exfoliative dermatitis.
 
PETHIDINE
Type: Opioid analgesic.
Uses: Severe pain, pain during labor, anxiety, during anesthesia.
Side effects: Nausea, vomiting, constipation, drowsiness, confusion.
 
PHENYTOIN
Type: Anticonvulsant.
Uses: Epilepsy, trigeminal neuralgia.
26Side effects: Nausea, vomiting, confusion, headache, dizziness, ache, increased body hair.
 
PIROXICAM
Type: NSAID.
Uses: Rheumatoid arthritis, acute gout, osteoarthritis, acute musculoskeletal disorders.
Side effects: Gastrointestinal upset.
 
PREDNISOLONE
Type: Corticosteroid.
Uses: Adrenal insufficiency, adrenogenital, syndrome, arthritides, collagen disease, asthma, lung and eye disease, malignancies, intestinal and skin disease.
Side effects: Peptic ulcer, indigestion, acne, osteoporosis, glaucoma, growth retardation, fetal abnormalities, muscular weakness, Cushing's habitus, fragile skin, psychiatric disturbances.
 
PROPRANOLOL
Type: Na+ channel blocker.
Uses: Sinus tachycardia, atrial and nodal ESs.
Side effects: Dizziness, nausea, vomiting, fatigue, cold peripheries, bronchoconstriction, bradycardia, heart failure, hypotension, gastrointestinal upset, sleep disturbances.27
 
QUININE
Type: Antimalarial.
Uses: Malaria. Also used to prevent nocturnal leg cramps.
Side effects: Tinnitus, headache, blurred vision, confusion, gastrointestinal upset, rashes, blood disorders.
 
RAMIPRIL
Type: ACE inhibitor.
Uses: Hypertension, congestive heart failure, myocardial infarction.
Side effects: Nausea, vomiting, dizziness, headache, cough, dry mouth, taste disturbance.
 
RANITIDINE
Type: H2 blocker.
Uses: Duodenal ulcer, gastric ulcer, gastritis, Zollinger-Ellison syndrome, GERD.
Side effects: Nausea, loose stool, muscle and joint pain, dizziness, abdominal pain.
 
RIFAMPICIN
Type: Antitubercular.
Uses: Tuberculosis, leprosy, meningitis, osteomyelitis.
28Side effects: Nausea, vomiting, malaise, bone pain, purpura, breathlessness.
 
SALBUTAMOL
Type: β2-agonist.
Uses: Asthma, chronic bronchitis, emphysema.
Side effects: Weakness, tremors, drowsiness, nervousness, tension. Anxiety, restlessness.
 
SALCATONIN
Please refer Calcitonin.
 
SENNA
Type: Stimulant laxative.
Uses/Side effects: Please refer Lactulose.
 
STREPTOKINASE
Type: Fibrinolytic agent.
Uses: Pulmonary embolism, thrombosed arteriovenous shunts.
Side effects: Excessive bleeding, hypotension, nausea, vomiting, allergic reactions.
 
STREPTOMYCIN
Type: Aminoglycoside antibiotics.
Uses: Tuberculosis, plague, bacterial endocarditis, tularemia.
29Side effects: Vestibular disturbances, auditory loss paresthesia.
 
SULFASALAZINE
Type: Aminosalicylate.
Uses: Ulcerative colitis, Crohn's disease, rheumatoid arthritis.
Side effects: Nausea, vomiting, loss of appetite, headache, joint pain, abdominal discomfort, anorexia.
 
TETRACYCLINE
Type: Alpha-adrenoceptor agonist.
Uses: For reducing spasticity associated with multiple sclerosis or spinal card injury.
Side effects: Lethargy, fatigue, dry mouth, gastrointestinal upset, hypotension.
 
THEOPHYLLINE
Type: Methylxanthine.
Uses: Asthma, bronchitis, emphysema.
Side effects: Nausea, vomiting, palpitations.
 
TIMOLOL
Type: Beta blocker.
Uses: Hypertension, angina, prophylaxis of myocardial infarction.
Side effects: Please refer Propranolol.30
 
TINIDAZOLE
Please refer Metronidazole.
 
TIZANIDINE
Type: Opioid analgesic.
Uses: For treating moderate to severe pain.
Side effects: Nausea, vomiting, dry mouth, tiredness, drowsiness, dependence.
 
TOLTERODINE
Type: Antimuscarinic.
Uses: Mainly used to treat urinary frequency, urgency and incontinence. Also used for reducing unstable contraction of the bladder.
Side effects: Headache, gastrointestinal upset, dry eye, dryness of mouth.
 
TRAMADOL
Type: Opioid analgesic.
Uses: For treating moderate to severe pain.
Side effects: Nausea, vomiting, dry mouth, tiredness, drowsiness, dependence.
 
TRAZODONE
Type: Antidepressant.
31Uses: Depression, anxiety.
Side effects: Drowsiness.
 
TRIHEXYPHENIDYL/BENZHEXOL
Type: Antimuscarinic.
Uses: For reducing rigidity and tremor in young patients with Parkinsonism.
Side effects: Blurring of vision, urine retention, constipation, dry skin, dryness of mouth.
 
VANCOMYCIN
Type: Glycopeptide antibiotic.
Uses: MRSA infections, endocarditis, gastrointestinal infection.
Side effects: Disorder of the blood, nephrotoxicity, ototoxicity.
 
VECURONIUM
Type: Muscles relaxants.
Uses: During general anesthesia, convulsions, trauma, tetanus, status epilepticus.
Side effects: Respiratory failure, muscle soreness, hypotension.
 
VERAPAMIL
Type: Calcium channel blocker.
32Uses: Hypertension, supraventricular dysrhythmias.
Side effects: Nausea, vomiting, constipation, headache, ankle swelling.
 
WARFARIN
Please refer Heparin.
 
ZALCITABINE
Type: Antiretroviral NRTI.
Uses: For prevention of AIDS (commonly used in combination with other antiretroviral drugs).
Side effects: Peripheral neuropathy, headache, insomnia, gastrointestinal upset, fatigue, liver damage, oral and esophageal ulcer, blood disorder, rashes, breathlessness, pancreatitis.
 
ZIDOVUDINE
Type: Antiretroviral NRTI.
Uses: Mainly used to prevent maternal-fetal HIV transmission.
Side effects: Peripheral neuropathy, headache, insomnia, gastrointestinal upset, fatigue, liver damage, oral and esophageal ulcer, blood disorder, rashes, breathlessness, pancreatitis, itching, chest pain, taste disturbance, anemia, increase frequency of urine, influenza like symptoms.33
 
LIST OF PHARMACOLOGY ABBREVIATIONS
Abbreviation
Meaning
ac
Before bed
ad lib
As desired
bd
Twice daily
cap
Capsule
IM
Intramuscular
IV
Intravenous
LA
Local anesthetic
liq
Liquid
OC
Oral contraceptive
od
Once daily
om
In the morning
on
At night
opv
Oral poliomyelitis vaccine
ORS
Oral rehydration salt
ORT
Oral rehydration therapy
pc
After food
prn
When required
qid
Four times a day
qqh
Every four hours
si
Sublingual
sos
As required
stat
Immediately
susp
Suspension
syr
Syrup
tab
Tablet
tds
Three times a day.
34

ElectrotherapyCHAPTER 2

  • Principles of electrotherapy application
  • Interferential
  • Short wave diathermy
  • Ultraviolet radiations
  • Laser therapy
  • Ultrasound
  • Transcutaneous electrical nerve stimulation (TENS)
  • Iontophoresis
  • Infrared radiation
  • Paraffin wax bath
  • Neuromuscular electrical stimulation (NMES)
  • Microwave diathermy
  • Cryotherapy (Cold therapy)
  • Hot packs/Electric heating pads
  • Whirlpool bath36
  • Contrast bath
  • Sauna bath
  • Electromyographic biofeedback
  • Fluidotherapy
  • Intermittent pneumatic compression
  • Continuous passive motion
  • Traction
  • Strength duration curve
  • Motor points
37
 
PRINCIPLES OF ELECTROTHERAPY APPLICATION
 
RECEIVING THE PATIENT
  • Good morning sir/madam.
  • Please be seated (Please take your seat).
  • I am your therapist who is going to treat you.
  • Do not worry; I will do my best for you.
 
CASESHEET READING
  • Laboratory investigation reports.
  • Assessment and diagnosis done by the physician.
 
CHECKING GENERAL CONTRAINDICATIONS
  • Hyperpyrexia
  • Epilepsy
  • Severe renal and cardiac problems
  • Cardiac pacemakers
  • Severe hypotension and hypertension
  • Infections
  • Pregnant women
  • Metal implants
  • Mentally retarded patients
  • Mentally upset patients
  • Malignancy
  • Eyes.
38
 
ANTERIOR ASPECT OF NECK AND CAROTID SINUS
 
Tray Preparation
Patient Tray or Skin Resistance Lowering Tray and Skin Sensation Testing Tray
  • Pillow
  • Cotton
  • Soap
  • Towel
  • Macintosh
  • Kidney tray
  • Petroleum jelly or vaseline
  • Test tubes (hot and cold)
  • U-pin (sharp and blunt)
  • Clips
  • Bowel of water
  • IR lamp
  • Hot and cold packs.
Treatment Tray
  • Pillow
  • Towel
  • Bedsheet
  • Cotton
  • Adhesive tapes
  • Straps
  • Salt
  • Powder
  • Scissor
  • Inch tape39
  • Paper
  • Graph paper
  • Pencil
  • Eraser
  • Scale
  • Goggles
  • Machine and accessories
  • Sand bags
  • Crepe bandages.
Checking Local Contraindications
  • Open wounds
  • Scars
  • Local skin infections
  • Cuts
  • Abrasions
  • Eczema
  • Localized hemorrhagic spots
  • Skin sensitivity (testing).
Apparatus Preparation
  • The apparatus and accessories needed should be assembled and suitably positioned.
  • Visually check the electrodes, leads, cables, plugs, power outlets, switches, controls, dials, and indicator lights for cracks and breaks.
Apparatus Checking
  • Check the apparatus in front of the patient.
  • Demonstrate the treatment to the patient.
  • Give an explanation of the treatment to the patient.40
  • Explained about the type of sensation, which will be experienced by the patient.
 
POSITIONING THE PATIENT
  • The position of the part to be treated should be completely relaxed.
  • Patient should be made comfortable by using maximum number of pillows and sand bags for the support.
  • Position of the patient should be such that all the joints of the body are completely relaxed.
  • If possible give the position in which patient can see the treatment.
  • Uncover the part to be treated.
  • Use pillows, macintosh, and towel for supporting and whipping off the water.
  • Make use of soap and possible hot water as it will make the skin surface warm.
 
PLACEMENT OF ELECTRODES
  • Place electrodes properly.
  • Use adhesive tapes or straps for placing the electrodes.
  • Apply electrode gel evenly on entire electrode.
  • Maintain good contact between the skin and the electrode.
  • Tie the electrodes with even pressure.
  • Wires or leads should not cross each other during the treatment.
Again check all the connections.41
 
INSTRUCTIONS AND WARNINGS
 
Instructions
  • Do not move during the treatment.
  • Do not sleep while the treatment is going on.
  • Do not touch the cables, apparatus, therapist, and any other metal nearby you.
 
Warnings
  • As there are chances of getting a blister due to excessive current or overheating, so please inform me if the current is not comfortable or heating is more.
  • If there is any burning sensation, immediately inform me, as it might lead to burn.
  • Inform me, if the position is not comfortable.
 
TREATMENT
  • Explain the examiner about my operations.
  • Increase the intensity knob till it is comfortable for the patient.
  • Duration of the treatment is decided on the basis of the condition.
  • The patient must be observed throughout to ensure that treatment is progressing satisfactorily and without adverse effects.
 
TERMINATION OF TREATMENT
  • Switch off the machine and the main supply.42
  • Inspect the treated part for any adverse reactions.
  • If there is any mild erythema, apply powder.
  • If it is too severe, advise him/her to go to the physician.
  • An accurate record of all parameters of treatment including region treated, technique, dosage, and the resultant effect must be made.
 
INTERFERENTIAL
 
INDICATIONS
  • Arthritis
  • Neuritis
  • Neuralgia
  • Muscle sprain
  • Muscle weakness
  • Sports injury
  • Circulatory disorders
  • Rheumatism
  • Stress incontinence
  • Contractures
  • Gynecological conditions
  • Migraine
  • Asthma
 
CONTRAINDICATIONS
  • Cardiac diseases
  • Hemorrhage43
  • Pregnant uterus
  • Artificial pacemakers
  • During menstruation over the abdomen only
  • Dermatological conditions
  • Febrile conditions.
 
SKIN SENSATION TEST
Pin-prick test.
 
PRESCRIPTION WRITING
  • Electrode type—Small/medium/large
  • Site of application
  • Type of current—Dipole/isoplaner vector filed
  • Frequency
  • Base frequency
  • Spectrum
  • Spectrum mode—Rectangular/triangular/trapezoidal
  • Treatment time
  • Intensity
  • Sessions
  • Specific precautions
  • Remarks.
 
SHORT WAVE DIATHERMY
 
INDICATIONS
  • Gynecology—Pelvic endometriosis44
  • Traumatology—Sprains, muscular pain
  • Rheumatology—Neuralgia, inflammatory pain, arthritis
  • Respiratory—Asthma, emphysema
  • Neurology—Anti spasmodic action
  • Others—Reynaud's diseases, visceral pain, automatic dystonia
  • Abscesses
  • Carbuncles.
 
CONTRAINDICATIONS
  • Metal implants
  • Pacemaker
  • Deep X-ray therapy recently
  • Circulatory deficiency
  • Pregnancy and menstruation
  • Local or general infection's
  • Diminished thermal sensation
  • Deep vein thrombosis
  • Severe swellings
  • Acute traumatic or inflammatory lesions
  • Malignancy.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patient position
  • Site of application45
  • Electrode type—Pad/disc/wire coil
  • Electrode placement—Coplanar/controplanar/crossfire
  • Spacing—Medium/narrow
  • Dosage:
    Acute
    -
    Subthermal
    Subacute
    -
    Mild thermal
    Chronic
    -
    Thermal
  • Duration:
    Acute
    -
    10-15 min
    Subacute
    -
    15-20 min
    Chronic
    -
    20-30 min
  • Session
  • Specific precautions
  • Supplementary therapy
  • Remarks.
 
ULTRAVIOLET RADIATIONS
 
INDICATIONS
  • Wounds
  • Acne vulgaris
  • Alopecia
  • Pressure sores
  • Rickets
  • Counter irritation
  • Psoriasis
  • Vitiligo
  • Psychological benefits.46
 
CONTRAINDICATIONS
  • Deep X-ray or cobalt therapy
  • Recent skin grafting
  • Hypersensitivity to sun rays
  • Arteriosclerosis
  • Cardiac, hepatic or renal failure
  • Diabetes
  • Hyperthyroidism
  • Febrile disorders.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Spectrum
  • Distance
  • Dosage
  • Focusing point
  • Duration
  • Session
  • Specific precautions
  • Remarks.47
 
LASER THERAPY
 
INDICATIONS
  • Wounds
  • Tensile strength of scar tissues pain
  • Musculoskeletal conditions (tendonitis/bursitis)
  • Fractures (for healing).
 
CONTRAINDICATIONS
  • Cardiac conditions
  • Pregnancy
  • Over the eye
  • Hemorrhage
  • Cancers
  • Photosensitized patients.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Therapist position
  • Site of application
  • Dosage
  • Duration
  • Session
  • Specific precautions
  • Remarks.48
 
ULTRASOUND
 
INDICATIONS
  • Bursitis
  • Capsulitis
  • Tendinitis
  • Epicondylitis
  • Ankylosing spondylitis
  • Scar tissue
  • Hematoma
  • Keloid tissue
  • Joint stiffness
  • Dupuytren's contracture
  • Plantar fasciitis
  • Chronic indurate edema
  • Myalgia
  • Herpes-zoster
  • Brachial neuritis, lumbago, sciatica intercostals neuritis (for reduction of pain), varicose ulcers and pressure sores
  • Plantar warts.
 
CONTRAINDICATIONS
  • Thrombophlebitis
  • Hemorrhage
  • Ischemic tissue
  • Pregnant uterus
  • Malignancy
  • Anesthetic area49
  • All intratissue prosthetic and metallic substances
  • Recent grafts
  • Defective skin sensation
  • Deep X-ray therapy
  • Acute infection
  • Over cardiac area (in advanced cardiac diseases).
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Mode
  • Method—Direct/water bag/under water bath
  • Site of application
  • Duration
  • Intensity
  • Pulsed ratio
  • Attenuation
  • Field
  • Coupling media: Water/oil/liquid paraffin/aqua sonic gel
  • Size of head
  • frequency
  • Phonophoretic agent (if used)
  • Session50
  • Specific precautions
  • Remarks.
 
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)
 
INDICATIONS
  • Postsurgical pain
  • Obstetric pain
  • Phantom limb pain
  • Sciatic pain
  • Periarthritic pain
  • Reflex sympathetic dystrophy
  • Low backache
  • Pain due to scoot tissue
  • Cervical spondylosis (with neurological involvement).
 
CONTRAINDICATIONS
  • Cardiac pacemakers
  • First trimester of pregnancy
  • Hemorrhagic conditions
  • Open wounds
  • Over carotid sinus, mouth and near eyes
  • Epilepsy.
 
SKIN SENSATION TEST
Pin-prick test.51
 
PRESCRIPTION WRITING
  • Type—High/low
  • Frequency
  • Pulse width
  • Intensity
  • Site of application
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
IONTOPHORESIS
 
INDICATIONS
  • Inflammation
  • Calcific tendonitis
  • Myositis ossification
  • Soft tissue adhesions
  • Soft tissue pain and inflammation
  • Muscle and joint pain
  • Edema
  • Skeletal muscle spasm
  • Skin ulcers
  • Hyperhidrosis.
 
CONTRAINDICATIONS
  • Cardiac pacemakers
  • Uncontrolled hypertension
  • Pregnancy52
  • Osteoporosis
  • Epilepsy
  • Cancer
  • Over the pharyngeal area.
 
SKIN SENSATION TEST
Pin-prick test.
 
PRESCRIPTION WRITING
  • Patients position
  • Drug/solutions
  • Type of electrode—Small/medium/large
  • Electrode placement
  • Site of application
  • Intensity
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
INFRARED RADIATION
 
INDICATIONS
  • Pain relief
  • Muscle relaxation
  • Edema
  • Elimination of waste products
  • Superficial wounds.53
 
CONTRAINDICATIONS
  • Vascular insufficiency
  • Arterial diseases
  • Hemorrhage
  • Anesthetic area
  • Pregnancy and during menstruation
  • Skin diseases, e.g. psoriasis, eczema
  • Thermal hypothesia
  • Deep X-rays therapy.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Apparatus type—Luminous/Nonluminous
  • Generator type—Lamp/tunnel bath
  • Distance
  • Focus point
  • Wave-length
  • Frequency
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
PARAFFIN WAX BATH
 
INDICATIONS
  • Joint stiffness54
  • Osteoarthritis
  • Adhesions
  • Scars
  • Rheumatoid arthritis.
 
CONTRAINDICATIONS
  • Skin rashes
  • Allergic conditions
  • Open wounds
  • Diminished skin sensation
  • Defective arterial supply
  • Open suture
  • After taking analgesic drugs
  • After application of liniments.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Temperature
  • Method—Pouring/brushing/dipping/bandaging
  • Site of application
  • Duration
  • Session
  • Specific precautions
  • Remarks.55
 
NEUROMUSCULAR ELECTRICAL STIMULATION (NMES)
 
INDICATIONS
  • Foot drop
  • Bell's palsy
  • Paraplegia
  • Hemiplegia
  • Quadriplegia
  • Radial nerve injury (wrist drop)
  • Median nerve injury (claw hand)
  • Erb's paralysis
  • Deltoid and quadriceps inhibition.
 
CONTRAINDICATIONS
  • Sensory deficit
  • Hypertension
  • Open wounds
  • Pacemakers
  • Malignant tissue
  • Epilepsy
  • Hyperpyrexia
  • Active tissue infections
  • Deep X-rays therapy
  • Peripheral vascular disease
  • Over the excessive adipose tissue
  • Mentally retarded.
 
SKIN SENSATION TEST
Pin-prick test56
 
PRESCRIPTION WRITING
  • Patients position
  • Instruction for patients
  • Site of application
  • Current type—Faradic/galvanic/others
  • Pulse
  • Frequency
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
MICROWAVE DIATHERMY
 
INDICATIONS
  • Pain relief
  • Trapezius spasm
  • Arthritic conditions
  • Abscesses
  • Carbuncles.
 
CONTRAINDICATIONS
  • Malignancy
  • Tuberculosis
  • Deep X-ray therapy
  • Non-palpable edema
  • Hypersensitive areas
  • Anesthetic areas
  • Psychic patients57
  • Paralytic patients
  • Recent injury.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Type of applicator—Small/large circular/rectangular
  • Site of application
  • Distance
  • Frequency
  • Intensity
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
CRYOTHERAPY (COLD THERAPY)
 
INDICATIONS
  • Spasticity
  • Swelling
  • Pain
  • Ligament sprain
  • Muscle strain.
 
CONTRAINDICATIONS
  • Cryoglobinemia58
  • Peripheral nerve injury
  • Cardiac diseases
  • Vascular diseases
  • Cold sensitivity
  • Cold urticaria
  • Psychic patients.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Type of application—Ice massage/towels/immersion/cold packs/evaporative cooling/excitatory cold/cold gel/cold compression
  • Site of application
  • Duration
  • Session
  • Special precautions
  • Remarks.
 
HOT PACKS (HYDROCOLLATOR PACKS)/ELECTRIC HEATING PADS
 
INDICATIONS
  • Muscle spasm
  • Pain
  • Joint stiffness.59
 
CONTRAINDICATIONS
  • Impaired skin sensation
  • Open wounds
  • Allergic conditions
  • Hemorrhage
  • Impaired circulation.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Layers of towel
  • Types of packs—Small/large/contoured
  • Site of application
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
WHIRLPOOL BATH
 
INDICATIONS
  • Rheumatic conditions
  • Stiffness
  • Joint pain
  • Fatigue.60
 
CONTRAINDICATIONS
  • Skin allergy
  • Skin infections
  • Open wounds61
  • Hemorrhage.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patients position
  • Temperature
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
CONTRAST BATH
 
INDICATIONS
  • Edema
  • Circulatory disorders
  • Tight amputation stump
  • Post-traumatic swelling
  • Joint sprains.
 
CONTRAINDICATIONS
  • Skin infections
  • Open wounds
  • Hemorrhage
  • Skin allergy
  • Diabetes.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Temperature:
    • Warm
    • Cold
  • Timing in:
    • Warm
    • Cold
  • Repetition
  • Session
  • Specific precautions
  • Remarks.
 
SAUNA BATH
 
INDICATIONS
  • Weight reduction
  • Pain
  • Relaxation
  • Psoriasis.
 
CONTRAINDICATIONS
  • Psychic conditions62
  • Loss of skin sensations
  • Dehydration.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Temperature of hot chamber
  • Expanded time in:
    • Sweating phase
    • Cooling phase
  • Pause between two phases
  • Duration (total)
  • Session
  • Specific precautions
  • Remarks.
 
ELECTROMYOGRAPHIC BIOFEEDBACK
 
INDICATIONS
  • Spinal card injury
  • Hemiplegia
  • Spasticity
  • Dystonic conditions
  • Recovering peripheral nerve injury
  • Specific muscle activity training
  • Balance control
  • Weight-bearing control
  • Incontinence control63
  • Joint angle control
  • Practice of movement
  • Control of posture
  • Functional breathing disorder
  • Hypertension
  • Epilepsy
  • Migraine
  • Cardiac arrhythmias
  • Raynaud's disease
  • Tension headache.
 
CONTRAINDICATION
Psychic conditions
 
SKIN SENSATION TEST
  • Hot and cold
  • Pin-prick test.
 
PRESCRIPTION WRITING
  • Patient position
  • Type of biofeedback devices—Myoelectrical/postural/goniometric/force/pressure/orofacial control/toilet training/cardiovascular/stress/temperature
  • Treatment duration
  • Type of electrode—Surface/needle
  • Session
  • Specific precautions
  • Remarks.64
 
FLUIDOTHERAPY
 
INDICATIONS
  • Swelling
  • Pain
  • Relaxation
  • Stiffness
  • Muscle spasm.
 
CONTRAINDICATIONS
  • Psychic conditions
  • Loss of skin sensations
  • Dehydration.
 
SKIN SENSATION TEST
Hot and cold.
 
PRESCRIPTION WRITING
  • Patient position
  • Area of treatment
  • Temperature
  • Exercise guidelines inside the unit
  • Specific precautions
  • Duration
  • Session
  • Remarks.65
 
INTERMITTENT PNEUMATIC COMPRESSION
 
INDICATIONS
  • Edema
  • Lymphedema
  • Arterial insufficiency
  • Wound healing
  • DVT
  • Stump reduction in amputee limbs
  • Venous stasis ulcer.
 
CONTRAINDICATIONS
  • Acute pulmonary edema
  • Congestive heart failure
  • Recent DVT
  • Acute fracture
  • Acute skin allergy.
 
SKIN SENSATION TEST
Pin-prick test.
 
PRESCRIPTION WRITING
  • Patient position
  • Area of treatment
  • Pressure
  • Inflation time
  • Deflation time
  • Duration
  • Session66
  • Specific precautions
  • Remarks.
 
CONTINUOUS PASSIVE MOTION
 
INDICATIONS
  • Decreased joint ROM after any surgical procedure
  • Joint stiffness
  • Decreased joint ROM after fracture management.
 
CONTRAINDICATIONS
  • Large wound
  • Excess pain
 
PRESCRIPTION WRITING
  • Patient position
  • Area of treatment—Knee/shoulder/elbow/ankle
  • Movement and range
    Shoulder:
      Abduction/adduction with synchronized rotation
      Abduction/adduction with fixed rotation
    Rotation with fixed abduction/adduction
    Flexion/extension
    Elbow:
      Extension/flexion
    67  Extension/flexion with synchronized pronation-supination
    Knee:
      Flexion/extension
    Ankle:
      Dorsiflexion/planter flexion
  • Duration
  • Session
  • Specific precautions
  • Remarks.
 
TRACTION
 
INDICATIONS
  • Radiculopathy
  • Tight soft tissues not muscle spasm.
 
CONTRAINDICATIONS
  • Fracture, dislocation or subluxation of the spine
  • Cancer, RA, OA, osteoporosis or infection of the spine
  • Hiatal or abdominal hernia
  • Spinal cord compression
  • Hypertension
  • Aortic aneurysm
  • Pregnancy
  • Temporomandibular joint pain or dysfunction
  • Chronic obstructive pulmonary disease (COPD).68
 
PRESCRIPTION WRITING
  • Position of the patient
  • Position of the spine—Neutral/flexion/extension
  • Method—Mechanical/manual/positional/gravity/inversion
  • Type—Static/intermittent
  • Magnitude of force
  • Total treatment duration
  • Duration of Hold
– Rest (if Intermittent)
  • Specific precautions
  • Remarks.
 
STRENGTH DURATION CURVE (FIGS 2.1 TO 2.5)
Fig. 2.1: Normally innervated muscle: In constant current
69
Fig. 2.2: Normally innervated muscle: In constant voltage
Fig. 2.3: Complete denervated muscle: In constant voltage
70
Fig. 2.4: Complete denervated muscle: In constant current
Fig. 2.5: Partially denervated muscle
71
 
MOTOR POINTS (FIGS 2.6 TO 2.11)
Fig. 2.6: Motor points of the muscles supplied by the facial nerve
Fig. 2.7: Motor points of the back
72
Fig. 2.8: Motor points of the posterior aspect of the right arm
73
Fig. 2.9: Motor points of the anterior aspect of the right arm
74
Fig. 2.10: Motor points of the anterior aspect of the right leg
75
Fig. 2.11: Motor points of the posterior aspect of right leg
76

CardiorespiratoryCHAPTER 3

  • Cardiorespiratory anatomy illustrations
  • Surface marking of the lungs
  • Respiratory volumes and capacities
  • Differences between central and peripheral cyanosis
  • Sputum analysis
  • Readings of chest X-ray
  • Abnormal ECG findings
  • Percussion note
  • Auscultation
  • Palpation of pulses
  • Apgar scoring method
  • Postural drainage
  • Manual chest clearance technique78
  • Suctioning
  • Forced expiratory techniques
  • Tracheostomies
  • Aerosol therapy
  • Humidity
  • Lung function test
  • Ambulatory manual breathing unit (AMBU) bag
  • Manual hyperinflation
  • Cardiorespiratory monitoring
  • Ventilations
  • Respiratory pathologies
  • Normal values
  • Blood values and their interfering factors
  • Respiratory assessment
  • Glossary of cardiorespiratory terms
79
 
CARDIORESPIRATORY ANATOMY ILLUSTRATIONS
Fig. 3.1: Surface marking of the fissures and lobes of the right lung
80
Fig. 3.2: Lung markings—anterior view
Fig. 3.3: Lung markings—posterior view
81
Fig. 3.4: Bronchial tree
Fig. 3.5: Bronchopulmonary segments (lateral aspect)
82
 
SURFACE MARKING OF THE LUNGS
 
APEX
  • Anteriorly 2.5 cm above the medial 1/3rd of clavicle.
  • Posteriorly 2 cm lateral to C7 spinous process.
 
ANTERIOR BORDER OF RIGHT LUNG
  • Sternoclavicular joint
  • Midline in the sternal angle
  • Above the xyphoid process in the midline.
 
INFERIOR BORDER OF RIGHT LUNG
  • 6th rib in the midclavicular line
  • 8th rib in the midaxillary line
  • 10th rib laterally to errecter spinae muscle
  • 2 cm lateral to spinous process of T10.
 
POSTERIOR BORDER OF RIGHT LUNG
  • 2 cm lateral to T10 spinous process
  • 2 cm lateral to C7 spinous process
 
ANTERIOR BORDER OF LEFT LUNGS
  • Sternoclavicular joint
  • Mid point in the sternal angle
  • 3 cm from sternal margin in the 4th rib
  • 4 cm lateral to midline in the 6th rib.83
 
INFERIOR AND POSTERIOR BORDER OF LEFT LUNG
Same as the right lung
 
FISSURES
 
Oblique
  • 7.5 cm lateral to midline in 6th rib
  • Midaxillary line in 5th rib
  • T3 spinous process.
 
Horizontal
  • Costal cartilage 4th rib
  • 5th rib, midaxillary line
  • T3 spinous process posteriorly.
 
TRACHEAL BIFURCATION
  • Anterior—Manubriosternal junction
  • Posterior—T4 vertebra.
 
DIAPHRAGM
 
Left
  • 6th rib anteriorly
  • T10 posteriorly
  • 8th rib midaxillary.84
 
Right
  • 5th rib anteriorly
  • T9 posteriorly
  • 8th rib midaxillary.
 
RESPIRATORY VOLUMES AND CAPACITIES (FIG. 3.6)
 
LUNG VOLUMES
 
Tidal Volume (TV)
Volume of the air moved into or out of the lungs during quiet breathing at rest.
Value—500 ml (0.5 liter).
 
Inspiratory Reserve Volume (IRV)
Maximum amount of air that can be inspired on top of a normal tidal inspiration.
Value—3300 ml (3.3 liter).
 
Expiratory Reserve Volume (ERV)
Maximum amount of air that can be exhaled following a normal tidal expiration.
Value—1000 ml (1 liter)85
 
Residual Volume (RV)
Volume of air remaining in the lungs after a maximum expiration.
Value—1200 ml (1.2 liter)
 
Minimal Volume (MV)
The amount of air that would remain when the lungs collapsed.
Value—30-120 ml.
Fig. 3.6: Lung volumes and capacities
 
LUNG CAPACITIES
It is the combination of two or more lung volumes.86
 
Total Lung Capacity (TLC)
Total volume of air in the lungs after a maximal inspiration.
TLC = VT + IRV + ERV + RV
Value—6000 ml
 
Vital Capacity (VC)
Maximum volume of air that can be expired after a maximum inspiration.
VC = VT + IRV + ERV
Value—4500 ml
 
Inspiratory Capacity (IC)
Maximum volume of air that can be inspired from the end point of quiet expiration at rest.
IC = VT + IRV
Value—3500 ml
 
Functional Residual Capacity (FRC)
Volume of the air remaining in the lungs at the end of quiet expiration at rest.
FRC = ERV + RV
Value—2500 ml
Note: The values for the average female adult are 25% less.87
 
DIFFERENCES BETWEEN CENTRAL AND PERIPHERAL CYANOSIS
Central
Peripheral
Mechanism
Diminished arterial oxygen saturation
Diminished flow of blood to the local part
Sites
On skin and mucous membranes, e.g. tongue, lips, cheeks, etc.
On skin only
Clubbing and polycythemia
Usually associated
Not associated
Temperature of the limb
Warm
Cold
Local heat
Cyanosis remains
Cyanosis abolished
Breathing pure oxygen
Cyanosis decreased
Cyanosis persists
 
SPUTUM ANALYSIS
Characteristic
Associated features
Interpretation
Saliva
Clear, watery fluid
Normal
Mucoid
Clear and sticky
Bronchial asthma, Chronic bronchitis
Purulent
Thick viscous
  • Yellow
  • Dark green/brown
  • Rusty
  • Redcurrant jelly
 
Haemophilus,
Pseudomonas,
Pneumococcus,
Mycoplasma,
Klebsiella
Mucopurulent
Initially the sputum is mucoid and later slightly discolored
Bronchiectasis, Cystic fibrosis, Lung abscess88
Foul smelling and copious
Long standing lung diseases
Bronchiectasis
Hemoptysis
Old blood
Infection or chest trauma Cardiac disease
Black
Black specks in mucoid secretions
Smoke inhalation
Frothy
Pink or white
Pulmonary edema, Heart failure
Sputum examination is noted in the terms of:
  • Quantity
  • Viscosity
  • Color
  • Odor
  • Frequency
  • Time of day
  • Ease of expectoration.
 
READINGS OF CHEST X-RAYS (FIGS 3.7A AND B)
 
DEFINITION
The X-rays are a form of invisible electromagnetic radiation that can penetrate the body and produce an image on an X-ray film.
 
INDICATIONS
  • Any type of sign and symptoms, which are related to respiratory or cardiovascular diseases.89
Figs 3.7A and B: (A) Normal PA chest X-ray, (B) Structures normally visible on X-rays
90
  • To identify the tumors.
  • Preoperative evaluation of patient's for intrathoracic surgery.
  • Follow-up and monitoring of patient's with life support devices.
  • To detect the trauma to the rib cage or lungs, see foreign bodies that may have been swallowed or inhaled.
 
VIEW APPEARANCES
Air (In the lungs)
-
Black
Fat, skin, muscles (Soft tissues)
-
Gray
Bone
-
White
 
DATABASE
Patient's name, Patient's identification number, given by radiologist, date, time, side markings L or R (L = Left, R = Right).
 
CHECKLIST
  • Skeletal frame, mainly rib's, clavicle, scapulae, costochondral junctions, vertebral column
  • Lung field, fissures
  • Lungs hilli
  • Heart shadow
  • Mediastinum
  • Trachea and bronchial air shadow
  • Costophrenic and cardiophrenic angles
  • Domes of both the diaphragms and the space beneath them
  • Soft tissue shadows (especially breast shadows in women).91
 
VIEWS
 
Posteroanterior (PA)
It means that the X-rays have entered the chest from the posterior chest wall. The X-rays should be ideally viewed from a distance of three to four feet.
 
Anteroposterior (AP)
Anteroposterior view is generally taken, when the clavicles are projected above the ribs and heart appear enlarged. AP views are taken with the patient erect but in ICU and casualty generally taken with supine position.
 
Lateral
Lateral view helps to easily indentify smaller lesions. The main problem in this view is positioning the arms out of the X-rays field.
 
Lateral Decubitus
Lateral decubitus view may help to identify the free fluid or air in the pleural cavity.
 
Apicogram or Lardotic
It is useful to demonstrate the calcifications, nodules azygos lobe and middle lobe collapse.
 
Expiratory Film
The view is taken during expiration. By the help of this view pulmonary hydatid cyst. Azygos vein and vascular lesions are easily demonstrated.92
 
Trendelenburg
The view is taken with Trendelenburg position. It is mainly help to demonstrate the movement of the fungal ball in cavity.
 
Oblique
It is most often used to demonstrate the ribs, assess the heart and aorta.
 
NORMAL CHARACTERISTICS OF A CHEST X-RAY—PA VIEW
  • No skeletal abnormalities.
  • Posterior portions of the ribs should be horizontally and the anterior portions should be oblique.
  • Trachea lies centrally and vertically.
  • The left hilum should be at a higher level than the right.
  • The right dome of diaphragm is about 2 cm higher than the left, because the right lobe of liver is situated directly underneath.
  • The diameter of heart is usually less than half the total diameter of the thorax.
  • Both lung fields should be equally translucent and should not have any other shadows.
Costophrenic angle: It is a angle where the diaphragms meets the ribs.
Cardiophrenic angle: It is a angle where the diaphragm meets the heart.93
Silhouette sign: Border of the adjacent organ will be blurred, if there is any lesion contiguous with the organ.
 
COMMON ABNORMALITIES IN X-RAYS
Lobar collapse—Homogeneous opacity
Consolidation—Patchy opacity
Pleural effusion—Dense opacity
Pneumothorax—No lung marking is present
Lung abscess—Rounded opacity
Pulmonary tuberculosis—Soft confluent shadow calcification
Bronchiectasis—Multiple ring shadows.
 
ABNORMAL ECG FINDINGS
Left atrial enlargement
Wide, notched P wave (lead II)
Right atrial enlargement
Tall P wave (lead II)
Ventricular hypertrophy
Wide QRS, ST depression
Atrial tachycardia
Abnormally shaped P waves
Atrial flutter
P wave replaced by saw-tooth baseline
Atrial fibrillation
No P waves visible
Sinoatrial block
P wave fails
Atrioventricular
Prolongation of PR
block
interval94
Bundle branch block
QRS interval abnormal, ST segment depressed, T wave inverted
Myocardial infarction (MI)
ST segment elevated, T wave inverted
Mitral valve disease
Bifid, broad P waves
Myocardial ischemia (Posterior MI)
ST segment depressed
Hyperkalemia, acute MI
Tall T waves
Hypokalemia, hypothyroidism, pericardial effusion
Small T waves
Pericardial effusion
Small QRS complex
Wolf-Parkinson-
White (WPW) syndrome
Short PR intervals, less than 0.12 sec.
 
PERCUSSION NOTE
Evaluation technique designed to assess the lung density, specifically the air to solid ratio in the lungs.
 
TECHNIQUE
The middle finger of the left hand (pleximeter finger) is placed in close contact with the chest wall in the intercostals space, a firm sharp tap is then made by the middle finger of the right hand (plexor finger), kept at right angle to the 95pleximeter finger. All areas of the chest are percussed (front, back, and both axillae).
The pitch of the note is determined by whether the lungs contain air, solid or fluid and will either sound normal or abnormal.
Abnormalities
Conditions
Impaired note
Decreasing amount of air in alveoli (consolidation, collapse, fibrosis)
Dull note
Consolidated lung area or area of collapse
Strong dull note
Pleural effusion
Tympanic note
Pneumothorax, emphysema
Skodaic resonance (boxy note)
Empty cavity and pleural effusion
Hyper-resonance
Pneumothorax, large cavity bullae formation, chronic bronchitis, congenital lung cyst
 
BELL TYMPANY
Metallic type of sound heard in case of massive pneumothorax. Coin is placed on one side of chest and percussed with another coin. Bell-like sound is heard on opposite side of chest through a stethoscope or ear.
 
AUSCULTATION
Stethoscope is used to determine the quality, character and intensity of breath sounds, vocal resonance and adventitious sound (Fig. 3.8).96
Fig. 3.8: Stethoscope position
 
BREATH SOUNDS
More prominent at the top of the lungs and centrally, with the volume decreasing towards the bases and periphery. The stethoscope diaphragm is placed near the root of the neck. Two lungs sounds are heard:
  1. On inspiration: A window through stress sound heard.
  2. On expiration: Low pitched sound. There is no pause between the two and they are rustling in quality. It is also called as vesicular breath sound.
97
Fig. 3.9: Location of normal breath sounds
 
ABNORMAL BREATH SOUNDS (FIG. 3.9)
 
Causes
  1. Abnormal generation—Abnormality in larger airways.
  2. Abnormal transmission—Abnormality at the level of alveoli.
There are two types of abnormal breath sounds:
  1. Tracheal breath sound heard over lung tissue areas (also called as bronchial breathing). Sound is heard in patients with cavity, consolidation, pleural effusion, partial collapse of lungs and open pneumothorax.98
  2. Absence of lung tissue sounds, occurs when transmission of sounds is impeded (e.g. in pneumothorax, lung tissue collapse, pleural effusion, asthma).
 
VOCAL RESONANCE
These are the sound heard through the stethoscope, when the patients is asked to say “99” or “aah.”
 
Normal
The sound can be clearly heard, over the trachea and are muffled and softer over lung tissue.
 
Abnormal
Bronchophony—”99” can be clearly heard over lung tissue.
Whispering pectoriloquy: The whispered “99” can be heard over lung tissue.
Both of these are due to consolidation.
 
ADVENTITIOUS SOUNDS
 
Rhonchi or Wheezes
These sound are either high or low pitched and monophonic (single notes) or polyphonic (where several airways may be obstructed).
These sound indicate obstruction or narrowing airways. These sounds is usually indicative of 99bronchial asthma, chronic bronchitis, lung tumors, COPDs, cardiac failure, etc.
 
Crepitation or Crackles
Heard when airways that have been narrowed or closed, are suddenly forced open on inspiration. This sound can help to determine the site of abnormally as follows:
  1. Start of inspiration—Large airways
  2. Mid inspiration—Medium smaller airways
  3. End of inspiration—Small airways and lung tissue.
Crackles are indicative of bronchitis. Left heart failure, pneumonia, lung abscess, bronchiectasis, pulmonary edema, pulmonary fibrosis and other obstructive respiratory diseases.
 
Pleural Rub
It is due to roughening of the pleural surfaces as in pleurisy. Pleural surfaces rub together and creating a cracking or grating sound.
 
Stridor
Loud sound, heard during inspiration due to obstruction of the respiratory track. It indicates a serious condition. Laryngeal stridor is a high pitched sound heard over the larynx due to laryngeal obstruction, with foreign body, diphtheria, etc. whereas tracheal stridor is a low pitched sound heard over the trachea due to trached obstruction.100
 
PALPATION OF PULSES
Pulse is palpated under following headings:
Rate
Rhythm
Volume
Force
Tension (pulsus mollis/pulsus durus)
Contour (rise/summit/fall)
Equality
Condition of arterial wall (hard/muscular/tube like)
Any abnormal character.
 
COMMON LOCATIONS
Radial: Slightly medical to the styloid process.
Brachial: Cubital fossa.
Carotid: Upper end of the thyroid cartilage along the medial border of the sternomastoid muscles.
Femoral: Groin region.
Popliteal: Popliteal fossa.
Posterior tibial: Groove between the medial malleolus and tendo Achilles.
Dorsalis pedis: Lateral to the extensor hallucis tendon.
Axillary: Groove behind coracobrachialis.101
Anterior tibial: Between tibialis anterior and extensor hallucis longus tendon, above the level of ankle joint.
Temporal: Temple directly in front of ear.
Ulnar: Little finger side of wrist.
 
APGAR SCORING METHOD
Sign
0
1
2
Heart rate
Absent
Below100
Over 100
Respiratory effort
Absent
Weak cry
Strong cry
Muscle tone
Limp
Flexion of extremities
Active movements
Reflex irritability
No response
Grimace
Cry
Color
Blue
Pink
Completely pink
 
SCORE
Under seven—Resuscitation require.
Seven or over—Normal
Between five and seven—Clearing airway and O2 therapy require.
 
POSTURAL DRAINAGE
Positioning the patient to allow gravity to assist the drainage of the secretions from specific areas of lungs (Figs 3.10 to 3.20).102
Fig. 3.10: Apical segments of both upper lobes—sitting upright
Fig. 3.11: Posterior segment of right upper lobe—left side lying, towards 45° turned prone
Fig. 3.12: Posterior segment of the left upper lobe—right side lying turned 45° towards prone, shoulder raised 30 cm
103
Fig. 3.13: Anterior segments of both upper lobes—supine position
Fig. 3.14: Lateral and medial segments of middle lobe—supine, quarter turned to left. Foot end of bed raised 35 cm
Fig. 3.15: Superior and inferior segments of the lingual lobe—supine, quarter turned to right. Foot end of bed raised 35 cm
104
Fig. 3.16: Apical segments of both lower lobes— prone, head turned to side
Fig. 3.17: Anterior basal segments of both lower lobes—supine, foot end of bed raised 46 cm
Fig. 3.18: Posterior segments of both lower lobes— prone, head turned to side, foot end of bed raised 46 cm
105
Fig. 3.19: Lateral basal segment of the left lower lobe and the medial basal segment of the right lower lobe—right side lying, foot end of bed raised 46 cm
Fig. 3.20: Lateral basal segment of the right lower lobe—left side lying, foot end of bed raised 46 cm
 
ALTERNATIVE METHOD OF POSTURAL DRAINAGE (FIGS 3.21 TO 3.23)
Fig. 3.21: Postural drainage over towels
106
Fig. 3.22: Postural drainage over chair
Fig. 3.23: Postural drainage over foam wedge
 
CONTRAINDICATIONS
  • Head injuries including cerebral vascular accidents
  • Hypertension
  • Hemoptysis
  • Aortic aneurysms107
  • Pulmonary edema
  • Surgical emphysemas
  • Tension pneumothorax
  • Eye operations
  • Facial burns
  • Filling cycle of peritoneal dialysis
  • Hiatus hernia
  • Cardiac arrhythmias
  • Pregnancy.
Note: In recent neurosurgery, head down positioning may cause increased intracranial pressure; if PD is required modified positions can be used.
 
MANUAL CHEST CLEARANCE TECHNIQUE
Percussion, vibration and shaking along with postural drainage are called manual chest clearance technique.
 
AIM
  • To mechanically loosen the secretions
  • To improve the distribution of ventilations
  • To assist the movement of secretions in larger airways.
 
PERCUSSION RATE
  • 100-460 times/min manually
  • Force: 58-65 N108
 
MODIFICATIONS OF TECHNIQUES FOR PEDIATRICS PATIENTS
In spite of hand percussion, we may use:
  • Bell of stethoscope
  • Facemask for babies
  • Small medicine cup (30 ml)
  • Tenting finger.
 
PRECAUTIONS
  • Rib fracture
  • Burns
  • Pain
  • Surgical emphysema
  • Flail chest
  • Hemoptysis
  • Pulmonary embolism
  • Acute infections
  • Metastatic conditions
  • Unstable cardiovascular conditions
  • Recent skin graft or flap
  • Severe clotting disorder.
 
SUCTIONING
The removal of bronchial secretions through a suction catheter is called suctioning.
 
INDICATIONS
  • Very sick spontaneously breathing patient
  • Patient unwilling to cough voluntarily109
  • Patient who have no cough reflex
  • All intubated patients.
 
CONTRAINDICATIONS
  • Pulmonary edema
  • Stridor
  • CSF leakage
  • Bronchospasm.110
 
MODES OF ENTRY
  • Nose (nasopharyngeal)
  • Mouth (oropharyngeal)
  • Via tracheostomy
  • Via endotracheal tube.
 
PRECAUTIONS
  • Lung transplant
  • Pneumonectomy
  • Recent esophagectomy
  • Clotting disorders.
 
HAZARDS
  • Infections
  • Mucosal trauma
  • Hypoxia
  • Atelectasis
  • Pneumothorax
  • Bronchospasm
  • Raised ICP
  • Cardiac arrhythmias.
 
FORCED EXPIRATORY TECHNIQUES
It consists of one or two huffs from midlung volume to low lung volume followed by a period of relaxed diaphragmatic breathing.
 
INDICATIONS
  • Cystic fibrosis
  • Chronic lung diseases
  • After surgery (sometimes).
 
TRACHEOSTOMIES
It is an operation performed on the anterior wall of trachea to facilitate ventilation. Surgery is performed at the level of 2nd and 3rd or 3rd and 4th tracheal rings done under general anesthesia in which a horizontal incision is made in neck.
 
FUNCTIONS
  • Increase alveolar ventilation
  • Provide alternate pathway for breathing
  • Protection of the airway from oral and gastric secretions.
 
INDICATIONS
  • Respiratory obstruction
  • Respiratory insufficiency
  • Retained secretion.111
 
CONTRAINDICATION
Anaplastic carcinoma thyroid.
 
TYPES OF TRACHEOSTOMY
  • Emergency—To save the life of patient
  • Permanent—When lesion of upper airway or esophagus.
 
Types of Tube
1. Metal or plastic
2. Cuffed or uncuffed
3. Single or double lumen.
 
Complications
  • Tracheal irritation, necrosis, ulceration
  • Hemorrhage
  • Pneumothorax
  • Secretions occluding tube
  • Surgical emphysema
  • Tracheoesophageal fistula
  • Infection of tracheostomy site
  • Stenosis of trachea.
 
Advice at Discharge
Tracheostomy done after laryngectomy is permanent. Patient should learn to use metal tracheostomy, cleaning the tubes, etc.112
 
AEROSOL THERAPY
Actual particulate matter suspended in a gas is called as aerosol. It act as a liquifire and mobilizer of pulmonary secretions in the respiratory tract. Only 0.15 to 0.25 μ particle shows the greater deposition in the alveoli.
The device that produces an aerosol is known as nebulizer.
 
TYPES OF NEBULIZER
 
Pneumatic Jet
Consist of a water reservoir and a capillary tube submerged into water. A high velocity gas flow is introduced into the system, which cause the water from the reservoir to advance upward through the tube. This creates fine mist of particles which are inturn move into the baffle. Aerosol particles hit the baffle and are broken down into smaller particle. It produces 3-5 μ size of particles.
 
Ultrasonic
Electrical energy is converted by a piezo-electric transducer to mechanical or vibrational energy with an ultra-high frequency of 1.35 mega cycle per second. The nebulizer chamber receive vibrational energy and aerosol effect is created. The nebulus is then transmitted via the buffle to the patients 0.5 to 3 μ sizes of particles is generated.113
 
PATIENT'S POSITION
Sitting or half lying.
 
USES
It is mainly used in delivery of drugs specially bronchodilator.
 
HAZARDS
Bronchospasm, shortness of breath because of swelling of secretions, cross contamination.
 
HUMIDITY
Adequate humidity is necessary for proper respiratory function. The device which deliver a maximum amount of water vapour to respiratory that is called humidifier.
 
INDICATIONS
  • Ventilated
  • Intubated
  • Receiving supplemental oxygen
  • Newborn babies
  • Patient's with severe chest injury
  • COPD, asthma, pneumonia, atelectasis
  • Thermal respiratory burns.
 
METHODS
  • Systemic hydration—By oral or intravenous
  • Water bath114
  • Nebulizers
  • Instillation/infusion
  • Heat and moisture exchangers/condensors.
 
HAZARDS
  • Bronchoconstriction
  • Infections.
 
LUNG FUNCTION TEST
 
USES
Understand clearly the type of functional disorder:
  • To measure progression or regression
  • To decide on feasibility of thoracic operation
  • To access the degree of respiratory failure.
 
TESTS
  1. Airways function test: All volumes and capacities are assessed by spirometry.
  2. Blood gas analysis: PaO2 and PaCO2 is assessed by blood gas analyzer.
  3. Blood acid/alkaline reaction
    Normal pH—7.4
    pH — a low pH (< 7.4 )—acidosis
    a high pH (> 7.4 )—alkalosis.
  4. Exercise tolerance test: During these test minute ventilation and oxygen consumption are measured.
115
 
In Field
Test
  • 12 minutes, 6 minutes, 2 minutes, walk test
  • Endurance walking test
  • Step test
  • Shuttle test.
 
In Laboratory
  • Treadmill
  • Cycle ergometer.
 
TEST PROTOCOLS
  • Bruce
  • Modified bruce or Sheffield
  • Cornell
  • Balkeware
  • ACIP and MACIP
  • Naughton
  • Ware
  • Modified Sheffield
  • Northwick park.
 
AMBULATORY MANUAL BREATHING UNIT (AMBU) BAG
This is the apparatus used for mouth to mouth respiration, by the help of face mask, endo-tracheal tube or tracheostomy, the air is driven into the patient's lung by squeezing the bag. When the pressure is released a self-restoring 116foam rubber insert causes the bag to inflate automatically. The chest recoil causes air to leave the lung by an expiratory valve protected by wire gauze. Bages without this filters are very dangerous since they allow bits of deteriorated rubber spong to enter the lungs.
 
MANUAL HYPERINFLATION
The technique of giving deep breaths manually to fully expand the lungs of loosen the secretions increasing the lung compliance of an anesthetic rebreathing bag is used for it. The maximum peak airway pressure is 40 cm H2O.
 
CONTRAINDICATIONS
  • Undrained pneumothorax
  • Bullae
  • Surgical emphysema
  • Severe bronchospasm (if PAP > 40 cm H2O).
  • Acute head injury
  • Cardiovascular instability
  • Recent pneumonectomy
  • Recent lobectomy
  • Hemoptysis
  • Patient at risk of barotrauma.
 
ADVERSE EFFECTS
  • Barotrauma
  • Cardiac arrhythmia117
  • Reduced oxygen saturation
  • Reduced respiratory drive
  • Raised intracranial pressure
  • Bronchospasm
  • Hemodynamic variations—Reduced or increased flow pressure.
 
CARDIORESPIRATORY MONITORING
 
ARTERIAL BLOOD PRESSURE (ABP)
It is the lateral pressure exerted by the contained column of blood on the wall of arteries. ABP is expressed in different terms.
Systolic pressure: Maximum pressure during systole of heart, i.e. 20 mm Hg.
Range—110 to 140 mm Hg.
Diastolic pressure: minimum pressure during diastole of heart, i.e. 80 mm Hg.
Range—60 to 90 mm Hg
Pulse pressure: Difference between systolic and diastolic pressure, i.e. 40 mm Hg.
Mean arterial pressure: Diastolic blood pressure plus one-third pulse pressure:
DBP + 1/3 PP, i.e. 93 mm Hg.
 
CARDIAC OUTPUT
Amount of blood pumped from each ventricles.
CO = Stroke volume × heart rate118
Normal value = 50 to 6 L/min
Average = 5.5 L/min/ventricles.
 
STROKE VOLUME
The amount of blood pumped out by each ventricle during each beat.
Normal value = 70 ml (60 to 80 ml).
 
MINUTE VOLUME
Amount of blood pumped by each ventricle in one minute.
Normal value = 5-6 L/min.
 
CARDIAC INDEX
This is the minute volume expressed in relation to square meter of body surface is called CI.
CI = CO ± body surface area.
Normal value = 2.5-4 L/min/m2.
 
HEART RATE
The number of time the heart contracts in a minute.
Normal = 50-100 bpm
Tachycardia > 100 bpm at rest
Bradycardia < 50 bpm at rest.
 
CENTRAL VENOUS PRESSURE
This is the pressure found in the veins emerging in heart.
Normal value—3-6 mm Hg or 3-15 cm H2O119
 
CEREBRAL PERFUSION PRESSURE (CPP)
Pressure required to ensure adequate blood supply to the brain.
CPP = MAP-ICP
Normal value > 70 mm Hg.
 
INTRACRANIAL PRESSURE
Pressure exerted by the brain tissue, CSF of blood volume with in the skull of meninges.
Normal value = 0-10 mm Hg
 
PULMONARY ARTERY PRESSURE (PAP)
It is measure of pressures of the vena cava, right atrium and right ventricle.
Normal value = 15-25/8-15 mm Hg.
Mean value = 10-20 mm Hg.
 
RESPIRATORY RATE
Number of breathes taken in a minute.
Normal value = 12-16 breaths/min
Tachypnea > 20 breaths/min
Bradypnea < 10 breaths/min.
 
EJECTION FRACTION
It is the ratio of stroke volume (i.e. blood ejected from left ventricle during systole) to the end diastolic volume (EDV).
EF = SV/EDV
Normal value = 65-75%.120
 
VENTILATIONS
 
SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)
Mandatory breaths are delivered in synchrony with the patient's breathing. The patient may breath on his own but the mandatory breaths will be delivered at a time in the ventilatory cycle, that is convenient for the patient.
 
INTERMITTENT MANDATORY VENTILATION (IMV)
Breaths are delivered at a respiratory rate and tidal volume that are determined by adjusting the ventilator controls, but patient may breath spontaneously between the mandatory breaths.
 
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Oxygen is delivered in a positive pressure throughout inspiration and expiration during spontaneous breathing. It decreases the work of breathing, O2 consumption but increases the forced respiratory capacity and PaO2.
 
POSITIVE END EXPIRATORY PRESSURE (PEEP)
PEEP is used when PaO2 is < 200 mm Hg. Generally PEEP is used in minimum 5 cm water in all mechanically ventilated patient's. It prevents the alveolar collapse and increases the forced respiratory cycle.121
 
INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB)
It is a mechanical device that augment gas flow. IPPB maintains positive airway pressure throughout inspiration with airway pressure returning to atmospheric pressure during expiration.
Model—Bird mak7, Bennett
Contraindications: Facial fracture, undrained pneumothorax, lung abscess, head injury, vomiting.
 
CONTROLLED MECHANICAL VENTILATION (CMV)
At a preset tidal volume, pressure and flow rate, CMV delivers a preset number of breaths to the patient.
 
BIPHASIC POSITIVE AIRWAY PRESSURE (BIPAP)
BiPAP is a single ventilation mode which permits spontaneous breathing not only during expiration but also during mandatory breaths. It reduces atelectasis, less sedation, higher inspiratory drive and maintained spontaneous breathing. BiPAP is most commonly used as a partial ventilatory support device, to reduce the workload of breathing in acute exacerbations of COPD. It can also be used as a step down measure leading up to weaning of mechanical ventilatory support.122
 
HIGH FREQUENCY VENTILATION (HFV)
It delivers low tidal volume or equal to anatomical dead space volume at high respiratory frequencies varing, between 60 and 300 breaths/minute.
 
Types
a. High frequency positive pressure ventilation
60-110 breaths/min.
b. High frequency jet ventilation (HFJV)
110-600 breaths/min.
c. High frequency oscillation (HFO)
600-3000 breaths/min.
 
ASSIST—CONTROL MODE VENTILATION (A/C MODE)
In this, breathing is initiated by a patient during ventilatory cycle and ventilator delivers gas at a preset tidal volume or preset pressure.
 
PRESSURE CONTROLLED VENTILATION (PCV)
During PCV, all breaths are pressure limited and time cycled. There is no possibility for patient triggering.
 
PRESSURE SUPPORT (PS)
During PS tidal volume, respiratory rate and flow rate is controlled by patient himself through his inspiratory efforts.123
 
NONINVASIVE VENTILATION (NIV)
NIV is the ventilatory support used without intubation through a mask. It is rarely used. Positive pressure devices are pressure, volume or time controlled. The modes which are used are pressure support ventilation, control/assist ventilation, controlled mechanical ventilation, BiPAP, CPAP and proportional assist ventilation.
 
RESPIRATORY PATHOLOGIES
 
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Progressive breathlessness and respiratory failure caused by a variety of acute diffuse lung injuries.
 
Causes
Shock, burns, severe nonthoracic trauma, septicemia, aspiration, pneumonia, fat embolism, overdoses of drugs likely to damage pulmonary circulation.
 
Clinical Features
Dyspnea, tachypnea, crackles and wheezes sound, shock, septicemia, renal failure, liver failure, CNS depression.
ARDS tends to reach its maximum initial severity over next 24 to 48 hours and may be rapidly fatal if severe.124
 
ATELECTASIS OF LUNG
Loss of volume in one or more segments or lobes of the lungs.
 
Causes
Bronchial obstruction, carcinoma of bronchus, aneurysm, enlarged glands.
 
Clinical Features
Fever, tachycardia, tachypnea, ineffectual cough, weakness of respiratory muscle.
 
BRONCHIAL ASTHMA
Increased responsiveness of trachea and bronchi to various stimuli and manifested by acute, recurrent or chronic attacks of widespread bronchial-bronchiolar narrowing.
 
Types
Extrinsic and intrinsic asthma.
 
Clinical Features
Cough, wheeze, chest tightness, dyspnea.
These symptoms can range from mild-to- severe; and may even result in death.
 
BRONCHIECTASIS
Chronic permanent dilatation of one or more bronchi, which impairs the drainage of bronchial 125secretions and leads to persistent infection in the affected segment or lobe.
 
Causes
Congenital: Kartagener's syndrome, cystic fibrosis, hypogammaglobulinemia with respiratory infection.
Acquired
  • Infections: Measles, whooping cough and influenza, pneumonia, lung disease, tuberculosis, bronchopulmonary aspergillosis
  • Obstruction: Foreign body, bronchial stenosis, bronchial carcinoma.
 
Types
Saccular: Affects proximal bronchi.
Cylindrical: Affect distal bronchi.
Varicose: Intermediate between saccular and cylindrical.
 
Clinical Features
Productive cough, fever with chills, weakness, lassitude, anorexia, loss of weight, pleuritic pain and night sweats.
 
BRONCHITIS
 
Types
Acute bronchitis: Acute infection of mucous membrane of trachea and bronchi produced by viruses, bacteria or external irritants.126
Chronic bronchitis: Condition associated with mucous production amounting to cough and expectoration for more than three months in a year and for two to three years consecutively with other causes rules out.
 
Clinical Features
Malaise, fever, palpitation, sweating, productive cough, wheezing, dyspnea.
Because of irreversible narrowing of the airway, patient leads to develop dyspnea, cyanosis, hypoxia, hypercapnia and some times heart failure. This condition is called blue bloaters.
 
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
COPD is mainly associated with emphysema and chronic bronchitis.
Risk factors: Smoking, recurrent infections, pollution, genetics.
 
Clinical Features
Chest tightness, cough, dyspnea, excessive mucus production.
 
CYSTIC FIBROSIS
A progressive genetic disorder of the mucus—secreting glands of the lungs. Pancreas, mouth, gastrointestinal tract and sweat glands.127
 
Clinical Features
Recurrent respiratory infection, poor growth malnutrition, abnormal heart.
Rhythms, dyspnea, malabsorption.
Complications: Vasculitis, liver disease, diabetes mellitus, infertility.
This is a fatal disease.
 
EMPHYSEMA
Enlargement of the airspaces distal to the terminal bronchioles, either from dilatation or destruction of their walls.
 
Clinical Features
Dyspnea, productive cough, wheeze, recurrent respiratory infection, weight loss, hyperinflated chest.
These patients are often called as pink puffers who may hyperventilate typically by overusing their accessory respiratory muscles, and breath with pursed lips in order to maintain airway pressure to decrease the amount of airway collapse.
 
EMPYEMA
An accumulation of pus in the pleural cavity following nearby lung infection.128
 
Clinical Features
Chest pain (increasing or inspiration, coughing, sneezing, laughing, etc.) dyspnea, fever, anorexia, malaise, weight loss.
 
HEMOTHORAX
An accumulation of blood in pleural cavity. It results from injury to internal mammary artery, intercostals artery and also found in patient's with lung and pleural cancer or in those who have undergone thoracic or heart surgery.
 
Clinical Features
Absent breath sounds on affected side, reduced chest expansion, dullness to percussion. If bleeding continue, features of shock develops.
 
LUNG ABSCESS
Circumscribed suppurative inflammation of lung by pyogenic organisms leading to cavitation and necrosis.
 
Clinical Features
Fever, pleuritic chest pain, cough, fetid breath, hemoptysis, clubbing of fingers, loss of weight, anorexia.129
 
PLEURAL EFFUSION
Pleural effusion is a collection of serous fluid in the pleural space.
 
Types
  1. Acute pleural effusion: Trauma, pancreatitis, pulmonary infraction.
  2. Purulent effusion: Pyogenic infections, septicemia, penetrating wound of chest
  3. Hemorrhagic effusion: Tumor, tuberculosis, pulmonary infarction, bleeding.
  4. Tuberculous pleural effusion.
  5. Milky effusion (chylous, opalescent).
  6. Iatrogenic.
  7. Recurrent.
  8. Bilateral.
  9. Phantom.
 
Clinical Features
Pleuritic pain, dyspnea, toxemia.
 
PLEURISY: INFLAMMATION OF PLEURA
 
Causes
Infection, infarction of lung, lung cancer injury to chest wall, rheumatoid arthritis.
 
Clinical Features
Pain on respiration, unproductive cough, rapid shallow breathing, chilly sensations, fever.130
 
PNEUMONIA
Inflammation of lung parenchyma, involving respiratory bronchioles and alveolar unit distal to the conduction zone.
 
Types
  1. Anatomical
    1. Lobar
    2. Segmental
    3. Lobular.
  2. Clinical
    1. Primary
    2. Secondary (associated with any disease).
  3. Etiological
    1. Bacterial (E. coli, Klebsiella, Pseudo-
    2. monas)
    3. Atypical (viral, mycoplasmal)
    4. Protozoal (E. histolytica)
    5. Fungal (actinomycosis, aspergillosis)
    6. Allergic
    7. Radiation
    8. Collagenosis
    9. Chemical.
 
Clinical Features
Dry and painful cough, pleuritic pain, fever, fatigue, after few days purulent with blood in sputum.131
 
PNEUMOTHORAX
Pneumothorax is air in the pleural cavity. Air may enter the pleural cavity through the chest wall, mediastinum or diaphragm or from a puncture of the visceral pleura covering the lung.
 
Causes
  1. Primary spontaneous: Idiopathic.
  2. Secondary spontaneous: Caused by ruptured emphysematous bullae or due to ulceration of active tuberculous lesion through the pleura or rupture of local emphysematous area from old tuberculous scarring. Frequently affected are tall, thin young men, especially smokers.
  3. Traumatic and iatrogenic: Stab wounds, fractured ribs, crush injury, lung biopsy, faulty tracheostomy, cardiothoracic surgery.
  4. Artificial: Because of an antitubercular drugs.
 
Types
Closed: The opening in the lungs is very small and rapidly heals. Thus allowing the lung to re-expand.
Open: The opening remains patent and pressure in the pleural cavity is equal to that of the atmosphere.132
Tension: The opening is valvular –air enters the pleural space during inspiration but cannot escape during expiration so that a positive pressure occurs in the pleural cavity.
 
Clinical Features
Increased respiration distress, hypotension, cyanosis, tachycardia, decreased movement of chest wall.
 
PULMONARY EMBOLISM
Blockage of the pulmonary vasculature by blood clots, venous thrombi, fat, air, foreign bodies or fragment of malignant tumors.
 
Clinical Features
Dyspnea, chest pain, hemoptysis
Risk factors: Prolonged sitting, femur fracture, surgery.
 
PULMONARY EDEMA
An increase in the fluid content of the extravascular tissues of the lung.
 
Cause
Myocardial infarction, LV failure, mitral stenosis, shock, infections, fluid overload, etc.133
 
Clinical Features
Wheezing, shortness of breath sweating tachycardia, short and copious frothy cough.
 
PULMONARY TUBERCULOSIS
A chronic infectious disease caused by mycobacterium tuberculosis that is spread via the circulatory system or the lymph nodes.
Sites: Lungs, lymph nodes, bones, gastrointestinal tract, kidney, skin, and meninges.
 
Types
  1. Miliary tuberculosis: The lungs are studded with firm white tubercles about 1 mm in diameter.
  2. Chronic fibrocaseous: Firstly cavities are formed at the apex.
  3. Acute tuberculous caseous pneumonia: Lesion ulcerate through bronchial walls.
 
Clinical Features
Cough, hemoptysis, weight loss, fatigue, fever, night sweats.
 
RESPIRATORY FAILURE
Condition when normal blood gas pressures cannot be maintained at rest.134
 
Types
Hypoxemic respiratory failure: A decreased PaO2 with a normal or low PaCO2
Causes: Chronic bronchitis, emphysema, ARDS
PaO2 < 8 kPa (60 mm Hg)
Ventilatory failure: A decreased PaO2 with an increased PaCO2.
Causes: Muscular dystrophy, lung disease, Guillain-Barré syndrome.
PaO2 < 8 ka (60 mm Hg)
PaCO2 > 6.7 kPa (50 mm Hg)
 
Clinical Features
Central cynosis, loss of judgment, fatigue, dizziness, dimness of vision, headache.
Arterial Blood Gas Classification of Respiratory Failure
pH
PaCO2
HCO3
Acute
Decreased
Increased
Normal
Chronic
Normal
Increased
Increased
Acute on chronic
Decreased
Increased
Increased
135
 
SARCOIDOSIS
Granulomatous disease involving several organs.
Common site: Mediastinal, lymph nodes, lungs, liver, spleen, skin, eyes.
 
Clinical Features
Lymph node enlargement, fever, weight loss, dry cough, uveitis arrhythmias.
 
SLEEP APNEA
There is recurrent collapse of upper airway due to which there is difficulty or obstruction in breathing for more than 10 sec leading to disturbed sleep.
 
Clinical Features
Restlessness, reduced sleep, reduced muscle tone, enlarged tonsils or adenoids, abnormal use of accessory respiratory muscle.
 
Complication
Pulmonary hypertension, respiratory or heart failure.
It occurs due to loss of muscle tone of pharynx or abnormal central nervous system.136
 
NORMAL VALUES
Age group
Heart rate mean (range) (beats/min)
Respiratory rate range (breaths/min)
Blood pressure systolic/diastolic (mm Hg)
Preterm
150 (100-200)
40-60
39-59/16-36
Newborn
140 (80-200)
30-50
50-70/25-45
< 2 years
130 (100-190)
20-40
87-105/53-66
> 2 years
80 (60-140)
20-40
95-105/53-66
> 6 years
75 (60-90)
15-30
97-112/57-71
Adults
70 (50-100)
12-16
95-140/60-90
 
ARTERIAL BLOOD
pH
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)
137
 
VENTILATION/PERFUSION
Alveolar
:
Arterial oxygen gradient A—PaO2
Breathing air
:
0.7-2.7 kPa (5-20 mm Hg)
Breathing
:
100% 3.3-8.6 kPa oxygen (25-65 mm Hg)
 
PRESSURES
mm Hg
kPa
Right atrial (RA) pressure
Mean
–1 to +7
0.13 to 0.93
Right ventricular (RV) pressure
Systolic Diastolic
15-25
0-8
2.0-3.3
0-1.0
Pulmonary artery (PA) pressure
Systolic
Diastolic mean
15-25
8-15
10-20
2.0-3.3
1.0-2.0
1.3-2.7
Pulmonary capillary wedge pressure (PCWP)
Mean
6-15
0.8-2.0
Central venous pressure
3-15 cm H2O
Intracranial pressure (ICP)
<10 mm Hg (<1.3 kPa)
Peak inspiratory mouth pressure (pi max)
Male
Female
103-124
65-87
cm H2O
cm H2O (Case dependent)
Peak expiratory mouth pressure (pe max.)
Male
Female
185-233
128-152
cm H2O
cm H2O
(Case dependent)
138
 
BLOOD VALUES AND THEIR INTERFERING FACTORS
 
WHITE BLOOD CELLS (WBCS)
Increase: Food, exercise, emotions, pain, menstruation, pregnancy, fever, anesthesia prolonged cold bath, infections, hemorrhage.
Decrease: Bone marrow depression, viral infection, hypersplenism.
 
NEUTROPHIL
Increase: Infection.
Decrease: Viral infection, influenza, mumps, anemia, thyrotoxicosis.
 
EOSINOPHIL
Increase: Lung and bone cancer parasitic diseases, Hodgkin's disease.
Decrease: Pyogenic infection, congestive heart failure hypersplenism.
 
RED BLOOD CELLS (RBCS)
Increase: Dehydration, poisoning, diarrhea, polycythemia vera.
Decrease: Anemia, bone marrow diseases, rheumatic fever, endocarditis.139
 
ESR
Increase: Anemia, burns, MI, infections, gout, rheumatoid arthritis, leukemia, sarcoidosis
Decrease: Polycythemia vera, congestive cardiac failure.
 
BLOOD UREA NITROGEN (BUN)
Increase: Shock, dehydration, diabetes, MI, impaired renal function.
Decrease: Malnutrition, liver failure, nephrotic syndrome.
 
URIC ACID
Increase: Metastatic cancer, shock, diabetic ketosis, leukemia.
Decrease: After drugs, ACTH phenothiazenes.
 
RESPIRATORY ASSESSMENT
Database
Reg No
Name
Age/sex       DOA.
Address
Occupation
Referred by (consultant) and Hospital
Consultant's probable diagnosis
Type of operation/illness
140DOD
Discharge summary
Instruction for physiotherapist
History of present illness
Past medical history
Drug history
ADL activities
Personal history
Family history
Social history
  • Support at home
  • Home environment
  • Hobbies.
 
 
Subjective Examination
Main symptoms:
  • Shortness of breath
  • Cough (productive or non-productive)
  • Pain
  • Wheeze.
 
FROM CHARTS
  • Blood pressure
  • Heart rate
  • Temperature
  • Oxygen requirement
  • Oxygen saturations
  • Respiratory rate
  • Peak flow141
  • Urine output
  • Mode of ventilations
  • FiO2
  • Pressure support/volume control
  • Airway pressure
  • CVP
  • ABGs.
 
ON OBSERVATION
  • Built of the patient
  • Cyanosis (central/peripheral)
  • Breathing pattern
  • Depth
  • Type
  • Use of accessory muscle
  • Chest symmetry
  • Facial expression
  • Assessment of chest pain
    • Site/side of pain
    • Type of pain
    • Mode of onset of pain (gradual/rapid).
    • Nature (shooting or dull pain)
  • Course
    • Radiation (if any)
    • Towards (Rt/Lt) UL
    Intensity of pain (constant or intermittent)
    Aggravating/relieving factors.
  • On palpation
    • Edema (pitting or non-pitting)
    • Inflammatory signs (present/absent)142
    • Wasting of muscle
    • Tracheal shift.
  • Percussion
    • Resonance (normal/hypo/hyper)
    • Cardiac dullness
    • Liver dullness
    • Spleen dullness
    • Shifting dullness
    • Coin test.
  • Auscultation
    • Heart sounds
    • Gallops
    • Breath sounds
    • Tactile vocal fremitus
    • Pleural rub
    • Abnormal lung sound (if any).
  • Investigation
    • X-ray
    • Sputum examination
    • ECG
    • Echo-cardiography
    • Pulmonary function test
    • Stress test
    • Scanning.
  • On examination
    • Pulse rate
    • Respiratory rate
    • Temperature
    • Blood pressure.
  • 143Measurements
    • Chest expansion
    • Spirometry
    • Dyspnea level.
  • Posture deformity
    • Chest
    • Spinal.
  • Functional ability/exercise tolerance.
 
GLOSSARY OF CARDIORESPIRATORY TERMS
Alkalosis: A pathological state of raised pH resulting from a loss of CO2.
Anoxia: Absence of O2 in the tissues despite an adequate blood supply.
Angiogram: A component of left heart catheterization in which a dye is injected into the coronary arteries to assess blood flow of the presence of occlusion.
Angle of Louis: Anatomical landmark on the chest wall for the RA, the bony demarcation of manubrium from the body of sternum.
Apnea: Cessation of respiration.
Arrhythmia: Disturbance of cardiac rhythm.
Asphyxia: Death due to lack of oxygen.
Autoregulation: A type of vascular regulation that occurs at the local level.
144Bradycardia: Abnormally slow heart rate.
Bradypnea: Decrease respiratory rate.
Bruit: Turbulence or an abnormal murmur in a vessel heard on auscultation.
Compliance: Change in lung volume for unit change in distending pressure.
Cor pulmonale: Right ventricular enlargement from a primary pulmonary cause.
Cyanosis: Bluish discoloration or skin color changes.
Dyspnea: Laboured, uncomfortable breathing.
Dysrhythmia: Disturbance of rhythm.
Fibrillation: Rapid uncoordinated contractions of the cardiac muscle.
Hemodynamics: The study of forces governing blood flow.
Hemoptysis: The presence of blood in the sputum.
Hypercarbia: Excess of CO2 in the blood.
Hypercapnia: An increase in the amount of CO within the arterial blood.
Hyperinflation: An abnormal increase in the amount of air in the lung tissue.
Hypocapnia: A decrease in the amount of CO2 in arterial blood.
145Hypoapnea: Diminution of tidal volume.
Hypoventilation: An increase in the amount of CO2 in arterial blood due to a decrease in alveolar ventilation.
Hypovolemia: Low blood volume.
Hypoxemia/Hypoxia: Reduction of O2 supply to the tissues.
Ischemia: O2 starvation of the tissues due to a lack of blood supply.
Orthopnea: Difficulty in breathing when lying.
Paradoxical movement/breathing: Inward drawing of the lower ribs on inspiration with relaxation on expiration.
Tachycardia: Rapid heart rate.
Tachypnea: Rapid respiratory rate.
Ventilation: The act of moving air in and out of the lungs.146

NeurologyCHAPTER 4

  • Neuroanatomy illustrations
  • Clinical manifestations of cerebrovascular lesions
  • Localization of lesion and their signs of impairment
  • Myotomes
  • Dermatomes
  • Peripheral nervous system
  • Splints used for various nerve injuries
  • Vertebrae and corresponding spinal segment relationship
  • Descending tracts/ascending tracts
  • Neurological tests
  • Cranial nerves
  • Reflexes148
  • Differences of upper motor neuron and lower motor neuron lesions
  • Glasgow coma scale
  • Modified Ashworth scale for grading spasticity
  • Neurological pathologies
  • Neurological assessment
  • Glossary of neurological terms
149
 
NEUROANATOMY ILLUSTRATIONS
 
ARTERIAL SUPPLY OF THE CEREBRAL HEMISPHERE (FIGS 4.1 TO 4.8)
Fig. 4.1: Lateral view of right cerebral hemisphere
Fig. 4.2: Medial view of right cerebral hemisphere
150
Fig. 4.3: Mid sagittal section of the brain
Fig. 4.4: Coronal section of the brain
151
Fig. 4.5: Anterior cerebral artery
Fig. 4.6: Middle cerebral artery
152
Fig. 4.7: Posterior cerebral artery
Fig. 4.8: Circular arteriosus
153
 
CLINICAL MANIFESTATIONS OF CEREBROVASCULAR LESIONS
 
MIDDLE CEREBRAL ARTERY
Involved structures
Clinical features
Internal capsule and primary motor cortex
Contralateral paresis of face, arm, trunk, and leg
Internal capsule and primary sensory cortex
Sensory impairment of the contralateral face, arm and leg
Broca's cortical area (dominant hemisphere)
Motor speech disorder
Wernicke's cortical area (dominant hemisphere)
Wernicke's aphasia
Parietal lobe (nondominant lobe)
Perceptual problems
Optic radiation in internal capsule
Homonymous hemianopia
Parietal lobe
Contralateral limb(s) ataxia
 
ANTERIOR CEREBRAL ARTERY
Involved structures
Clinical features
Motor cortex
Paresis of opposite foot and leg to a lesser extent the arm
Unknown
Mental impairment
Somatosensory cortex
Sensory impairments (lower limb>upper limb)154
Superior frontal gyrus
Urinary incontinence
Corpus callosum
Apraxia
Uncertain localization
Abulia, slowness, lack of spontaneity
 
POSTERIOR CEREBRAL ARTERY
Involved structures
Clinical features
Optic radiation or primary visual cortex
Contralateral homonymous hemianopia
Inferomedial portions of temporal lobe bilaterally
Amnesia
Calcarine sulcus and lingual gyrus (non dominant occipital lobe)
Prosopagnosia
Ventral posterolateral nucleus of thalamus
Thalamic syndrome: sensory impairments, spontaneous pain, dysesthesias
Cerebral peduncle of mid brain and III cranial nerve
Weber's syndrome—contralateral hemiplegia, occulomotor nerve palsy
Subthalamic nucleus
Contralateral hemiballismus
155
 
LOCALIZATION OF LESION AND THEIR SIGNS OF IMPAIRMENT
Prefrontal area
Dementia, stage of catatonic stupor, incontinence of urine
Precentral area
Jacksonion march (in irritation), UMN type of paralysis (in destruction)
Parietal lobe
Paraesthesia (in irritation), sensory ataxia, sensory loss (in destruction)
Temporal lobe
Visual and auditory hallucination, uncinate fits, homonymous superior quadrantic hemianopia
Occipital lobe
Vision hallucination, convulsions (in irritation),visual agnosia, visual sensory aphasia (in destruction)
 
CLINICAL MANIFESTATIONS OF HEMORRHAGE TO OTHER AREAS OF THE BRAIN
Involved structures
Clinical features
Parts of basal ganglia
Contralateral hemiparesis/hemiplegia, contralateral hemisensory loss, hemianopia (posterior segment),
Somatosensory cortex
Sensory impairments (lower limb>upper limb)
Superior frontal gyrus
Urinary incontinence
Corpus callosum
Apraxia
Uncertain localization
Abulia, slowness, lack of spontaneity
156
 
BASAL GANGLIA
 
Nuclei
  • Putamen
  • Caudate
  • Globus pallidus.
 
Clinical Manifestations
  • Bradykinesia
  • Rigidity
  • Tremors
  • Akinesia
  • Chorea
  • Athetosis
  • Choreoathetosis
  • Hemiballismus
  • Dystonia.
 
MYOTOMES
Root
Action to be tested
C1
Flexion of upper cervical
C2
Extension of upper cervical
C3
Side flexion of cervical
C4
Elevation of shoulder girdle
C5
Shoulder abduction
C6
Elbow flexion
C7
Elbow extension
C8
Ulnar deviation
T1
Digits—abduction, adduction157
L2
Hip flexion
L3
Knee extension
L4
Dorsiflexion
L5
Great toe extension
S1
Planter flexion
S2
External rotation
 
DERMATOMES (FIG. 4.9)
Fig. 4.9: Dermatomes of the whole body
158
 
UPPER QUARTER SCREEN
C2
Occipital protuberance
C3
Supraclavicular fossa
C4
Acromioclavicular joint
C5
Lateral antecubital fossa
C6
Thumb
C7
Middle finger
C8
Little finger
T1
Medial antecubital fossa
T2
Apex of axilla
 
LOWER QUARTER SCREEN
L1
Upper anterior thigh
L2
Mid anterior thigh
L3
Medial femoral condyle
L4
Medial malleolus
L5
Dorsum 3rd MTP joint
S1
Lateral heel
S2
Popliteal fossa
S3
Ischial tuberosity
S4
Perianal area
 
PERIPHERAL NERVOUS SYSTEM
 
AXILLARY NERVE (C5, C6)
Innervation of muscles: Deltoid, teres minor.
Sensory distribution: Lateral arm over lower portion of deltoid. 159
Clinical features: Loss of shoulder abduction, also affect the lateral rotation of shoulder.
 
MUSCULOCUTANEOUS NERVE (C5, C6)
Innervation of muscles: Coracobrachialis biceps brachialis.
Sensory distribution: Anterolateral surface of forearm.
Clinical features: Loss of elbow flexion, also affect supination.
 
RADIAL NERVE (C6, C7, C8, T1)
Innervation of muscle
  • Before the radial groove: Long and medial heads of triceps.
  • After the radial groove
    Before crossing the elbow: Lateral head of triceps, anconeus brachioradialis, external carpi radialis longus.
  • After crossing the elbow
    Before piercing the supinator: Extensor carpi radialis brevis, supinator.
    After piercing the supinator
Other extensor muscles of the forearm and hand.
Sensory distribution: Posterior aspect of arm, forearm and radial side of posterior hand.
160Clinical features: Wrist drop (loss of elbow, wrist, finger and thumb extension).
 
MEDIAN NERVE (C6, C7, C8, T1)
Innervation of muscle:
In the forearm
Proximal 1/3: All flexor muscles of the forearm (except the flexor carpi ulnaris and medial half of the flexor digitorum profundus).
Distal 1/3: Nil.
In the hand: Flexor pollicis brevis, opponens pollicis, abductor pollicis, first two lumbricals.
Sensory distribution: Palmar aspect of thumb, second, third and fourth (radial half) fingers.
Clinical features: Ape hand (loss of thumb opposition, flexion and abduction).
 
ULNAR NERVE (C8, T1)
Innervation of muscles
In the forearm
Proximal 1/3: Flexor carpi ulnaris, medial half of flexor digitorum profundus.
Distal 1/3: Nil.
In the hand
Superficial branch: Hypothenar muscles.
Deep branch: Adductor pollicis, all interossei and medial two lumbricals.
161Sensory distribution: Fourth finger (medial portion), fifth finger.
Clinical features: Loss of wrist ulnar deviation.
Also affect flexion of wrist and finger Pope's blessing—weakened fourth and fifth finger flexion, thumb abduction loss, claw hand.
 
FEMORAL NERVE (L2, L3, L4)
Innervation of muscle: Iliopsoas, sartorius, pectineus, quadriceps femoris.
Sensory distribution: Anterior and medial thigh, medial leg and foot.
Clinical features: Loss of knee extension, also affect hip flexion.
 
OBTURATOR NERVE (L2, L3, L4)
Innervation of muscle: Hip adductors, obturator externus.
Sensory distribution: Medial thigh (middle part)
Clinical features: Loss of hip adduction, also affect lateral rotation of hip.
 
SCIATIC NERVE (L4, L5, S1, S2, S3)
Innervation of muscle: Hamstring.
Sensory distribution: Nil.
Clinical features: Loss of knee flexion, also affect hip extension.162
 
TIBIAL NERVE (L4, L5, S1, S2, S3)
Innervation of muscle: Popliteus, ankle plantar flexors tibialis posterior, intrinsics muscles of foot.
Sensory distribution: Medial side of ankle.
Clinical features: Loss of toe flexion and ankle plantar flexion, also affect ankle inversion.
 
COMMON PERONEAL NERVE (L4, L5, S1, S2)
Innervation of muscle:
Superficial branch: Peroneals.
Deep branch: Tibialis anterior, toe extensors.
Sensory distribution: Anterolateral aspect of leg and foot.
Clinical features: Foot drop (loss of ankle dorsiflexion). Loss of toe extension and ankle eversion.
 
SPLINTS USED FOR VARIOUS NERVE INJURIES
Nerve injured
Splint
Axillary nerve
Shoulder abduction splint
Radial nerve palsy
Cock-up splint
Ulnar nerve palsy
Knuckle-bender splint
Sciatic nerve palsy
Foot drop splint
163
 
VERTEBRAE AND CORRESPONDING SPINAL SEGMENT RELATIONSHIP
Vertebrae
Spinal segments
C1 to C4 (upper cervical)
Same
C4 to C7 (lower cervical)
+1
T1 to T7
+2
T7 to T9
+3
T10
L1,L2
T11
L3, L4
T12
L5 S1
L1
Sacral and coccygeal nerve
 
DESCENDING TRACTS (FIG. 4.10)
Corticospinal tract: Voluntary movements, finger finer movements.
Rubrospinal tract: Inhibits extensor muscles, facilitates flexors movements.
Vestibulospinal tract: Inhibits flexors, facilitates extensors.
Reticulospinal tract: Control muscle activity.
Tectospinal tract: Vision reflex.
 
ASCENDING TRACTS (FIG. 4.10)
Medial lemniscus: Kinesthetic, touch and vibration sense.
Lateral spinothalamic: Temperature, pain.
Anterior spinothalamic: Crude touch, pressure.164
Fig. 4.10: Ascending and descending spinal cord tracts
Spinocerebellar: Kinesthetic sensation
Spino-olivary: Carries message to fascia, tendon and ligaments.
Spinoreticular: Works on conscious level.
Spinotectal: Vision.
 
NEUROLOGICAL TESTS
 
ALTERNATE NOSE-TO-FINGER TEST
Procedure: Keep your finger away about an arm's length from the patient. Ask the patients to touch 165your finger with his index finger and then touch his nose. Repeat the movement.
Response: Patient missing your finger or intention tremor.
Indicates: Possible cerebellar dysfunction.
 
FINGER-TO-NOSE TEST
Procedure: Keep the patient shoulder in 900 abduction with elbow extension. Ask the patient to touch the tip of the nose with the help of the tip of the index finger.
Response: Patient missing your finger or intention tremor.
Indicates: Possible cerebellar dysfunction.
 
FINGER-TO-FINGER TEST
Procedure: Keep the patient both shoulders in 90° abduction with the elbow extension. Ask the patients to bring both the hand towards the midline and approximate the index fingers from opposing hand.
Response: Patients missing your finger or intention tremor.
Indicates: Possible cerebellar dysfunction.
 
HEEL-SHIN TEST
Procedure: Patient lying down. Ask him to place one heel on the opposite knee and then drag the 166heel down or the shin towards the ankle and back again.
Response: Inability to keep the heel on the shin or uncoordinated movement or intention tremor.
Indicates: Possible cerebellar dysfunction.
 
ALTERNATE HEEL-TO-KNEE TEST
Procedure: With supine position, ask the patients to touch the knee and big toe alternately, with the heel of opposite extremity.
Response: Uncoordinated movement or intention tremor.
Indicates: Possible cerebellar dysfunction.
 
HOFFMANN REFLEX
Procedure: Flick the distal phalanx of the patient's third or fourth finger.
Response: Reflex flexion of the patient's thumb.
Indicates: Possible upper motor neuron lesion.
 
JOINT POSITION SENSE (KINESTHESIA)
Procedure: The test is generally performed at distal joint of the limb. Demonstrate the movement with patient's eye open. Then ask the patient to close his eyes to test. Grasp the joint to be tested between two fingers and move it up and down. Ask the patient to identify the direction of movement.
167Response: Inability to identify.
Indicates: Loss of proprioception.
 
LIGHT TOUCH
Procedure: Take a wisp of cotton wool. Demonstrate the procedure with the patient's eye open. Then ask the patient to close his eyes. Stroke the patient's skin with the cotton wool at random point, ask him to indicate every time they feel the touch.
Response: Inability to indicate every time.
Indicates: Altered touch sensation.
 
PIN-PRICK (PAIN)
Procedure: Demonstrate the procedure with patient's eyes open. Then ask him to close his eyes. Test random areas of limb by using sharp end object and ask the patient to tell, which sensation they feel.
Response: Inability to identify the type of sensation of pain.
Indicates: Altered pain sensation.
 
RAPIDLY ALTERNATING MOVEMENT
Procedure: Ask the patients to hold out one hand palm up and then alternately slap it with the palmar and then dorsal aspects of the fingers of the other hand.
For the lower limbs get the patient to tap first one foot on the floor and then the other.
168Response: Loss of rhythm.
Indicates: Possible cerebellar dysfunction.
 
TEMPERATURE
Procedure: Take cold and warm water and ask the patients to distinguish between the two sensation.
Or
A cold tuning fork is taken and ask the patient to identify the sensation, when applied to various parts of the body.
Response: Inability to differentiate the temperature.
Indicates: Altered temperature sensation.
 
VIBRATION SENSE
Procedure: Ask the patient to close his eyes. Put the vibrating tuning fork (128 Hz) over bony prominence or on the finger tips or toes.
Response: Unable to report the feeling of vibration.
Indicates: Altered vibration sense.
 
TWO-POINT DISCRIMINATION
Procedure: Demonstrate the procedure with patient's eye open. Ask the patient to close his eyes, with either one prong or two touches the patient alternately and reduces space between two prongs.
Response: Inability to discriminate.
Indicates: Indicates sensory dysfunction. 169
 
ROMBERG'S TEST
Procedure: Patient stand with feet parallel to each other with a normal width between the feet and then close eyes for 20-30 seconds.
Response: Excessive postural sway or loss of balance.
Indication: Proprioceptive or vestibular deficit.
 
SHARPENED ROMBERG'S TEST
Procedure: Ask the patient to stand with the feet in a tandem stance with arm folded across the chest and stand for about a minute.
Response: Excessive postural sway or loss of balance.
Indication: Proprioceptive or vestibular deficit.
 
OTHER BALANCE TESTS
One leg stance, timed stance, postural sway test, functional reach test, nudge test, get up and go test, Berg balance test.
 
CRANIAL NERVES
 
ORIGINATION OF NERVE
Forebrain
I, II
Midbrain
III, IV
Pons
V, VI, VII, VIII
Medulla
IX, X, XI, XII
170
 
TYPES OF NERVE
Motor
III, IV, VI, XI, XII
Sensor
I, II, VIII
Mixed
V, VII, IX, X
Name
Function
Assessment
Abnormal signs
I Olfactory
Smell
Tested by use of non irritating volatile oils or liquids
Inability to detect smell
II Optic
Vision
  • Tested for visual acuity by Snellen's chart (distance vision) and Jaeger's (near vision)
  • Tested for color vision by Ishihara's chart
  • Tested for visual field by perimetry or comfrontation test
Loss of visual acuity
Color blindness
Defects visual fields
III Oculo-motor
Pupil constriction accommodation of lens, movement of eyeball and eyelid
Test pupillary light reflex
Test accommodation reflex
Test eyeball and eyelid movements
Papillary dilatation Loss of accommodation reflex Diplopia Ptosis, squint171
IV Trochlear
Movement of eyeball in upward direction
Assess the eye movement
Diplopia, Adductor paralysis
V Trigeminal
Mastication, Somatosensation: face cornea, anterior tongue
Ask the patient to clench jaws, hold against resistance test sensation: forehead, cheeks, chin test corneal reflex
Weakness and wasting of mastica tion muscle, loss of sensation in eye face, sinuses and teeth, trigeminal neuralgia
VI Abducent
Facial movement, Tearing-lacrimal gland Salivary secretions-Submandibular, Sublingual Taste for anterior two-thirds of tongue Somatosensation
Ask the patients to raise eye frows, show teeth, smile, close eyes, tightly puff cheeks
Test for taste-sweet, salty, sour, bitter
Bells palsy, loss of taste, inability to close eye172
VIII Vesti-bulocochlear
Hearing
Equilibrium
Test for hearing: Rinne (sensori-neural) and Weber test (conduction) Assess the balance, nystagmus and eye head co-ordination
Deafness, Tinnitus
Vertigo, nystagmus
IX Glosso-pharyngeal
Elevation of pharynx Salivary secretion: parotid, sensation of test for posterior third of tongue reflexes
Assess taste–sweet, salty, sour, bitter
Test gag reflex
Dysphagia, Dry mouth, loss of tongue sensation and taste, dysphonia
X Vagus
Phonation and deglutition, secretion of digestive fluid, cardiac depressor, reflexes, somatosensations
Assess phonation and articulation Observe movement of soft palate
Test gag reflex Test for pharyngeal sensation
Dysphonia
Dysphagia
Loss of gag reflex
XI Accessory
Deglutition and phonation, Movement of sterno-cleidomastoid and trapezius (spinal part)
Test for muscle strength and tone
Test for muscle strength and tone
Muscle weakness
Muscle weakness
XII Hypoglossal
Movement of tongue
Test for strength of tongue movement
Dysphagia, dysarthria, wasting of tongue
 
REFLEXES
 
DEEP TENDON REFLEXES
Reflex
Nerve
Mode of elicitation
Response
Biceps C5-6
Musculo-cutaneous
Striking over the biceps tendon
Elbow flexion
Supinator C5-6
Radial
Striking over the Brachio-radialis tendon at the distal end of radius
Forearm flexion with supination
Triceps C7–8
Radial
Striking over the tendon of triceps
Arm extension
Finger flexion C7-8
Median and ulnar
Striking over the palmar surface of the semiflexed fingers
Finger and thumb flexion174
Knee L2-4
Femoral
Striking over the tendon of quadriceps
Knee extension
Ankle S1-2
Sciatic
Striking over the tendocal-caneous
Ankle plantar flexion
 
SUPERFICIAL REFLEXES
Reflex
Mode of elicitation
Response
Plantar S1
Flexor response—slightly scratching the lateral border of the sole
Extensor response—slightly scratching the lateral border of the sole
All toes flexion
Small toe fanning, ankle and big toe dorsiflexion
Abdominal T6-12
Slightly scratching the abdomen with blunt object
Homolateral contraction of the abdominal muscles, retraction of linea alba and umbilicus
Cremasteric L1
Slightly scratching the skin on the upper, inner aspect of the thigh from above downwards with a blunt object
Cremasteric muscle contraction with homolateral elevation of testicle175
Bulbocavernous S2-4
Pressing the glans penis
Bulbocavernous muscle contraction
Anal S4-5
Pricking the skin on mucous membrane in the perianal region
External anal sphincter muscle contraction
 
PATHOLOGICAL REFLEXES
Reflex
Mode of elicitation
Positive response
Babinski (UMN Lesion)
Scratching the lateral border of sole of foot and across the footpad
Big toe extension and other toes fanning
Clonus (UMN Lesion)
Sudden dorsiflexion of foot passively
Three or more then three rhythmic contraction of plantar flexors
 
DIFFERENCES OF UPPER MOTOR NEURON AND LOWER MOTOR NEURON LESIONS
UMNL
LMNL
Origin
Cerebral cortex
Cranial nerve motor nuclei or spinal cord anterior horn
Termination
Cranial nerve nuclei or spinal cord anterior horn
Motor unit of skeletal muscle176
Affects
Muscle group
Individual muscle
Muscle tone
Increased
Decreased
Paralysis
Spastic
Flaccid
Wastage of muscle
Do not occur
Occur
Involuntary movements
Flexor spasms sometimes
Fasciculation sometimes
Superficial reflexes
Lost
Lost
Deep reflexes
Exaggerated
Lost
Plantar reflex
Abnormal (Babinski's sign)
Lost
Clonus
Present
Lost
Electrical activity
Normal
Absent
Fasciculation twitch in EMG
Absent
Present
Speech
Aphasia, aphonia
Normal, unless Laryngeal Muscles are affected
Posture and gait
Hemiplegic or scissoring
High stepping
Palpation
Hard
Soft
177
 
GLASGOW COMA SCALE
 
EYE OPEN
Spontaneous
4
To speech
3
To pain
2
None
1
 
BEST VERBAL RESPONSE
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensible sound
2
None
1
 
BEST MOTOR RESPONSE
Obeys commands
6
Localize the pain
5
Withdrawal to pain
4
Flexion to pain
3
Extension to pain
2
None
1
 
SCORE
Total
15
Minimum
3
Coma
7 or less than 7
178
 
MODIFIED ASHWORTH SCALE FOR GRADING SPASTICITY
0
No increase in muscle tone
1
Slight increase in muscle tone manifested by a catch and release or by a minimal resistance at the end of the range of motion when the affected part or parts are moved in flexion or extension
1+
Slight increase in muscle tone manifested by a catch, followed by minimal resistance through the reminder (less then half) of the ROM, but affected parts are easily moved
2
Marked increase in muscle tone through most of the ROM, but affected parts are easily moved
3
Considerable muscle tone passive increases, passive movement difficult
4
Affected part(s) rigid in flexion or extension
 
NEUROLOGICAL PATHOLOGIES
 
ALZHEIMER'S DISEASE
Commonest form of dementia characterized by slow, progressive mental deterioration. Neuritic plaques (primarily in the hippocampus and parietal lobes) and neurofibrillary tangles (mainly affecting the pyramidal cells of the cortex) are present.
 
Clinical Features
Memory loss both in short and long-term apraxia, aphasia, visuospatial impairment, aggressive behavior.179
 
ARACHNOIDITIS
Chronic inflammation of the nerve root sheath in the spinal canal with or without nerve root symptoms. Chronic arachnoiditis occurs as a result of meningitis, myelography or spinal surgery.
 
Clinical Features
Severe low back pain, radicular pain, leg weakness, gait disorder, incontinence.
 
ANTERIOR CORD SYNDROME
Occurs due to the flexion injury at the cervical region resulting into damage of anterior portion of spinal cord or its vascular supply.
 
Clinical Features
Loss of motor function, loss of sense of pain and temperature.
 
BELL'S PALSY
Lower motor neuron paralysis of the face, related to inflammation and swelling of the facial nerve (VII) within the facial canal or at the stylomastoid foramen. Usually unilateral. Good recovery is common.
 
Clinical Features
Asymmetry of face, weakness or paralysis of facial muscle, unable to close eye of affected side, 180difficulty in chewing, drooling of saliva from affected side, verbal communication is affected.
 
BROCA'S DYSPHASIA
Caused due to lesion or damage of Broca's area on the inferior frontal cortex. Broca's area is near the motor cortex for the face and arm and so may be associated with weakness in these areas.
 
Clinical Features
Difficulty in speaking, non-fluent speech, difficulty in writing, reducing word output.
 
BROWN-SEQUARD SYNDROME
It occurs due to damage to one side of the spinal cord commonly caused by stab injuries.
 
Clinical Features
Loss of sensory sensation on same side, loss of sense of pain and temperature on the opposite side.
 
BULBAR PALSY
Occurs due to lower motor neuron lesion, may be unilateral or bilateral. The nerve supplying the bulbar muscles of head and neck are mainly affected. 181
 
Clinical Features
Paralysis or weakness of muscles of face, jaw, pharynx, larynx and palate, impairment in swallowing, coughing, speaking and gag reflex.
 
CEREBRAL PALSY
Group of condition characterized by motor dysfunction due to nonprogressive brain damage early in life classified into various types:
  1. Topographical classification: Quadriplegia, triplegia, paraplegia, diplegia, hemiplegia monoplegia
  2. According to types: Spastic, athetoid, ataxic, floppy, mixed
Common causes include intrauterine cerebrovascular insult, intrauterine infection, birth asphyxia, postnatal meningitis and postnatal cerebrovascular insult.
 
Clinical Features
Retarded development, the performance of various movements in pattern, there will be persistence of infantile behaviour in all function including primitive reflexes.
 
CENTRAL CORD SYNDROME
Occurs from hyperextension injury to the cervical region, associated with congenital or degenerative narrowing of spinal canal, resulting due to 182compressive force causing hemorrhage and edema.
 
Clinical Features
Sensory impairment, neurological deficit of upper and lower extremity.
 
CHARCOT-MARIE-TOOTH DISEASE
Progressive disorder of peripheral nerve which is hereditary, characterized by gradual progressive distal weakness and wasting, mainly affecting the peroneal muscle in the leg. In the later stages arm muscles can also be involved. This is also known as hereditary motor sensory neuropathy (HMSN).
 
Clinical Features
Difficulty in running, foot deformity, muscle wasting, lower extremity weakness.
 
DISSEMINATED ENCEPHALOMYELITIS
Occurs due to prevascular CNS demyelination resulting due to viral infection. Myelin loss is followed by axonal degeneration and then by cell body degeneration (irreversible).
 
Clinical Features
Neurological and motor dysfunction, limb weakness.183
 
GUILLAIN-BARRé SYNDROME (GBS)
An acute or subacute symmetrical predominantly motor neuropathy involving more than one peripheral nerve, frequently it may involve the facial and other cranial nerve, does not have any known etiology, and reaches a peak of disability by one to four weeks. There is distruction of myelin sheath and inflammatory cell. Infiltration of nerve mostly affects the proximal part of nerve root. In most of the cases, onset of symptoms is preceded by a mild gastrointestinal or respiratory infection. GBS usually ends up with recovery.
 
Clinical Features
Neurological dysfunction, lower limb weakness, difficulty in walking, muscle weakness, facial paralysis, diminished reflexes, pain and autonomic disturbances. In severe cases, respiratory problems are seen.
 
HEMIPLEGIA
Paralysis of half side of the body, i.e. it affects both upper and lower limbs of same side. It may be due to thrombosis, embolism, hemorrhage, hypertension, intracranial infections, trauma or hysteria.
 
Clinical Features
Upper and lower limb weakness, facial paralysis, in some cases there may be sensory loss.184
 
HORNER'S SYNDROME
A group of symptoms occurring due to lesion of the sympathetic pathways in the brainstem, spinal cord, hypothalamus, superior cervical ganglion, internal carotid sheath or C8-T2 ventral spinal roots.
 
Clinical Features
Pupil constrictions of same side, loss of facial sweating on affected side of face, drooping of the upper eyelid.
 
HUNTINGTON'S DISEASE
Disease caused by a defect in chromosome IV, which can be transmitted by either of the parent. It can be hereditary in nature. Onset is insidious and occurs between 35 and 50 years of age.
 
Clinical Features
Chorea, progressive dementia, changes in behavior.
 
HYDROCEPHALUS
An increase in cerebrospinal fluid (CSF) volume, usually resulting from impaired absorption, rarely from excessive secretion. Classified into two types: communicating and non-communicating. Causes includes congenital, intrauterine infection, 185intracranial bleeding, hemorrhage, congenital malformation, etc.
 
Clinical Features
Vomiting, nausea, irritability, behavioural changes, bradycardia, delayed milestone development, drowsiness, papilledema.
 
LOCKED-IN SYNDROME
This is a neurological disorder in which there occurs total paralysis of all the voluntary muscles except those of face. Caused due to trauma of demyelinating diseases and vascular diseases.
 
Clinical Features
Inability in speaking, difficulty in hearing.
 
MENINGITIS
It is the inflammation of the leptomeninges and underlying subarachnoid C and F, caused by bacteria or viral infections, commonly occurs in children under 5 years of age and adults over 15 years of age. Classified into acute and chronic meningitis.
Acute due to meningococcal, Pneumococcal Haemophilus influenzae, gram-negative meningitis, chronic neoplasm infection, AIDS, syphilis.186
 
Clinical Features
Headache, high fever, cold hands and feet, lethargy, change in level of alertness, respiratory distress, apnea, cyanosis.
 
MOTOR NEURON DISEASE
This is a pathological progressive degenerative disease. Changes are more marked in anterior horn cell of spinal cord, motor nuclei of medulla and the corticospinal tracts.
 
Clinical Features
Wasting of muscles especially upper limbs and those innervated from the medulla, combined with symptoms of corticospinal tract degeneration various types are:
Amyotrophic lateral sclerosis: Occur due to lower motor neuron lesion. There is weakness of limbs and face muscular atrophy may also be seen.
Progressive bulbar palsy: Caused due to damage of motor nuclei is area of brainstem. There is pain and spasm, dyspnea, dysphagia, sore eyes and dysarthria, paralysis of muscles of face, larynx, pharynx and muscle wasting.
 
MULTIPLE SCLEROSIS
This is a slow progressive CNS disease characterized by disseminated patches of demyelination in the brain and spinal cord resulting in multiple 187and varied neurologic symptoms and signs with remission and exacerbation. Women are affected more; age of onset is 20 to 40 years.
 
Clinical Features
Ataxia, motor and sensory disturbance, visual disturbances, fatigue, bowel and bladder dysfunction, pain and spasm, behavioural changes, bulbar dysfunction.
 
MUSCULAR DYSTROPHY
This is a group of inherited and progressive muscle disorder. There is selective distribution of weakness. Muscle fibers are replaced by fat and connective tissue. Commonly affected are boys below four years of age and the disease is further classified as:
  • Duchenne's muscular dystrophy
  • Becker's muscular dystrophy
  • Facioscapulohumeral muscular dystrophy
  • Limb girdle muscular dystrophy.
 
Clinical Features
Pseudohypertrophy of proximal muscles, difficulty in walking, postural abnormalities diminished reflexes, Gower's sign.
 
MYASTHENIA GRAVIS
A disorder of the neuromuscular junction caused by an impaired ability of the neurotransmitter 188acetylcholine to induce muscular contraction, most likely due an autoimmune destruction of the post synaptic receptors for acetylcholine. Male: female ratio is 2:3. Age of onset – neonates, 20-30 years or 50 years.
 
Clinical Features
Muscle weakness, ptosis in bulbar muscle, respiratory distress,weakness of facial muscles and jaw-slack, face expressionless.
 
PARKINSONISM
This is the degenerative disease of substantia nigra, because of which there is decreased amount of dopamine in the basal ganglia. It has a gradual and incidious onset that affects the age group between 50 to 60 years. Syndrome is characterized by tremor, muscular rigidity, bradykinesia, postural instability.
 
Clinical Features
Poor posture reflexes, resting tremor, depression, mask like face, shuffling gait, difficulty in speaking, slowness of voluntary movements.
 
POLIOMYELITIS
Is an infectious disease usually affecting children under five year of age. It is caused by three types of poliovirus. It enters feco-oral route. It destroys 189the motor neuron of anterior horn, showing the symptoms of lower motor neuron lesion. Divided into various stages according to the involvement. They are acute stage/pre-paralytic/paralytic stage/convalescent stage/stage of early/recovery residual stage/post-polio residual phase.
 
Clinical Features
Weakness or paralysis of lower limb is more than upper limb, difficulty in speaking and swallowing, respiratory complications due to paralysis of muscles of thorax and abdomen.
 
POSTERIOR CORD SYNDROME
It is very rare and occurs when there is any deficits in function served by posterior column. This is usually seen with tabes dorsalis, a late stage syphilis condition.
 
Clinical Features
Loss of proprioception and two point discrimination of stereognosis. Gait pattern is wide based.
 
POSTPOLIO SYNDROME
Persistence of symptom like paralysis or weakness after two years of illness. In this the symptoms progresses after the recovery from acute paralytic stage.190
 
Clinical Features
Pain in muscles and joints, neurological dysfunctions, progressive muscular weakness, severe fatigue.
 
PSEUDOBULBAR PALSY
It occurs when the corticomotor neuron pathways are affected due to upper motor neuron lesion resulting in spasticity and weakness of the pharyngeal and oral musculature.
 
Clinical Features
Dysphagia and slurring of speech, emotional incontinence, inability to control the expressions like laughing or crying.
 
SACRAL SPARING
Incomplete lesion in it the centrally located sacral tracts are preserved or remains unaffected. The differing level of innervations remains intact.
 
Clinical Features
Loss of acute contraction of toe flexors supplied by sacral nerve, cutaneous sensation is lost, rectal/sphincter contraction is affected, perianal sensation is lost.191
 
SPINAL MUSCULAR ATROPHIS (SMA)
Degenerative disorders of the anterior horn cells, that are inherited and cause muscle atrophy. This is classified according to the age of onset and is of three types:
SMA I: Also known as Werdnig-Hoffmann disease. This is the most severe, one in onset and cause weakness and hypotonia.
SMA II: It is of intermediate type. It progresses a bit slower and has same features age of onset of 6 to 15 months.
SMA III: Wohlfart-Kugelberg-Welander disease has late onset, leads to progressive limb weakness and occurs between one year.
 
STROKE/CEREBROVASCULAR ACCIDENT
It is an acute onset of neurological dysfunction, because of abnormality in circulation in cerebral area with resulting signs and symptoms and it also involves the focal areas of brain. Two mechanisms resulting in stroke—ischemic and hemorrhagic. Major risk factors causing stroke are atherosclerosis, hypertension, smoking, endocarditis and cardiac disease.
 
Clinical Features
Headache, nausea, vomiting, dizziness, papilledema, shallow respiration and increased heart rate.192
 
TRANSVERSE MYELITIS
It is a syndrome not a disease in which acute inflammation affectes gray and white matter in one or more adjacent thoracic segments. Etiology is unknown, but in some cases there is viral infection, vasculitis.
 
Clinical Features
Ascending weakness and numbness of feet and legs, sensorimotor, paraplegia below the lesion, urinary retention and loss of bowel control, local back pain, headache and stiff neck.
 
TRIGEMINAL NEURALGIA
Characterized by paroxysmal attack of severe, short, sharp, stabbing pain affecting one or more divisions of the trigeminal nerve. It can be caused by degeneration of the nerve or compression on it, though often the cause is unknown. Paroxysmal attacks last for several days or weeks, they are often superimposed on a more constant ache. When the attacks settle, the patient may remain pain free for many months.
 
Clinical Features
Chewing, speaking, washing the face, tooth-brushing, cold winds or touching a trigger point, e.g. upper lip or gum, may all precipitate an attack of pain. 193
 
WERNICKE'S DYSPHASIA
Occurs due to the lesion of posterolateral left temporal and inferior parietal region of the left cortex, i.e. the Wernicke's area. The person suffering from unaware of the language problem.
 
Clinical Features
Fluent but nonsensical speech, impairment of comprehension and writing.
 
NEUROLOGICAL ASSESSMENT
Reg. No.
Name
Age/sex
Date of admission
Address
Occupation
Referred by (consultant) and hospital
Consultant's probable diagnosis
Type of operation/illness
Date of discharge
Discharge summary
Instruction for physiotherapist
Subjective examination
History of present condition
Past medical history
Drug history
Social situation
Normal daily routine194
 
GENERAL EXAMINATION
  • Pulse rate
  • Respiratory rate
  • Temperature
  • Blood pressure
  • State of consciousness—Glasgow Coma Scale
 
On Observation
  • Attitude of limbs
  • Facial expression
  • Deformity
  • Posture
    • Lying
    • Sitting
    • Standing
  • Pain
    • Type
    • Onset
    • Nature
    • Radiation
    • Intensity
    • Aggravating/relieving factor
    • Associated symptoms
    • Severity: Visual analog scale
 
On Palpation
  • Temperature
  • Tenderness
  • Edema: Pitting/non-pitting195
  • Inflammatory sign
  • Muscle wasting
  • Contractures
 
On Examination
  • Range of movement
  • Muscle girth
  • Limb length
  • End feel
    • Capsular
    • Noncapsular
  • Differential tests
  • Gait
    • Pattern
    • Distance
    • Velocity
    • Walking aids
    • Orthoses
  • MMT
  • Reflexes
    • Superficial
    • Deep
 
STATES OF HIGHER FUNCTION
  • Orientation
  • Consciousness
  • Behavior
  • Memory
  • Intelligent capacity196
  • Counting and calculation
  • Speech
  • Reading and writing
  • Vision
  • Speech and articulation
  • Cranial nerve examination
  • Muscle tone
    • Spasticity
    • Rigidity
    • Flaccidity
 
SENSORY ASSESSMENT
  • Pain
  • Temperature
  • Vibration
  • Touch
    • Light
    • Crude
  • Pressure
  • Two-point discrimination
  • Spine
    • Tenderness
    • Deformity
  • Limb attitude
    • Lying
    • Sitting
    • Standing
  • Co-ordination (UL/LL)
  • Balance197
  • Bladder and bowel
  • Dermatomes and myotomes
  • Exercise tolerance test
  • Fatigue
  • Specific investigations/blood test/X-rays/CT scan/MRI
 
GLOSSARY OF NEUROLOGICAL TERMS
Acalculia: Inability to calculate
Agnosia: Inability to interpret sensations (types—auditory, tactile, visual)
Agraphia: Inability to write
Akinesia: Difficulty in initiating movement
Alexia: Inability to read
Amnesia: Partial or total loss of memory
Amusia: Impaired recognition of music
Amyotrophy: Muscle wasting
Aneurysm: An expanded segment of an artery
Anomia: Inability to name objects
Anosmia: Loss of ability to smell
Anosognosia: Existence of a hemiplegic limb
Aphasia: Inability to generate and understand language
Astereognosis: Inability to perceive shape by touch
198Ataxia: Incoordinated voluntary movements
Athetosis: Involuntary writhing movements
Bradykinesia: Slowed voluntary movements
Catatonia: Freezing of movements
Charcot's joint: Damaged joints with neurological involvement
Chorea: Jerky, irregular, involuntary movement
Clonus: Rhythmic, rapid, repetitive muscle contraction associated with increased tone
Dementia: Loss of mental function
Diplegia: Weakness and spasticity, affecting all limbs but legs more than arms
Diplopia: Double vision
Dysesthesia: Abnormal burning or aching sensations
Dysarthria: Difficulty in articulating speech
Dysdiadochokinesia: Impaired ability to perform rapid alternating movement
Dysmetria: Impaired ability to judge the distance
Dysphagia: Difficulty in swallowing
Dysphasia: Difficulty in understanding language
Dysphonia: Difficulty in producing the voice
Dyspraxia: Inability to perform skilled movements 199
Dyssynergia: Impaired ability to complex movements
Dystonia: Abnormal postural movements caused by mainly co-contraction of agonists and antagonists group of muscles.
Embolism: Cerebral-blood clot in the circulation blocking an artery in the brain
Encephalopathy: Disorder of brain substances
Ependymoma: Tumor of brain and spinal cord
Euphoria: An exaggerated felling of wellbeing
Fasciculation: Visible involuntary contraction of bundles of muscle fibers
Fibrillation: Involuntary contraction of individual muscle fibers
Glioma: One type of brain tumor
Gliosis: Proliferation of neurological tissue
Graphesthesia: Inability to recognize number, figures or letter traced onto the skin with blunt object
Hemianopia: Loss of half of field of vision
Hemiballismus: Violent involuntary movements of a limb
Hemiparesis: Weakness of one side of the body
Hemiplegia: Paralysis of one side of the body
Homonymous: Affecting the same side 200
Hyperacusis: Increased sensitivity to sound
Hyperreflexia: Increased reflexes
Hypertonia: Increased muscles tone
Hypertrophy: Increased size
Hypotonia: Decreased muscles tone
Kinesthesia: Perception of body position and movements
Miosis: Contraction of pupil
Monoparesis: Weakness of one limb
Myoclonus: Brief shock like involuntary muscular contraction
Myopathy: Disorder of muscle
Myotonia: State of persistence of muscle contraction
Nystagmus: Jerk, involuntary movement of eye
Paresthesia: Tingling sensation
Paraparesis: Weakness of both legs
Paraphasia: Inappropriate or incorrect word during speech
Paraplegia: Paralysis of both legs
Paresis: Muscles weakness
Photophobia: Intolerance to light
Prosopagnosia: Inability to recognize the person
Ptosis: Drooping of upper eyelid201
Quadrantanopia: Loss of quarter than normal visual field
Quadriparesis: Weakness of all four limbs
Quadriplegia: Paralysis of all four limbs
Scotoma: Area of defective vision
Stereognosis: Tactile perception of shape
Tetraparesis: Quadriparesis
Tetraplegia: Quadriplegia
Tremor: Quivering or continuous shaking
Vertigo: Sensation of movements of one's body or of object's moving about or spinning.202

MusculoskeletalCHAPTER 5

  • Muscles listed by function
  • Manual muscle testing grading
  • Alphabetical listing of the muscles
  • Joint range of movement
  • Common musculoskeletal tests
  • Musculoskeletal pathologies
  • Grades of sprain and treatment
  • Stages of fracture healing
  • Fractures with eponyms
  • Musculoskeletal assessment
204
 
MUSCLES LISTED BY FUNCTION
 
SHOULDER
Flexors: Pectoralis major, deltoid (anterior fibers), biceps brachii (long head), coracobrachialis.
Extensors: Latissimus dorsi, teres major, pectoralis major, deltoid (posterior fibers), triceps (long head).
Abductors: Supraspinatus, deltoid (middle fibers).
Adductors: Coracobrachialis, pectoralis major, latissimus dorsi, teres major.
Medial rotators: Subscapularis, teres major, latissimus dorsi, pectoralis major, deltoid (anterior fibers).
Lateral rotators: Teres minor, infraspinatous, deltoid (posterior fibers).
 
ELBOW
Flexors: Biceps brachii, brachialis, brachioradialis, pronator teres.
Extensors: Triceps brachii, anconeus.
Pronators: Pronator teres, pronator quadratus.
Supinators: Supinator, biceps brachii.
 
WRIST
Flexors: Flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis, 205flexor digitorum profundus, flexor pollicis longus.
Extensors: Extensor carpi radialis brevis, extensor carpi radialis longus, extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, extensor pollicis longus, extensor pollicis brevis, extensor indicis.
Radial deviation: Flexor carpi radialis, extensor carpi radialis longus, extensor carpi radialis brevis, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis.
Ulnar deviation: Extensor carpi ulnaris, flexor carpi ulnaris.
 
FINGERS
Flexors: Flexor digitorum profundus, flexor digitorum superficialis, lumbricals, Flexor digiti minimi brevis.
Extensors: Extensor digiti minimi, extensor digitorum, extensor indicis, lumbricals.
Abductors: Abductor digiti minimi, opponens digiti minimi, dorsal interossei.
Adductors: Palmaris interossei.
 
THUMB
Flexors: Flexor pollicis longus, flexor pollicis brevis.
206Extensors: Extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus.
Abductors: Abductor pollicis longus, abductor pollicis brevis.
Adductors: Adductor pollicis.
Opposition: Opponens pollicis.
 
HIP
Flexors: Psoas major, iliacus, rectus femoris, sartorius, pectineus.
Extensors: Gluteus maximus, semitendinosus, semimembranosus, biceps femoris.
Abductors: Gluteus maximus, gluteus medius, gluteus minimus, sartorius, tensor fasciae latae, piriformis.
Adductors: Adductor longus, adductor magnus, adductor brevis, gracilis, pectineus.
Medial rotators: Gluteus medius, gluteus minimus, tensor fasciae latae.
Lateral rotators: Gluteus maximus, piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, sartorius.
 
KNEE
Flexors: Semitendinosus, semimembranosus, biceps femoris, gastrocnemius, gracilis, sartorius, plantaris, popliteus.
207Extensors: Rectus femoris, vastus medialis, vastus lateralis, vastus intermedius, tensor fasciae latae.
Medial rotators: Semitendinosus, semimembranosus, sartorius, gracilis, popliteus.
Lateral rotators: Biceps femoris.
 
ANKLE
Dorsiflexors: Tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius.
Plantar flexors: Gastrocnemius, soleus, plantaris, peroneus longus, tibialis posterior, flexor digitorum longus, flexor hallucis longus, peroneus brevis.
Invertors: Tibialis anterior, tibialis posterior.
Evertors: Peroneus longus, peroneus brevis, peroneus tertius.
 
TOES
Flexors: Flexor digitorum longus, flexor digitorum accessorius, flexor digitorum brevis, flexor hallucis longus, flexor hallucis brevis, flexor digiti minimi brevis, interossei, lumbricals, abductor hallucis.
Extensors: Extensor hallucis longus, extensor digitorum longus, extensor digitorum brevis, lumbricals, interossei.
Abductors: Abductor hallucis, abductor digiti minimi, dorsal interossei.
Adductors:Adductor hallucis, plantar interossei.208
 
SCAPULA
Protractors: Serratus anterior, pectoralis minor.
Retractors: Rhomboid major, rhomboid minor, trapezius, levator scapulae.
Elevators: Trapezius, levator scapulae.
Depressors: Trapezius.
Medial rotators: Rhomboid major, rhomboid minor, pectoralis minor, levator scapulae.
Lateral rotators: Trapezius, serratus anterior.
 
HEAD AND NECK
Flexors: Longus colli, longus capitis, anterior sternocleidomastoid, scalenus anterior.
Lateral flexors: Erector spinae, rectus capitis lateralis. Scalene (anterior, middle and posterior), splenius cervicis, splenius capitis, trapezius, levator scapulae, sternocleidomastoid.
Extensors: Splenius cervicis, levator scapulae, trapezius, splenius capitis, semispinalis, superior oblique, sternocleidomastoid, erector spinae, rectus capitis posterior major, rectus capitis posterior minor.
Rotators: Semispinalis, multifidus, scalenus anterior, splenius cervicis, sternocleidomastoid, splenius capitis, rectus capitis posterior major, inferior oblique.209
 
TRUNK
Flexors: Rectus abdominis, external oblique, internal oblique, psoas major, psoas minor, iliacus.
Rotators: Multifidus, rotatores, semispinalis, internal oblique, external oblique.
Lateral flexors: Quadratus lumborum, intertransversarii, external oblique, internal oblique, erector spinae, multifidus.
Extensors: Quadratus lumborum, multifidus, semispinalis, erector spinae, interspinales, rotatores.
 
MANUAL MUSCLE TESTING GRADING
Grade
Response
0
No movement
1
Flicker of contraction
2
Active movement with gravity eliminated
3
Active movement against gravity
4
Active movement against resistance but not to full strength
5
Normal in power
Note
Grade 4 may be divided into
4 – Movements against slight resistance.
4 + Movements against strong resistance.
210
 
ALPHABETICAL LISTING OF THE MUSCLES
 
ABDUCTOR DIGITI MINIMI (FOOT)
Origin: Medial and lateral process of the calcaneal tuberosity, plantar aponeurosis, intermuscular septum.
Insertion: Lateral side of base of proximal phalanx of fifth toe.
Nerve: Lateral plantar nerve (S1–S3).
Action: Abducts fifth toe.
 
ABDUCTOR DIGITI MINIMI (HAND)
Origin: Pisiform, tendon of flexor carpi ulnaris, pisohamate ligament.
Insertion: Ulnar side of base of proximal phalanx of little finger.
Nerve: Ulnar nerve (C8, T1).
Action: Abducts little finger.
MMT: Place the palm over a table and try to abduct the little finger in full abduction without resistance shows grade III power.
 
ABDUCTOR HALLUCIS
Origin: Flexor retinaculum, calcaneal tuberosity, plantar aponeurosis, intermuscular septum.
Insertion: Medial side of the base of proximal phalanx of great toe.
211Nerve: Medial plantar nerve (S1, S2).
Action: Abduct and flexes great toe.
MMT: Stand erect with equal body weight on both legs. Try to abduct the great toe. Full abduction shows grade III power.
 
ABDUCTOR POLLICIS BREVIS
Origin: Flexor retinaculum, tubercles of scaphoid and trapezium, tendon of abductor pollicis longus.
Insertion: Radial side of base of proximal phalanx of thumb.
Nerve: Median nerve (C8, T1).
Action: Abducts thumb.
Manual muscle testing (MMT): Put your palm in mid prone position over a table, abduct your thumb. Full abduction shows grade III power.
 
ABDUCTOR POLLICIS LONGUS
Origin: Upper part of posterior surface of ulna, middle third of posterior surface of radius, interosseous membrane.
Insertion: Radial side of first metacarpal base, trapezium.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Abducts and extends thumb, abducts wrist.
212MMT: Put your palm in mid-prone position over a table, try to abduct and extend your thumb. Full range of motion shows grade III power.
 
ADDUCTOR BREVIS
Origin: External aspect of body and inferior ramus of pubis.
Insertion: Upper half of linea aspera.
Nerve: Obturator nerve (L2, L3).
Action: Adducts hip.
MMT: Same as for adductor longus.
Stretching: Patient lies supine, therapist stand at right side of patient with his left hand at patient's right hip and right hand over patient's right ankle. Then he abducts the leg with his right hand upto a full range, where the person feels stretching at the medial aspect of the right thigh.
 
ADDUCTOR HALLUCIS
Origin: Oblique head—base of second to fourth metatarsal, sheath of peroneus longus tendon; transverse head-plantar metatarsophalangeal ligaments of lateral three toes.
Insertion: Lateral side of base of proximal phalanx of great toe.
Nerve: Lateral plantar nerve (S2, S3).
Action: Adducts great toe.
213MMT: Stand erect over a platform with your great toe in abducted position. The therapist keep his index finger at the lateral side of the toe and resist your adduction of great toe. Full range of motion shows grade III power.
 
ADDUCTOR LONGUS
Origin: Front of pubis.
Insertion: Middle third of linea aspera.
Nerve: Anterior division of obturator nerve (L2–L4).
Action: Adducts thigh.
MMT: Patients in side lying. Uppermost limb in 25° abduction supported by examiner. Therapist standing behind patient at knee level, his hand give resistance to the lowermost limb at the medial surface of distal femur, just proximal to the knee resistance is directed straight downward towards the table.
Full range of action against gravity shows grade III power while against resistance show grade V power.
 
ADDUCTOR MAGNUS
Origin: Inferior ramus of pubis, conjoined ischial ramus, inferolateral aspect of ischial tuberosity.
Insertion: Linea aspera, proximal part of medial supracondylar line.
214Nerve: Obturator nerve and tibial division of sciatic nerve (L2–L4).
Action: Adducts thigh.
MMT: Same as above.
 
ADDUCTOR POLLICIS
Origin: Oblique head: Palmar ligaments of carpus, flexor carpi radialis tendon, base of second to fourth metacarpals, capitate, transverse head-palmar surface of third metacarpal.
Insertion: Base of proximal phalanx of thumb.
Nerve: Ulnar nerve (C8, T1).
Action: Adducts thumb.
MMT: Forearm in pronation, wrist in neutral and thumb relaxed and hanging down in abduction. Therapist stabilize the all metacarpals by grasping the patient's hand around the ulnar side, ask patient to adduct the thumb. Full range of motion with no resistance shows grade III power.
 
ANCONEUS
Origin: Posterior surface of lateral epicondyle of humerus.
Insertion: Lateral surface of olecranon, upper quarter of posterior surface of ulna.
Nerve: Radial nerve (C6–C8).
Action: Extends elbow.
215MMT: Patients prone on table with arm in 90° abduction and forearm flexed and hanging vertically over the side of the table. Therapist provides support just above the elbow. Patients extend elbow to end of available range. Full range of motion with no resistance shows grade III power.
 
BICEPS BRACHII
Origin: Long head: Supraglenoid tubercle of scapula and glenoid labrum.
Short head: Apex of coracoid process.
Insertion: Posterior part of radial tuberosity, bicipital aponeurosis into deep fascia over common flexion origin.
Nerve: Musculocutaneous nerve (C5, C6).
Action: Flexes shoulder and elbow, supinate forearm.
MMT: Patient in short sitting, with forearms at side and testing forearm in supination. Therapist cups the test elbow. Patient flexes elbow through range of motion. Full range of motion without resistance shows grade III power.
Stretching: Patient in supine lying with right upper limb fully extended and hanging by the side of bed. Therapist right hand over the patient wrist and left hand at back of elbow to prevent flexion put the limb in the full extension starting from 216wrist, then elbow and upto shoulder till a stretch is felt over anterior arm.
 
BICEPS FEMORIS
Origin: Long head: Ischial tuberosity, sacrotuberous ligament.
Short head: Lower half of lateral lip of linea aspera, lateral supracondylar line of femur, lateral intramuscular septum.
Insertion: Head of fibula, lateral tibia condyle.
Nerve: Sciatic nerve (L5–S2).
Long head—tibial division.
Short head—common peroneal division.
Action: Flexes knee and extends hip, laterally rotates tibia on femur.
MMT: Prone with knee flexed to less than 90°. Leg is in external rotation (toe pointing laterally). Patient flexes knee, maintaining leg in external rotation (heel away from examiner, toes pointing toward examiner).
Full range of motion without resistance shows grade III power.
 
BRACHIALIS
Origin: Lower half of anterior surface of humerus, intermuscular septum.
Insertion: Coronoid process and tuberosity of ulna.
217Nerve: Musculocutaneous nerve (C5, C6) radial nerve (C7).
Action: Flexes elbow.
MMT: All is same as for biceps brachii except forearm in pronation.
Stretching: Same as for biceps brachii.
 
BRACHIORADIALIS
Origin: Upper two-third of lateral supracondylar ridge of humerus lateral intermuscular septum.
Insertion: Lateral side of radius above styloid process.
Nerve: Radial nerve (C5, C6).
Action: Flexes elbow.
MMT: All same as for biceps brachii except forearm in mid-position between pronation and supination.
 
CORACOBRACHIALIS
Origin: Apex of coracoid process.
Insertion: Midway along medial border of humerus.
Nerve: Musculocutaneous nerve (C5–C7).
Action: Adducts shoulder and acts as weak flexor.
MMT: Patient in short sitting, arm at side with elbow slightly flexed and forearm pronated. 218Patient flexes shoulder to 90°. Complete test range (90°) shows grade III power.
 
DELTOID
Origin: Clavicle (anterior superior border of lateral 1/3 of shaft).
Insertion: Humerus (deltoid tuberosity on shaft).
Nerve: Axillary nerve (C5, C6).
Action: Anterior fibers: Flex and medially rotate shoulder.
Middle fibers: Abduct shoulder.
Posterior fibers: Extend and laterally rotate shoulder.
MMT:
  • For anterior deltoid, the test is same as for coracobrachialis.
  • For middle fibers—position of hand is side- way and action is to abduct the shoulder upto 90°.
  • For posterior fibers—hand in side way and action is extension upto 90° with lateral rotation.
  • Full range (test range 90°) of function shows grade III power.
 
DIAPHRAGM
Origin: Posterior surface of xiphoid process, lower six costal cartilages and adjoining ribs on each 219side, medial and lateral arcuate ligament, anterolateral aspect of bodies of lumbar vertebrae.
Insertion: Central tendon.
Nerve: Phrenic nerve (C3–C5).
Action: Draw central tendon inferiorly, changes volume and pressure of thoracic and abdominal cavities.
MMT: Patient lies supine. Therapist standing next to patient at approximately waist level. One hand is placed lightly on the abdomen in the epigastric area just below the xiphoid process. Patient inhales with maximal effort and holds maximum inspiration. Completion of maximal inspiratory expansion shows grade III power.
 
DORSAL INTEROSSEI (FOOT)
Origin: Proximal half of sides of adjacent metatarsals.
Insertion: Bases of proximal phalanges and dorsal digital expansion (first attaches medially to second toe; second, third and fourth attach laterally to second, third and fourth toes respectively).
Nerve: Lateral plantar nerve (S2, S3).
Action: Abducts toes, flexes metatarsophalangeal joints.220
 
DORSAL INTEROSSEI (HAND)
Origin: Adjacent side of two metacarpal bones (four bipennate muscles).
Insertion: Bases of proximal phalanges and dorsal digital expansions (first attaches laterally to index finger; second and third attach to both sides of middle finger; fourth attaches medially to ring finger).
Nerve: Ulnar nerve (C8, T1).
Action: Abducts index, middle and ring fingers, flexes metacarpophalangeal joints and extends interphalangeal joints.
 
EXTENSOR CARPI RADIALIS BREVIS
Origin: Lateral epicondyle via common extensor tendon.
Insertion: Posterior surface of base of third metacarpal.
Nerve: Posterior interosseous branch of radial nerve (C7, C8).
Action: Extends and abducts wrist.
MMT: Patient in short sitting. Elbow is flexed, forearm is fully pronated, and both are supported on the table. Therapist supports the patient's forearm. The patient then extends and abducts the wrist. Completion of full range of motion with no resistance shows grade III power.221
 
EXTENSOR CARPI RADIALIS LONGUS
Origin: Lower third of lateral supracondylar ridge of humerus, intermuscular septa.
Insertion: Posterior surface of base of second meta- carpal.
Nerve: Radial nerve (C6, C7).
Action: Extends and abducts wrist.
MMT: Same as for extensor carpi radialis brevis, but the patient will only extend the wrist.
 
EXTENSOR CARPI ULNARIS
Origin: Lateral epicondyle via common extension tendon.
Insertion: Medial side of fifth metacarpal base.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Extends and adducts wrist.
MMT: All is same as for extensor carpi radialis longus except that patient will extend the wrist with ulnar deviation.
 
EXTENSOR DIGITI MINIMI
Origin: Lateral epicondyle via common extensor tendon, intermuscular septa.
Insertion: Dorsal digital expansion of fifth digit.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Extends fifth digit and wrist.
222MMT: Patient's forearm in pronation, wrist in neutral, MP joints and IP joints are in relaxed flexion position. Therapist stabilizes the wrist in neutral. Patient extends the MP joint of 5th digit. Complete active range with no resistance shows grade III power.
 
EXTENSOR DIGITORUM
Origin: Lateral epicondyle via common extensor tendon, intermuscular septa.
Insertion: Lateral and dorsal surface of second to fifth digits.
Nerve: Posterior interosseous branch of radial nerve (C7, C8).
Action: Extends fingers and wrist.
MMT: Position same as for extensor digiti minimi, patient extends MP joint (all finger simultaneously), allowing the IP joints to be in slight flexion. Complete active range, with no resistance shows grade III power.
 
EXTENSOR DIGITORUM BREVIS
Origin: Calcaneus (anterior superolateral surface), lateral talocalcaneal ligament. Extensor retinaculum (inferior).
Insertion: Base of proximal phalanx of great toe, lateral side of dorsal hood of adjacent three toes.
Nerve: Deep peroneal nerve (L5, S1).
223Action: Extends great toe and adjacent three toes.
MMT: Patient in short sitting, with foot on examiner's lap. Alternate position supine. Ankle in neutral position, therapist sitting on low stool in front of patient, or standing beside table near the patient's foot. One hand stabilizes the metatarsals with the fingers on the plantar surface and the thumb on the dorsum of foot. If patient can extend the toes to complete range without resistance, it shows grade III power.
 
EXTENSOR DIGITORUM LONGUS
Origin: Upper three quarter of medial surface of fibula, interosseous membrane, lateral tibial condyle.
Insertion: Middle and distal phalanges of four lateral toes.
Nerve: Deep peroneal nerve (L5, S1).
MMT: Same as for extensor digitorum brevis.
 
EXTENSOR HALLUCIS LONGUS
Origin: Fibula (shaft, middle ½ of medial aspect), interosseous membrane.
Insertion: Hallux (distal phalanx, dorsal aspect of bases), expansion to proximal phalanx.
Nerve: Deep peroneal nerve (L5).
Action: Extends great toe, ankle dorsiflexor.
224MMT: Patient's and therapist's position same as for extensor digitorum longus and brevis. Therapist stabilizes the metatarsal area by contouring the hand around the plantar surface of the foot, with the thumb curving around to the base of the hallux. The other hand stabilizes the foot at the heel. If the patient can extend the great toe upto full range without resistance, it shows grade III power.
 
EXTENSOR INDICIS
Origin: Lower part of posterior surface of ulna, interosseous membrane.
Insertion: Dorsal digital expansion on back of proximal phalanx of index finger.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Extends index finger and wrist.
MMT: Patient's forearm in pronation, wrist in neutral, MP joint and IP joint are in relaxed flexion posture. Therapist stabilizes the wrist in neutral, patient extends the MP joint of the index finger. Complete range of extension shows grade III power.
 
EXTENSOR POLLICIS BREVIS
Origin: Radius (posterior surface), interosseous membrane.
225Insertion: Dorsolateral base of maximal phalanx of thumb.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Extends thumb and wrist, abducts wrist.
MMT: Patient's forearm in mid-prone position and wrist in neutral; CMC and IP joints of thumb are relaxed and in slight flexion. The MP joint of the thumb is in abduction and flexion. Therapist stabilizes the first metacarpal firmly, allowing motion to occur only at the MP joint. If the patient moves proximal phalanx of the thumb through full range of extension, it shows grade III power.
 
EXTENSOR POLLICIS LONGUS
Origin: Ulna (middle 3rd of posterior surface), interosseous membrane.
Insertion: Dorsal surface of distal phalanx of thumb.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Extends thumb and wrist, abducts wrist.
MMT: Same as for extensor pollicis brevis.
 
EXTERNAL OBLIQUE
Origin: Ribs 5–12 (interdigitating on external and inferior surface).
Insertion: Iliac (rest outer border) thoracolumbar fascia, linea alba, aponeurosis from 9th costal 226cartilage to ASIS, both sides meet at midline to form linea alba, pubic symphysis (upper border).
Nerve: Ventral rami of lower six thoracic nerve (T7–T12).
Action: Flexes, laterally flexes and rotates trunk.
MMT: Patient in supine with arms outstretched above plane of body. Ask the patient to lift your head and shoulders from the table taking your right elbow toward your left knee. Then lift the shoulder from the table, taking your left elbow towards right knee. The patient is able to perform this at full range, it shows grade III power.
 
FLEXOR CARPI RADIALIS
Origin: Medial epicondyle via common flexor tendon.
Insertion: Front of base of second and third metacarpals.
Nerve: Median (C6, C7).
Action: Flexes and abducts wrist.
MMT: Patient in short sitting forearm is supported on its dorsal surface in a table. To start, forearm is supinated and wrist is in neutral position. The therapist supports the patient's forearm under the wrist. The patient flexes the wrist in radial deviation. Full range of motion without resistance shows grade III power.227
 
FLEXOR CARPI ULNARIS
Origin: Humeral head: Medial epicondyle via common flexor tendon.
Ulnar head: Medial border of olecranon and upper 2/3rd of border of ulna.
Insertion: Pisiform, hook of hamate and base of fifth metacarpal.
Nerve: Ulnar nerve (C7–T1).
Action: Flexes and adducts wrist.
MMT: Patient's and therapist's position same as for flexor carpi radialis. Patient flexes the wrist in ulnar deviation. Full range of motion without resistance shows grade III power.
 
FLEXOR DIGITI MINIMI BREVIS (FOOT)
Origin: Plantar aspect of base of fifth metatarsal, sheath of peroneus longus tendon.
Insertion: Lateral side of base of proximal phalanx of fifth toe.
Nerve: Lateral plantar nerve (S2, S3).
Action: Flexes fifth metatarsophalangeal joint, supports lateral longitudinal arch.
 
FLEXOR DIGITI MINIMI BREVIS (HAND)
Origin: Hook of hamate, flexor retinaculum.
Insertion: Ulnar side of base of proximal phalanx of little finger.
228Nerve: Ulnar nerve (C8, T1).
Action: Flexes little finger.
 
FLEXOR DIGITORUM ACCESSORIUS
Origin: Medial head—medial tubercle of calcaneus, lateral head—lateral tubercle of calcaneus and long plantar ligament.
Insertion: Flexor digitorum longus tendon.
Nerve: Lateral plantar nerve (S1–S3).
Action: Flexes distal phalanges of lateral fourth toes.
 
FLEXOR DIGITORUM BREVIS
Origin: Calcaneal tuberosity, plantar aponeurosis, intermuscular septa.
Insertion: Tendons divide and attach to the both sides of the middle phalanges of second to fifth toes.
Nerve: Medial plantar nerve (S1, S2).
Action: Flexes proximal interphalangeal joints and metatarsophalangeal joints of lateral four toes.
MMT: Patients in short sitting with foot on examiner's lap or supine. Therapist sitting on short stool in front of patient or standing at side of table near patient's foot. His one hand grasp the anterior foot with the finger's placed across the dorsum of the foot and the thumb under the 229proximal phalanges or digital phalanges. Patient is asked to flex the toes. Full range of flexion without resistance shows grade III power.
 
FLEXOR DIGITORUM LONGUS
Origin: Medial part of posterior surface of tibia, deep transverse fascia.
Insertion: Plantar aspect of base of distal phalanges of second to fifth toes.
Nerve: Tibial nerve (L5–S2).
Action: Flexes lateral four toes, plantar flexes ankle.
MMT: Same as for flexor digitorum brevis.
 
FLEXOR DIGITORUM PROFUNDUS
Origin: Ulna (proximal 3/4th of anterior and medial shaft, medial coracoid process), interosseous membrane (ulnar).
Insertion: Four tendons to digits 2–5 (distal phalanges, at the base of palmar surface).
Nerve: Medial part—ulnar nerve (C8, T1).
Lateral part—anterior interosseous branch of median nerve (C8,T1).
Action: Flexes fingers and wrist.
MMT: Patient's forearm in supination, wrist in neutral and PIP joint in extension. Therapist stabilizes middle phalanx in extension by 230grasping in on either side. Patient flexes distal phalanx of each finger individually. Full range of motion without resistance shows grade III power.
 
FLEXOR DIGITORUM SUPERFICIALIS
Origin: Humero-ulnar head—humerus (medial epicondyle via common flexion tendon).
Ulna (medial collateral ligament of elbow joint); coronoid process (medial side).
Intermuscular septum.
Radial head—radius (oblique line on anterior shaft).
Insertion: Four tendon arranged in two pairs:
Superficial pair—middle and ring fingers (side of the middle phalanges).
Deep pair—index and little fingers (side of middle phalanges).
Nerve: Median (C8, T1).
Action: Flexes fingers and wrist.
MMT: Patient's forearm supinated, wrist at neutral, finger to be tested is in slight flexion at the MP joint. Therapist holds all fingers (except one being tested) in extension at all joints. Isolation of the index finger may not be complete. Each of four fingers is tested separately. Patient flexes the PIP joint without flexing the DIP joint. Do not allow motion of any joint of the other fingers. Flick the terminal end of the finger being tested with the thumb to make certain that the 231flexor digitorum profundus is not active; that is the DIP joint goes into extension. The distal phalanx should be floppy. Ask the patient “bend your index [then long, ring or little] finger, hold it. Full range of motion without resistance shows grade III power.
 
FLEXOR HALLUCIS BREVIS
Origin: Medial side of plantar surface of cuboid, lateral cuneiform.
Insertion: Medial and lateral side of base of proximal phalanx of great toe.
Nerve: Medial plantar nerve (S1, S2).
Action: Flexes metatarsophalangeal joint of great toe.
MMT: Patient in short sitting, with legs hanging over edge of table. Ankle is in neutral position, therapist sitting on low stool infront of patient. Test foot rests on examiner's lap. One hand is contoured over the dorsum, of the foot just below the ankle for stabilization. The index finger of the other hand is placed beneath the proximal phalanx of the great toe alternatively, the tip of the finger is placed up under the proximal phalanx. Patient flexes great toe. Full range of great toe flexion shows grade III power.
 
GASTROCNEMIUS
Origin: Medial head—femur (posterior part of medial condyle).
232Lateral head—femur (lateral surface of lateral condyle).
Insertion: Posterior surface of calcaneus.
Nerve: Tibial nerve (S1, S2).
Action: Plantar flexes ankle, flexes knee.
MMT: The patient stands over testing limb with one or two fingers supported over a table. Patient attempts to raise heel from base consecutively through full range of plantar flexion. Ask him to “stand on your right leg. Go up on your tiptoes. Now down. Repeat this 20 times”. If the patient completes nine times or above and one heel raise correctly with no rest or fatigue it shows grade III power.
Stretching: Standing on the steps with the ball of the toes.
 
GEMELLUS INFERIOR
Origin: Upper part of ischial tuberosity.
Insertion: With obturator internus tendon into medial surface of greater trochanter.
Nerve: Nerve to quadratus femoris (L5, S1).
Action: Laterally rotates hip.
MMT: Patient is in short sitting. The therapist sit over a low stool towards the testing limb. One hand is contoured over the distal thigh (lateral 233aspect). Patient attempts to externally rotate the hip. If the patient can hold the end position, it shows grade III power.
Stretching: Patient is supine, lying with hip and knee joint of testing limb in 90°. Therapist is standing beside the patient and facing the hip joint. His left hand stabilizes the thigh of the patient, while his right hand is grasping the lower leg. Therapist performs medial rotation.
 
GEMELLUS SUPERIOR
Origin: Ischial spine (gluteal surface).
Insertion: Greater trochanter (with obturator internus tendon into medial surface).
Nerve: Nerve to obturator internus (L5, S1).
Action: Laterally rotates hip.
MMT and stretching: Same as G. inferior.
 
GLUTEUS MAXIMUS
Origin: Ilium (posterior gluteal line, posterior border, adjacent part of iliac crest), aponeurosis of erector spinae, sacrum (posterior aspect) side of coccyx, sacrotuberous ligament, gluteal aponeurosis.
Insertion: Iliotibial tract of fascia lata, femur (gluteal tuberosity).
Nerve: Inferior gluteal nerve (L5–S2).
234Action: Extends, laterally rotates and abducts hip.
MMT: Patient is on prone lying. Therapist stands at side of testing limb at the level of pelvis. Ask patient to lift the leg towards ceiling. If the patient can hold the full range of motion, it shows grade III power.
Stretching: (Passive): Patient lies supine. Therapist stands beside the patient and facing the limb. Therapists right hand grasping the ankle while his left hand holds the knee posteriorly. The leg is lifted with hip and knee flexed, towards the cranial side of the patient.
Self-stretching
Position: Knee sitting.
Procedure: Patient flexing hip and knee himself, in supine with the help of both hands.
 
GLUTEUS MEDIUS
Origin: Gluteal surface of ilium between posterior and anterior gluteal line.
Insertion: Greater trochanter (anterolateral ridge).
Nerve: Superior gluteal nerve (L4–S1).
Action: Abducts and medially rotates hip.
MMT: Patient in side-lying with testing leg in uppermost position. The therapist stands behind patient. For palpating the muscle, he puts his hand just proximal to the greater trochanter of the femur. Ask him to abduct hip through complete 235range of motion without flexed hip or rotation. Full range of motion and holds at end position, shows grade III power.
Stretching: Patient lies supine. Therapist stands beside the patient and faces the hip joint. Therapist left hand stabilizes the opposite leg of patient, while his right hand grasping lower thigh, therapist right hand pushes the leg inside.
 
GLUTEUS MINIMUS
Origin: Ilium (gluteal surface between anterior and inferior gluteal lines).
Insertion: Anterior lateral ridge on greater trochanter.
Nerve: Superior gluteal nerve (L4–S1).
Action: Abducts and medially rotates hip.
MMT and stretching: Same as G. medius.
 
GRACILIS
Origin: Pubis (interior ramus and lower half of body), adjacent ischial ramus.
Insertion: Tibia (upper part of medial surface).
Nerve: Obturator nerve (L2, L3).
Action: Flexes knee, adducts hip, medially rotates tibia on femur.
MMT: Same as for hip adductors.
Stretching: Patient in supine lying. Therapist stand 236beside the patient and facing the hip joint. His left hand stabilizes the opposite leg, while his right hand grasping the lower thigh and the leg is placed on the therapist forearm. Leg is pulled apart by the therapist's right hand.
 
ILIACUS
Origin: Iliacus fossa (superior 2/3), iliac crest (inner lip), ala of sacrum, sacroiliac and iliolumbar ligaments.
Insertion: Blends with insertion of psoas major into lesser trochanter.
Nerve: Femoral nerve (L2, L3).
Action: Flexes hip and trunk.
MMT: Patient in short sitting with thigh over table and leg hanging at the edge. Therapist stands at the testing side. Ask the patient to lift off his leg. Full range of motion, shows grade III power.
Stretching: Patient in side-lying. Therapist is standing beside the patient, facing the hip joint. Therapist's left hand stabilizes the patient pelvis, while his right hand grasping the upper thigh and the leg is resting on the forearm of the therapist. Patients thigh is lifted by the therapist's right hand and performing the extension movement of the hip.
 
ILIOCOSTALIS CERVICIS
Origin: Angles of third to sixth ribs.
237Insertion: Posterior tubercles of transverse process of C4 to C6.
Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral.
MMT: Patient in prone with head off at the edge of table. Therapist puts one hand below patient's forehead. Ask patient to extend neck without tilting chin, or looking up full range of motion, shows grade III power.
 
ILIOCOSTALIS LUMBORUM
Origin: Sacral crest (medial and lateral) spines of T11, T12 and lumbar vertebrae and their supraspinous ligament, medial part of iliac crest.
Insertion: Angle of lower six or seventh ribs.
Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral column.
MMT: Patient in prone with arms at side. Therapist stands at side of table, stabilizing lower extremities just above the ankle. Ask patient to raise his head, arms, and chest from the table as high as he can. Full range of motion, shows grade III power.
Stretching: Patient in long sitting. Ask him to put his hands together in front of his foot and try to cross the toes by his finger as much as he can, looking towards his lower legs.238
 
ILIOCOSTALIS THORACIS
Origin: Angle of lower six ribs.
Insertion: Angle of upper six ribs, transverse process of C7.
Nerve: Dorsal rami.
Action: Extend and laterally flexes vertebral column.
MMT: Same as for iliocostalis lumborum.
 
INFERIOR OBLIQUE
Origin: Lamina of axis.
Insertion: Transverse process of atlas.
Nerve: Dorsal ramus (C1).
Action: Rotates atlas and head.
 
INFRASPINATUS
Origin: Infraspinous fossa and its medial 2/3.
Insertion: Humerus (middle facet on greater tubercle), shoulder joint (posterior aspect of capsule).
Nerve: Suprascapular nerve (C5, C6).
Action: Laterally rotates shoulder.
MMT: Patient prone with head turned towards test side. Abduct the shoulder to 90° with arms supported on table. Forearm hanging vertically over the edge. Place folded towel under the arm 239at the edge. Ask patient to move forearm upwards through the range of external rotation. Full range of motion, shows grade III power.
Stretching: Patient in supine lying. Therapist stands beside patient and faces the limb. The therapist now grasps the lower arm of the patient with his left hand and with right hand grasping the wrist and applying the stretch force towards the medial rotation.
 
INTERCOSTALIS EXTERNI
Origin: Lower border of the rib above.
Insertion: Upper border of the rib below.
Nerve: Intercostal nerves.
Action: Elevate ribs below towards rib above to increase thoracic cavity volume for inspiration.
MMT: Patient lies supine. Therapist stands at the side. Tape measure placed lightly around thorax at level of xiphoid. Ask patient to hold maximal inspiration for measurement and then hold maximal expiration for a second measurement. The difference between the two measurements is recorded as chest expansion.
 
INTERCOSTALIS INTERNI
Origin: Lower border of costal cartilage and costal groove of rib above.
Insertion: Upper border of rib below.
240Nerve: Intercostal nerves.
Action: Draw ribs downwards to decrease thoracic cavity volume for expiration.
MMT: Same as for I. externi.
 
INTERNAL OBLIQUE
Origin: Inguinal ligament (lateral 2/3), iliac crest (anterior 2/3 of intermediate line), thoracolumbar fascia.
Insertion: Lower four ribs and their cartilages, pubic crest, abdominal aponeurosis to linea alba.
Nerve: Ventral rami of lower six thoracic nerves, first lumbar nerve.
Action: Flexes, lateral flexes and rotates trunk.
MMT: Patient is supine with arms outstretched in full extension above the plane of body. Ask patient to raise his head, shoulders and arm off the table. Full range of motion, shows grade III power.
Stretching: Patient lies prone on table. Ask him to lift his head, shoulder and upper trunk as much as possible and turn towards one side to look at the ceiling of that side. The opposite side of the muscle will feel stretch.
 
INTERSPINALIS
Origin and insertion: Extend between adjacent spinous processes.
241Nerve: Dorsal rami of spinal nerves.
Action: Extend and stabilize vertebral column.
MMT: Same as for iliocostalis muscles.
 
INTERTRANSVERSARII
Origin: Cervical and lumbar vertebrae (transverse process).
Insertion: Transverse process of vertebra, superior to origin.
Nerve: Ventral and dorsal rami of spinal nerve.
Action: Laterally flex lumbar and cervical spine, stabilize vertebral column.
 
ISCHIOCAVERNOSUS
 
In the female
Origin: Ischium (tuberosity and ramus), crus clitoridis (surface).
Insertion: Aponeurosis inserting into side and inferior surface of crus clitoridis.
Nerve: Pudendal nerve (S2–S4).
Action: Compress crus clitoridis, retarding venous return and thus assisting erection.
 
In the male
Origin: Ischium (tuberosity, medial aspect dorsal to crus penis and ischial rami).
242Insertion: Aponeurosis into the sides and under surface of the body of the penis.
Nerve: S2–S4 spinal nerves (pudendal nerve, perineal branch, ventral rami).
Action: Compression of crus penis, maintaining erection by retarding return of blood through the veins.
 
LATERAL CRICOARYTENOID
Origin: Cricoid cartilage (cranial border of arch).
Insertion: Arytenoid cartilage on same side (front of muscular process).
Nerve: Vagus (X) nerve (recurrent laryngeal branch).
Action: Closes glottis by rotating arytenoid cartilages medially, approximating (adducting) the vocal folds for speech.
 
LATISSIMUS DORSI
Origin: Spinous process of lower six thoracic and all lumbar and sacral vertebrae, intervening supra and interspinous ligament, outer lip of iliac crest, outer surface of lower three or four ribs, inferior angle of scapula.
Insertion: Intertubercular sulcus of humerus.
Nerve: Thoracodorsal nerve (C6–C8).
243Action: Extends, adducts and medially rotates shoulder.
MMT: Patient prone with head turned to one side. Arms at side; test arm is internally rotated (palm up). Therapist stands at test side. Ask the patient to push his arm towards feet (reach down toward your feet). If the patient completes full range of motion, with no resistance, it shows grade III power.
Stretching: Patient in supine lying. Therapist stands beside the patient and facing the limb. Therapist left hand grasps the lower arm region and the patient's forearm resting over the therapist forearm. Therapists right hand apply opposite force on the scapular region to prevent scapular movement. Stretch force is given towards the flexion of the shoulder with the therapists left hand.
 
LEVATOR SCAPULAE
Origin: C1–C3/C4 (transverse processes).
Insertion: Scapula (medial border between superior angle and base of spine).
Nerve: Ventral rami (C3, C4) dorsal scapular nerve (C5).
Action: Elevates, medially rotates and retracts scapula, extends and laterally flexes neck.244
 
LONGISSIMUS CAPITIS
Origin: T1–T4,5 (transverse process) articular process of C4/5–C7.
Insertion: Posterior aspect of mastoid process.
Nerve: Dorsal rami.
Action: Extends, laterally flexes and rotates head.
MMT: Patient prone with head off the end of table. Arm at side. Therapist standing next to patient's head with one hand supporting the forehead.
Ask the patient to lift your forehead from my hand and keep looking at the floor. Full range of motion, shows grade III power.
 
LONGISSIMUS CERVICIS
Origin: Transverse process of T1–T4/5.
Insertion: Transverse process of C2–C6.
Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral column.
MMT: Same as for L. capitis.
 
LONGISSIMUS THORACIS
Origin: Transverse and accessory process of lumbar vertebrae and thoracolumbar fascia.
Insertion: Transverse processes of T1–T12 and lower nine or ten ribs.
245Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral column.
MMT: Same as for iliocostalis thoracic.
 
LONGUS CAPITIS
Origin: Occipital bone.
Insertion: Anterior tubercles of transverse processes of C3–C6.
Nerve: Anterior primary rami (C1–C3).
Action: Flexes neck.
MMT: Patient in supine with head supported on table. Arm at side. Therapist stands at head of the table facing patient. Ask patient to tuck his chin into his neck. Do not raise his head from table. If patient completes available ROM without resistance, it shows grade III power.
 
LONGUS COLLI
Origin: T1–T2/3 (inferior oblique part, front of bodies).
T1–T3 and C5–C7 (vertical intermediate part front of bodies).
C3–C5 (superior oblique part—anterior tubercles of transverse process).
Insertion: C5 and C5 (inferior oblique part–anterior tubercles of transverse process), C2–C4 (vertical 246intermediate part: front of bodies); superior oblique part—anterior tubercle of atlas.
Nerve: Anterior primary rami (C2–C6).
Action: Flexes neck.
MMT: Patient supine with arms at side. Patient flexes neck, keeping eyes on the ceiling. If the patient completes available range of motion, it shows grade III power.
 
LUMBRICALS (FOOT)
Origin: Tendon of flexor digitorum longus.
Insertion: Medial side of extensor hood and base of proximal phalanx of lateral four toes.
Nerve: First lumbrical-medial plantar nerve (S2, S3), Lateral three lumbrical-lateral plantar nerve (S2, S3).
Action: Flexes metatarsophalangeal joint and extends interphalangeal joint of lateral four toes.
MMT: Patient short sitting with foot on examiner's lap. Therapist sitting on low stool in front of patient, his hand grasps the dorsum of the foot just below the ankle to provide stabilization. The index finger of the other hand is placed under the MP joints of the four lateral toes to provide resistance to flexion. Ask the patient to bend your toes over my finger. Full range of motion without resistance, shows grade III power.247
 
LUMBRICALS (HAND)
Origin: Tendons of flexor digitorum profundus.
Insertion: Lateral margin of dorsal digital expansion of extensor digitorum.
Nerve: I and II—median nerve (C8, T1).
III and IV—ulnar nerve (C8, T1).
Action: Flexes metacarpophalangeal joint and extends interphalangeal joints of fingers.
MMT: Patient short sitting with forearm in supination. Wrist is maintained in neutral. The MP joints are flexed. Therapist stabilizes the metacarpals proximal to the MP joints, resistance is given on the palmar surface of the proximal row of phalanges in the direction of MP extension. Ask patient to simultaneously flex the MP joint and extend the IP joints. If the patient completes both motions correctly and simultaneously without resistance, it shows grade III power.
 
MULTIFIDUS
Origin: Back of sacrum, aponeurosis of erector spinae, posterior superior iliac spine, dorsal sacroiliac ligaments, mamillary processes in lumbar region, all thoracic transverse process, articular process of lower four cervical vertebrae.
Insertion: Spines of all vertebrae from L5 to axis.
Nerve: Dorsal rami of spinal nerves.
248Action: Extends, rotates and laterally flexes vertebral column.
MMT: Same as for interspinales and intertransversarii.
 
OBTURATOR EXTERNUS
Origin: Outer surface of obturator membrane and adjacent bone of pubic and ischial rami.
Insertion: Trochanteric fossa of femur.
Nerve: Posterior branch of obturator nerve (L3, L4).
Action: Laterally rotates hip.
MMT: Patient in short sitting. Therapist sits on a low stool or kneels beside limb to be tested. Ask the patient to turn his leg in full range of motion, shows grade III power.
 
OBTURATOR INTERNUS
Origin: Internal surface of obturator membrane and surrounding bony margin.
Insertion: Medial surface of greater trochanter.
Nerve: Nerve to obturator internus (L5, S1).
Action: Laterally rotates hip.
MMT: Same as for O. externus.
 
OPPONENS DIGITI MINIMI
Origin: Hook of hamate; flexor retinaculum.
Insertion: Medial border of fifth metacarpal.
249Nerve: Ulnar nerve (C8, T1).
Action: Abducts fifth digit, pulls it forwards and rotates it laterally.
MMT: Patient's forearm supinated, wrist in neutral. He raises the thumb away from the palm and rotates it, so that its distal phalanx opposes the distal phalanx of the little finger. Opposition must be pad to pad. It the patient moves thumb and 5th digit through full range of opposition with no resistance, it shows grade III power.
 
OPPONENS POLLICIS
Origin: Flexor retinaculum, tubercles of scaphoid and trapezium, abductor pollicis longus tendon.
Insertion: Radial side of base of proximal phalanx of thumb.
Nerve: Median nerve (C8, T1).
Action: Rotates thumb into opposition with fingers.
MMT: Patient forearm supinated, wrist in neutral position, thumb in adduction with MP and IP flexion. Therapist stabilizes the hand by holding the wrist on the dorsal surface. If the patient moves thumb and 5th digit through full range of opposition with no resistance, it shows grade III power.250
 
PALMAR INTEROSSEI
Origin: Shaft of metacarpal of digit on which it acts.
Insertion: Dorsal digital expansion and base of proximal phalanx of same digit.
Nerve: Ulnar nerve (C8, T1).
Action: Adducts thumb, index, ring and little finger.
MMT: Patient's forearm pronated, wrist in neutral and fingers extended and adducted. MP joints are neutral; avoid flexion. Ask patient to hold his fingers together. If the patient can adduct finger towards middle finger, but cannot hold against resistance, it shows grade III power.
 
PALMARIS LONGUS
Origin: Medial epicondyl via common flexor tendon.
Insertion: Flexor retinaculum, palmar aponeurosis.
Nerve: Median (C7, C8).
Action: Flexes wrist.
Stretching: Patient is sitting on stool. Therapist is standing beside the patient and facing his wrist. Therapist left hand grasping the lower forearm of the patient, while his right hand grasps the palm and fingers.The therapist extends the wrist of the patient with his right hand.251
 
PECTINEUS
Origin: Pecten pubis, iliopectineal eminence, pubic tubercle.
Insertion: Along a line from lesser trochanter to linea aspera.
Nerve: Femoral nerve (L2,3) occasionally accessory obturator (L3).
Action: Flexes and adducts hip.
MMT: Same as for adductors of hip.
 
PECTORALIS MAJOR
Origin: Clavicular attachment—sternal half of anterior surface of clavicle sternocostal attachment—anterior surface of manubrium, body of sternum, upper six costal cartilages, sixth rib, aponeurosis of external oblique muscle.
Insertion: Lateral lip of intertubercular sulcus of humerus.
Nerve: Medial and lateral pectoral nerve (C5-T1).
Action: Adducts, medially rotates, flexes and extends shoulder.
MMT: Patient lies supine, shoulder at 90° of abduction and elbow 90° of flexion. Therapist stands at side of testing shoulder. For testing both heads of P. major, ask the patient to move his arm across his chest and hold it. Full range of motion, without resistance shows grade III power.252
 
PECTORALIS MINOR
Origin: Outer surface of third to fifth ribs and adjoining intercostal fascia.
Insertion: Upper surface and medial border of coracoid process.
Nerve: Medial and lateral pectoral nerves (C5–T1).
Action: Protracts and medially rotates scapula.
 
PERONEUS BREVIS
Origin: Lower 2/3 of lateral surface at fibula, intermuscular septa.
Insertion: Lateral side of base of fifth metatarsal.
Nerve: Superficial peroneal nerve (L5, S1).
Action: Everts and plantar flexes ankle.
MMT: Patient in short sitting with ankle in neutral position. Therapist sitting on low stool in front of patient or standing at end of table, if patient is supine.
His one hand grips the ankle just above the malleoli for stabilization. Ask patient to turn your foot down and out, hold it. If the patient completes available range of eversion, it shows grade III power.
Stretching: Assisted full range of inversion in sitting or supine position.253
 
PERONEUS LONGUS
Origin: Lateral tibial condyle, upper 2/3 of lateral surface of fibula, intermuscular septa.
Insertion: Lateral side of base of first metatarsal, medial cuneiform.
Nerve: Superficial peroneal nerve (L5, S1).
Action: Everts and plantar flexes ankle.
MMT: Same as for peroneus brevis.
 
PERONEUS TERTIUS
Origin: Distal third of medial surface of fibula, interosseous membrane, intermuscular septum.
Insertion: Medial aspect of base of fifth metatarsal.
Nerve: Deep peroneal nerve (L5, S1).
Action: Everts and dorsiflexes ankle.
MMT: Same as for peroneus longus.
 
PIRIFORMIS
Origin: Front of second to fourth sacral segment, gluteal surface of ilium, pelvic surface of sacrotuberous ligament.
Insertion: Medial side of greater trochanter.
Nerve: Anterior rami of sacral plexus (L5–S2).
Action: Laterally rotates and abducts hip.
MMT: Same as for obturators internus and externus.254
 
PLANTAR INTEROSSEI
Origin: Base and medial side of lateral three toes.
Insertion: Medial side of base of proximal phalanx of same toes and dorsal digital expansions.
Nerve: Lateral plantar nerve (S2, S3).
Action: Adduct third to fifth toes, flex metatarsophalangeal joints of lateral three toes.
 
PLANTARIS
Origin: Lateral supra condylar ridge, oblique popliteal ligament.
Insertion: Tendocalcaneus.
Nerve: Tibial nerve (S1, S2).
Action: Plantar flexes ankle, flexes knee.
 
POPLITEUS
Origin: Outer surface of lateral femoral condyle.
Insertion: Posterior surface of tibia above soleal line.
Nerve: Tibial nerve (L4–S1).
Action: Medially rotates tibia, flexes knee.
Stretching: Patient on side lying, with testing limb (right) upward. Therapist stands behind the patient's left hand over anterior thigh just proximal to knee. His right hand just around the posterior side of the ankle joint from his left hand, 255he pushes the knee joint towards himself and with his right hand, he attempts to pull the leg away from him and rotates it upwards, so that the toes face towards ceiling.
 
PRONATOR QUADRATUS
Origin: Ulna (lower quarter of anterior surface).
Insertion: Radius (lower quarter of anterior surface).
Nerve: Anterior interosseous branch of median nerve (C7, C8).
Action: Pronates forearm.
MMT: Patient short sitting over a table. Arms at side with elbow flexed to 90° and forearm in supination. Therapist standing at side or in front of patient. Support the elbow, ask the patient to turn the palm down and hold it. If the patient completes available range of motion it shows grade III power.
 
PRONATOR TERES
Origin: Humeral head—medial epicondyle via common flexor tendon, intermuscular septum, antebrachial fascia, ulnar head—medial part of coronoid process.
Insertion: Middle of lateral surface of radius.
Nerve: Median nerve (C6, C7).256
Action: Pronates forearm, flexes elbow.
MMT: Same as for pronator quadratus.
 
PSOAS MAJOR
Origin: Bodies of T12 and all lumbar vertebrae, bases of transverse processes of all lumbar vertebrae, lumbar intervertebral disks.
Insertion: Lesser trochanter.
Nerve: Anterior rami of lumbar plexus (L1–L3).
Action: Flexes hip and lumbar spine.
MMT: Same as for iliacus.
 
PSOAS MINOR (NOT ALWAYS PRESENT)
Origin: Bodies of T12 and L1 vertebrae and intervertebral disks.
Insertion: Pecten pubis, iliopubic eminence, iliac fossa.
Nerve: Anterior primary ramus (L1).
Action: Flexes trunk (weak).
MMT: Same as for psoas major.
 
QUADRATUS FEMORIS
Origin: Ischial tuberosity.
Insertion: Quadrate tubercle midway down intertrochanteric crest.
Nerve: Nerve to quadratus femoris (L5, S1).
257Action: Laterally rotates hip.
MMT: Same as for obturator and piriformis.
 
QUADRATUS LUMBORUM
Origin: Iliolumbar ligament, posterior part of iliac crest.
Insertion: Lower border of 12th rib, transverse process of L1–L4.
Nerve: Ventral rami of T12 and L1–L3,4.
Action: Laterally flexes trunk, extends lumbar vertebrae, steadies 12th rib during deep inspiration.
MMT: Same as for interspinales lumborum.
 
RECTUS ABDOMINIS
Origin: Symphysis pubis, pubic crest.
Insertion: 5th–7th costal cartilages, xiphoid process.
Nerve: Central rami T6,7–T12.
Action: Flexes trunk.
MMT: Patient supine with arms outstretched in full extension above plane of body. Instruct the patient to raise your head, shoulders and arms off the table. Full range of motion till inferior angle of scapulae are off the table, shows grade III power.258
 
RECTUS CAPITIS ANTERIOR
Origin: Anterior surface of lateral mass of atlas and root of its transverse process.
Insertion: Occipital bone.
Nerve: Anterior primary rami (C1, C2).
Action: Flexes neck.
MMT: Same as for longus capitis.
 
RECTUS CAPITIS LATERALIS
Origin: Atlas (transverse process).
Insertion: Jugular process of occipital bone.
Nerve: Ventral rami (C1, C2).
Action: Laterally flexes neck.
MMT: Same as for rectus capitis anterior.
 
RECTUS CAPITIS POSTERIOR MAJOR
Origin: Axis (spinous process).
Insertion: Occipital bone (lateral part of inferior nuchal line).
Nerve: Dorsal ramus (C1).
Action: Extends and rotates neck.
MMT: Same as for longissimus capitis.
 
RECTUS CAPITIS POSTERIOR MINOR
Origin: Atlas (posterior tubercle).
259Insertion: Medial part of inferior nuchal line of occipital bone.
Nerve: Dorsal ramus (C1).
Action: Extends neck.
MMT: Same as for longissimus capitis.
 
RECTUS FEMORIS
Origin: Straight head—anterior inferior iliac spine; Reflected head—area above acetabulum, capsule of hip joint.
Insertion: Base of patella, then forms part of patellar ligaments.
Nerve: Femoral nerve (L2–L4).
Action: Extends knee, flexes hip.
MMT: MMT of rectus femoris is carried out jointly as for quadriceps femoris.
Patient in short sitting place wedge under the distal thigh to maintain the femur in the horizontal position. Patient should lean backward to relieve hamstring muscle tension. Therapist standing at side of testing limb. Ask patient to extend his knee through available range of motion, but not beyond 0°. If patient completes available range of motion and holds the position without resistance, its shows grade III power.
Stretching: Patient is in side lying with stretching limb in side. Therapist stand behind the patient at the level of his pelvis, keeping his one hand 260over pelvis to stabilize and one hand to support the knee. He then gradually pulls the limb in backward direction till a stretch is felt over anterior part of the thigh.
 
RHOMBOID MAJOR
Origin: T2–T5 [spines and supraspinous ligaments].
Insertion: Medial border of scapula between root of spine and inferior angle.
Nerve: Dorsal scapular nerve [C4, C5].
Action: Retracts and medially rotates scapula.
MMT: Patient on prone lying. Shoulder is internally rotated and arm is adducted across the back with elbow flexed and hand resting on the back. Ask the patient to lift his hand and hold it. Full range of motion shows grade III power.
 
RHOMBOID MINOR
Origin: C7–T1 (spine and supraspinous ligaments), lower part of ligamentum nuchae.
Insertion: Medial end of spine of scapula.
Nerve: Dorsal scapular nerve [C4, C5].
Action: Retracts and medially rotates scapula.
MMT: Same as for rhomboid major.
 
ROTATORES
Origin: Transverse process of each vertebra.
261Insertion: Lamina of vertebra above.
Nerve: Dorsal rami of spinal nerves.
Action: Extends vertebral column and rotates thoracic region.
 
SARTORIUS
Origin: Anterior superior iliac spine and area just below.
Insertion: Upper part of medial side of tibia.
Nerve: Femoral nerve [L2, L3].
Action: Flexes hip and knee, laterally rotates and abducts hip, medially rotates tibia on femur.
MMT: Short sitting with thigh supported on table and legs hanging over side. Ask Patient to side your heel up the shin of your other leg. Complete range of motion with hold at end position shows, grade III power.
 
SCALENUS ANTERIOR
Origin: C3–C6 [anterior tubercles of transverse process].
Insertion: Scalene tubercle on inner border of first rib.
Nerve: Ventral rami [C4–C6].
Action: Flexes, laterally flexes and rotates neck, raises first rib during respiration.
262MMT: Patient supine lying with head on table. Ask the patient to bring your head off the table, keeping your eyes on ceiling. Keep your shoulders completely on the table. Full range of motion without resistance, show grade III power.
 
SCALENUS MEDIUS
Origin: Atlas and axix (transverse process), C3–C7 (posterior tubercles of transverse processes).
Insertion: Upper surface of first rib.
Nerve: Ventral rami (C3–C8).
Action: Laterally flexes neck, raises first rib during respiration.
MMT: Patient supine with cervical spine in neutral. Ask patient to turn your head and face the ceiling and hold it. If the patient rotates head through full range to both right and left without resistance, it shows grade III power.
 
SCALENUS POSTERIOR
Origin: C4–C6 [posterior tubercles of transverse process].
Insertion: Outer surface of second rib.
Nerve: Ventral rami [C6–C8].
Action: Laterally flexes neck, raises second rib during respiration.
263MMT: Same as for scalenus medius.
 
SEMIMEMBRANOSUS
Origin: Ischial tuberosity
Insertion: Posterior aspect of medial tibial condyle.
Nerve: Tibial division of sciatic nerve [L5–S2].
Action: Flexes knee, extends hip and medially rotates tibia on femur.
MMT: Patient in prone lying. Therapist stands beside the patient. Ask the patient to lift the leg off the table, as high as without bending the knee. If the patient completes full range of motion and hold the position without resistance, it shows grade III power.
Stretching: Patient in supine lying. Therapist stands beside the patient and facing the hip joint. Therapist grasps lower leg region of the patient with his right hand, while his left hand grasps the patient's knee. He flexes the patients hip and knee with his both hands.
 
SEMISPINALIS CAPITIS
Origin: C7–T6/7 (transverse process).
C4–C6 (articular process).
Insertion: Between superior and inferior nuchal lines of occipital bone.
Nerve: Dorsal rami of spinal nerve.
Action: Extends and rotates head.
264MMT: Patients prone with head off end of table. Arm at sides.
Therapist standing next to patients head with one head supporting (or ready to support the forehead). Ask the patient to look at the wall in front. If the patient completes range of motion, but takes no resistance, it shows grade III power.
 
SEMISPINALIS CERVICIS
Origin: T1–T5/6 (transverse processes).
Insertion: Spinous process of C2–C5.
Nerve: Dorsal rami of spinal nerve.
Action: Extends and rotates vertebral column.
MMT: Patient in prone lying with head off end of table. Arm at side. Therapist standing next to patient's head with one hand supporting the forehead. Ask the patient to lift forehead and keep looking at floor. If the patient completes the full range without resistance, it shows grade III power.
 
SEMISPINALIS THORACIS
Origin: T6–T10 (transverse processes).
Insertion: C6–T4 spinous processes.
Nerve: Dorsal rami of spinal nerve.
Action: Extends and rotates vertebral column.
265MMT: Prone with arm at sides. Therapist standing at side of table. Lower extremities are stabilized just above the ankle. Ask the patient to raise your head arm and chest from the table as high as you can.
 
SEMITENDINOSUS
Origin: Ischial tuberosity.
Insertion: Tibia (upper part of medial surface).
Nerve: Tibial division of sciatic nerve (L5–S2).
Action: Flexes knee, extends hip and medially rotates tibia on femur.
MMT: Same as for semimembranosus.
Stretching: Same as for semimembranosus.
 
SERRATUS ANTERIOR
Origin: Outer surface and superior border of upper eight, nine or ten ribs and intervening intercostal fascia.
Insertion: Costal surface of medial border of scapula.
Nerve: Long thoracic nerve (C5–C7).
Action: Protracts and laterally rotates scapula.
MMT: Patient in short sitting over end or side of table. Hands on lap. Therapist standing at test side of patient. Hand giving resistance is on the arm proximal to the elbow. The other hand uses the 266webspace along with the thumb and index finger to palpate the edges of the scapula at the inferior angle and along the vertebral and axillary borders. Ask the patient to raise arm forward over head, keep the elbow straight; hold it, do not let push your arm down. If patient's scapula moves through full range of motion without winging but can tolerate no resistance other than the weight of the arm.
 
SOLEUS
Origin: Soleal line and middle third of medial border of tibia, posterior surface of head and upper quarter of fibula, fibrous arch between tibia and fibula.
Insertion: Posterior surface of calcaneus.
Nerve: Tibial nerve (S1, S2).
Action: Plantar flexes ankle.
MMT: Patient standing on testing limb with knee slightly flexed. Use one or two finger for balance assist. Therapist standing or sitting with clear lateral view of test limb. Ask patient to stand on right leg with knee bent. Keep knee bent and go up and down on toes atleast 20 times. If the patient completes between nine and one correct heel rises, with the knee flexed then it shows grade III power.
Stretching: Patient in supine lying. Therapist standing beside the patient. The therapist holds 267the lower thigh region with his left hand and flexing the knee. The therapist's right hand holds the heel in neutral position. Slowly dorsiflex the ankle to full range.
 
SPINALIS (CAPITIS, CERVICIS, THORACIS)
Origin: Spinalis thoracis-spinous processes of T11–L2.
Insertion: Spinalis thoracis-spinous processes of upper four to eight thoracic vertebrae.
Nerve: Dorsal rami.
Action: Extends vertebral column.
MMT: Spinalis capitis and spinalis cervicis are poorly developed. So test is done for only spinalis thoracis. The test is same as for semispinalis thoracis.
 
SPLENIUS CAPITIS
Origin: Ligamentum nuchae (lower half), spinous processes of C7–T3/4 and their supraspinous ligaments.
Insertion: Mastoid process of temporal bone, lateral third of superior nuchal line of occipital bone.
Nerve: Dorsal rami (C3–C5).
Action: Extends, laterally flexes and rotates neck.
MMT: Same as for semispinalis capitis.268
 
SPLENIUS CERVICALS
Origin: T3 T6 (spinous processes).
Insertion: Posterior tubercles of transverse processes of C1–C3/4.
Nerve: Dorsal rami (C5–C7).
Action: Laterally flexes, rotates and extends neck.
MMT: Same as for semispinalis cervicis.
 
STERNOCLEIDOMASTOID
Origin: Sternal head-anterior surface of manubrium sterni, calvicular head—upper surface of medial third of clavicle.
Insertion: Mastoid process of temporal bone, lateral half of superior nuchal line of occipital bone.
Nerve: Accessory nerve (XI).
Action: Laterally flexes and rotates neck; anterior fibers flex neck, posterior fibers extend neck.
MMT: Same as for scalenus anterior.
 
SUBSCAPULARIS
Origin: Medial 2/3 of subscapular fossa and tendinous intramuscular septa.
Insertion: Lesser tubercle of humerus, anterior capsule of shoulder joint.
Nerve: Upper and lower subscapular nerve (C5, C6).
269Action: Medially rotates shoulder.
MMT: Patient prone with head turned towards test side. Shoulder is abducted to 90° with folded towel placed under distal arm and forearm hanging vertically over edge of table. Ask patient to move your forearm up and back and hold it. If the complete range is achieved, it shows grade III power.
Stretching: Patient is supine lying. Therapist is standing beside the patient and facing the limb. The therapist grasps the lower arm of patient with his left hand while his right hand grasping the wrist of the patient and applying the stretch force towards lateral rotation.
 
SUPERIOR OBLIQUE
Origin: Atlas (upper surface of transverse process).
Insertion: Superior and inferior nuchal lines of occipital bone.
Nerve: Dorsal ramus (C1).
Action: Extends neck.
 
SUPINATOR
Origin: Lateral epicondyle (inferior aspect), radial collateral ligament, annular ligament, supinator crest and fossa of ulna.
Insertion: Posterior, lateral and anterior aspects of upper third of radius.
270Nerve: Posterior interosseous nerve (C6, C7).
Action: Supinates forearm.
MMT: Patient in short sitting. Arm at side and elbow flexed to 90° forearm in pronation. Therapist stands at side and supports the elbow. Ask patient to turn your palm up. If the patient completes available range of motion without resistance, it shows grade III power.
Stretching: Patient in supine lying. Therapist is standing beside the patient and facing the limb. Therapist's left hand stabilizing the anterior aspect of proximal humerus of the patient. Therapist's right hand grasping the lower forearm, wrist and hand of the patient and elbow is in 90° flexed position. Therapist's right hand supinates and pronates the forearm and stretches the structures.
 
SUPRASPINATUS
Origin: Supraspinous fossa (medial 2/3) and supraspinous fascia.
Insertion: Capsule of shoulder joint, greater tubercle of humerus.
Nerve: Suprascapular nerve (C5, C6).
Action: Abducts shoulder.
MMT: Patient in short sitting with arm at side and elbow slightly flexed. Ask the patietnt to lift arm out to the side to shoulder level and hold it. If the 271patient completes the range of motion (90°), it shows grade III power.
 
TENSOR FASCIAE LATAE
Origin: Outer lip of iliac crest between iliac tubercle and anterior superior iliac spine.
Insertion: Iliotibial tract.
Nerve: Superior gluteal nerve (L4–S1).
Action: Extends knee, abducts and medially rotates hip.
MMT: Patient in side-lying, with testing limb in upper side and flexed to 45° and lies across the lowermost limb with the foot resting on the table.
Ask the patient to lift your leg and hold it. If the patient completes the movement and holds it without resistance, then it shows grade III power.
 
TERES MAJOR
Origin: Dorsal surface of inferior scapular angle.
Insertion: Medial lip of intertubercular sulcus of humerus.
Nerve: Lower subscapular nerve (C5, C7).
Action: Extends, adducts and medially rotates shoulder.
MMT: Patient in prone with head turned to one side, arm at side, test arm is internally rotated 272(palm up). Ask the patient to lift arm as high as you can. If the patient completes available range of motion without resistance, it shows grade III power.
Stretching: Patient in supine lying, therapist is standing beside the patient and facing the limb. The therapist grasps the lower arm region with his left hand and the patient forearm resting over the therapist forearm. Therapist right hand apply opposite force on the scapular region to prevent scapular movement. Stretch force is given towards the flexion of the shoulder with the therapist left hand.
 
TERES MINOR
Origin: Upper 2/3 of dorsal surface of scapula.
Insertion: Lower facet on greater tuberosity of humerus, lower posterior surface of capsule of shoulder joint.
Nerve: Axillary nerve (C5, C6).
Action: Laterally rotates shoulder.
MMT: Same as for infraspinatous.
Stretching: Patient in supine lying. Therapist is standing beside the patient and facing the limb. Therapist grasps the lower arm of the patient with his left hand and his right hand grasps the wrist and applying the stretch force towards the medial rotation.273
 
TIBIALIS ANTERIOR
Origin: Lateral tibial condyle and upper 2/3 of lateral surface of tibia, interosseous membrane.
Insertion: Medial and inferior surface of medial cuneiform, base of first metatarsal.
Nerve: Deep peroneal nerve (L4,5).
Action: Dorsiflexes and inverts ankle.
MMT: Patient in short sitting. Therapist sitting on stool in front of patient with patient's heel resting on thigh. Ask the patient to bring foot up and holds it. If the patient completes the available range of motion and holds it, shows grade III power.
Stretching: Patient in supine lying. Therapist is standing beside the patient and facing the ankle joint. The therapist left hand grasps the lower leg region and his right hand palm holding the heel of the patient. Therapist's right hand plantar flexes the ankle and stretches the tightened structures.
 
TIBIALIS POSTERIOR
Origin: Tibia (lateral aspect of posterior surface, below soleal line, interosseous membrane, upper half of posterior surface of fibula, deep transverse fascia).
Insertion: Tuberosity of navicular, medial cuneiform, sustentaculum tali, intermediate cuneiform, base of second to fourth metatarsals.
274Nerve: Tibial nerve (L4,5).
Action: Plantar flexes and inverts ankle.
MMT: Patient in short sitting with ankle in slight plantar flexed. Therapist sitting on low stool in front of patient or on side of test limb. One hand is used to stabilize the ankle just above the malleoli. Ask the patient to turn your foot down and in and hold it. If the patient is able to invert the foot through the full available range of motion, it shows grade III power.
Stretching: Patient in supine lying, therapist is standing beside the patient and facing the ankle joint. He then grasps the ankle joint of the patient with his left hand while his right hand grasps the foot region. Therapist's right hand is applying stretch force towards the inversion and eversion movement and stretches the tightened structure.
 
TRANSVERSUS ABDOMINIS
Origin: Lateral third of inguinal ligament, anterior two-third of inner lip of iliac crest, thoracolumbar fascia between iliac crest and 12th rib, lower six costal cartilages where it interdigitates with diaphragm.
Insertion: Abdominal aponeurosis to linea alba.
Nerve: Ventral rami of lower six thoracic and lumbar spinal nerve.
Action: Compresses abdominal contents, raises intra-abdominal pressure.275
 
TRAPEZIUS
Origin: Medial 1/3 of superior nuchal line, external occipital protuberance, ligament nuchae, C7 spine, T1–T12 spines, corresponding supraspinous ligament.
Insertion: Upper fibers—posterior border of lateral third of clavicle; middle fibers—medial border of acromion, superior lip of crest of spine of scapula; lower fibers—tubercle at medial end of spine of scapula.
Nerve: Accessory nerve (XI) ventral rami (C3, C4).
Action: Upper fibers elevate scapula, middle retract scapula, lower fibers depress scapula.
MMT:
  1. For upper fibers: Patient in short sitting over end of table hands relaxed on lap. Ask patient to raise his shoulder towards his ear.
  2. For middle fibers: Patient in prone lying with shoulder at the edge of table and 90° abducted elbow is flexed to 90°. Ask patient to lift elbow towards ceiling and hold it.
  3. For lower fibers: Patient in prone with arms over head to about 145° of abduction. Forearm is in midposition with the thumb pointing towards the ceiling. Therapist stands at test side. His finger tip of one hand palpate below the spine of scapula and across to the thoracic vertebrae, following the muscle as it curves down to the lower thoracic vertebrae. Ask 276patient to raise your arm from the table as high as possible and hold it. If the patient completes the available ROM in all above 3 tests, then the muscle is in grade III.
 
TRICEPS BRACHII
Origin: Long head: infraglenoid tubercle of scapula, shoulder capsule.
Lateral head: Above and lateral to spiral groove on posterior surface of humerus.
Medial head: Below and medial to spiral groove on posterior surface of humerus.
Insertion: Upper surface of olecranon, deep fascia of forearm.
Nerve: Radial nerve (C6, C8).
Action: Extends elbow and shoulder.
MMT: Patient in prone on table. His shoulder of testing limb is in 90° of flexion and forearm hanging vertically at the edge of the table. Ask patient to straighten your elbow and hold it. If the patient completes the available ROM with no resistance, it shows grade III power.
Stretching: Patient in supine lying or sitting. Therapist is standing beside the patient. Therapist left hand hold's the patient hand and flexes the elbow after the hand reaches the shoulder. Therapist left hand stabilizes the shoulder also. Therapist right hand grasping the elbow, lifts up to gain shoulder flexion.277
 
VASTUS INTERMEDIUS
Origin: Upper 2/3 of anterior and lateral surface of femur, lower part of lateral intermuscular septum.
Insertion: Deep surface of quadriceps tendon, lateral border of patella, lateral tibial condyle.
Nerve: Femoral nerve (L2–L4).
Action: Extends knee.
MMT: Done along with quadriceps femoris.
Stretching: Done along with quadriceps femoris.
 
VASTUS LATERALIS
Origin: Intertrochanteric line, greater trochanter, gluteal tuberosity, lateral lip of linea aspera.
Insertion: Tendon of rectus femoris, lateral border of patella.
Nerve: Femoral nerve (L2, L4).
Action: Extends knee.
MMT: Done along with quadriceps femoris.
Stretching: Done along with quadriceps femoris.
 
VASTUS MEDIALIS
Origin: Intertrochanteric line, spiral line, medial lip of linea aspera, medial supracondylar line, medial intermuscular septum, tendon of adductor longus and adductor magnus.
278Insertion: Tendon of rectus femoris, medial border of patella, medial tibial condyle.
Nerve: Femoral nerve (L2–L4).
Action: Extends knee.
MMT: Done along with quadriceps femoris.
Stretching: Done along with quadriceps femoris.
 
JOINT RANGE OF MOVEMENT
 
TYPES OF GONIOMETER
  1. Universal goniometer (by Mr Moore)
  2. Gravity depended or fluid goniometer (by Mr Schenkar)
  3. Pendulum goniometer (by Mr Fox and van Breemen)
  4. Electrogoniometer (by Mr Karpovich and Karpovich)
 
RANGE OF MOTION FOR VARIOUS JOINTS
 
Shoulder
Flexion
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°)
279
 
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°)
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
280
 
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
 
Ankle
Plantar flexion
0–45°
Dorsi flexion
0–20°
Inversion
0–45°
Eversion
0–15°
 
MTP
Flexion
0–40°
Extension
0–80°
(10°–90°)
Abduction
0–15°
 
Intraphalangeal
Flexion
0–60°
(50°–70°)
Extension
0
281
 
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°
Note:
MCP: Metacarpophalangeal joint
PIP: Proximal interphalangeal joint
DIP: Distal interphalangeal joint
 
MEASURING PROCEDURES
 
Shoulder Joint
Flexion
Axis: Greater tuberosity of humerus
Moving arm: On the midline of lateral aspect of arm
Fixed arm: Straight to the moving arm.
Extension
Axis: Greater tuberosity of humerus
Moving arm: Midline of the lateral aspect of arm
Fixed arm: Straight to the moving arm.
282Abduction
Axis: One inch below the acromion process of the scapula
Moving arm: Midline of the anterior aspect of arm
Fixed arm: Horizontally on the clavicle.
Medial and lateral rotation
Axis: Olecranon process of the ulna
Moving arm: Midline of the posterior aspect of forearm
Fixed arm: Straight to moving arm.
 
Elbow Joint
Flexion
Axis: Lateral epicondyle of humerus
Fixed arm: Lateral midline of humerus
Moving arm: Lateral midline of forearm.
 
Radioulnar Joint
Pronation
Axis: Ulnar styloid process
Fixed arm: Perpendicular to the moving arm without any body contact
Moving arm: Anterior aspect of wrist
Supination
Axis: Ulnar styloid process
283Fixed arm: Perpendicular to the movable arm without any body contact
Moving arm: Posterior aspect of wrist.
 
Wrist Joint
Flexion and extension
Axis: Medial margin of wrist
Fixed arm: Lateral midline of forearm
Moving arm: Lateral midline of little finger.
Ulnar and radial deviation
Axis: Middle of the posterior aspect of wrist
Fixed arm: Middle of posterior aspect of forearm
Moving arm: Midline of posterior aspect of the middle finger.
 
MCP
Flexion
Axis: Midline of the posterior aspect of the joint line of the MCP
Fixed arm: Midline of the posterior aspect of wrist and forearm
Moving arm: Midline of the posterior aspect of the metacarpal.
Extension
Axis: Middle of the anterior aspect of the joint line of MCP.
284Fixed arm: Midline of the anterior aspect of wrist and forearm
Movable arm: Midline of the anterior aspect of the metacarpal and phalanx.
Abduction and adduction
Axis: Middle of the posterior aspect of the joint line of the MCP
Fixed arm: Midline of the posterior aspect of wrist and forearm
Moving arm: Midline of the posterior aspect of the metacarpal.
 
PIP
Flexion and extension
Axis: Middle of the posterior aspect of the joint line of the PIP
Fixed arm: Midline of the posterior aspect of the MC, wrist and forearm
Moving arm: Midline of the posterior aspect of phalanx.
 
Hip Joint
Flexion
Axis: Greater trochanter of the femur
Fixed arm: Midline of the lateral aspect of lower trunk
Moving arm: Midline of the lateral aspect of thigh.
285Extension
Axis: Greater trochanter of femur
Fixed arm: Midline of the lateral aspect of lower trunk
Moving arm: Midline of lateral aspect of the thigh.
Adduction
Axis: Two inches below the ASIS
Moving arm: Midline of the anterior aspect of the thing
Fixed arm: 90° to the movable arm.
Medial and lateral rotation
Axis: Tip of patella
Moving arm: Midline of the anterior aspect of the leg
Fixed arm: Straight to moving arm.
 
Knee Joint
Flexion
Axis: Lateral joint line
Moving arm: Midline of lateral aspect of leg
Fixed arm: Midline of the lateral aspect of thigh.
 
Ankle Joint
Plantar and dorsiflexion
Axis: Tip of medial malleolus.
286Fixed arm: Midline of the medial aspect of the leg
Moving arm: 90° to stable arm.
 
Subtalar Joint
Inversion
Axis: Medial joint line of the head of the first metatarsal
Fixed arm: Parallel to the medial aspect of the ankle and lower leg
Moving arm: Perpendicular to the fixed arm.
Eversion
Axis: Lateral aspect of the head of the fifth metatarsal
Fixed arm: Parallel to the lateral aspect of the lower leg
Moving arm: Perpendicular to the fixed arm.
 
Cervical Spine
Atlanto-occipital and atlanto-axial joint
Flexion—Extension
Axis: External auditory meatus
Fixed arm: Perpendicular to the ground
Moving arm: Base of nares.
Lateral flexion
Axis: Spinous process of C7 vertebrae
287Fixed arm: Perpendicular to the ground
Moving arm: Midline of head.
Rotation
Axis: Center of cranial aspect of head
Fixed arm: Parallel to the line joining both acromion process
Moving arms: Along the line of the tip of the nose.
 
Thoraco-lumbar Spine
Flexion—extension
  1. Measure distance between C7 and S1 spinous process and then ask the patient to bend forward.
  2. Again take measurement and calculate difference between first and final measurement.
Lateral flexion
Axis: Posterior aspect of S1 spinous process
Fixed arm: Perpendicular to the ground
Moving arm: Parallel to the spine with reference to the spinous process of C7 vertebra.
Rotation
Axis: Center of the cranial aspect of the head
Fixed arm: Parallel to the imaginary line between the tubercles of the iliac crest
Moving arm: Parallel to the imaginary line between acromion process.288
 
COMMON MUSCULOSKELETAL TESTS
 
CERVICAL SPINE
 
Distraction Test
Tests: Nerve root compression.
Patient's position: Sitting.
Procedure: Put one hand under chin and other hand under occiput, then gently lift patient's head.
Positive sign: Relief or decrease in pain.
 
Quadrant Test
Tests: Vascular involvement in spine.
Patient's position: Sitting or supine lying.
Procedure: Examiner passively takes patient's head and neck in extension and side.
Flexion and rotation, hold it for 30 seconds.
Positive sign: Dizziness, nausea, headache, nystagmus.
 
Romberg's Test
Tests: Cervical neuropathy, UMNL.
Patient's position: Standing.
Procedure: Ask the patient to close his eyes and hold the position for 20 to 30 seconds.
Positive sign: Body sways, patients looses balance. 289
 
Sharp-Purser Test
Tests: Cervical instability (subluxation).
Patient's position: Sitting.
Procedure: Examiner's one hand over forehead while thumb of other hand over spinous process of axis, patient is asked to flex his head.
Positive sign: The head slides backward during the movement.
 
Spurling's Test
Tests: Nerve root compression.
Patient's position: Sitting.
Procedure: Neck of unaffected side in side flexion, apply gentle pressure on the top of patient's head. Test is repeated on affected side.
Positive sign: Onset or increase in pain radiating into shoulder or arm on fixed side.
 
Upper Limb Tension Test
Tests: Brachial plexus tension.
Procedure: Test should be done in sequence given below:
ULTT 1
  • Depress and abduct (110°) shoulder
  • Elbow extension
  • Forearm supination290
  • Wrist extension
  • Finger and thumb extension
  • Contralateral side flexion of cervical spine.
ULTT 2
  • Depress and abduct (10°) shoulder
  • Elbow extension
  • Forearm supination
  • Wrist extension
  • Finger and thumb extension
  • Shoulder lateral rotation
  • Contralateral side flexion of cervical spine.
ULTT 3
  • Depress and abduct (10°) shoulder
  • Elbow extension
  • Forearm pronation
  • Wrist flexion and ulnar deviation
  • Finger and thumb flexion
  • Shoulder medial rotation
  • Contralateral side flexion of cervical spine.
UTLL 4
  • Depress and abduct (10°–90°) shoulder
  • Elbow extension
  • Forearm supination
  • Wrist extension and radial deviation
  • Finger and thumb extension
  • Shoulder lateral rotation
  • Contralateral side flexion of cervical spine.
Positive sign: Radiculating pain and stress over the nerve of brachial plexus.291
 
THORACIC SPINE
 
Slump Test
Tests: Dural stretch.
Patient's position: Sitting.
Procedure
  1. Patient sits on table, slumps so that spine flexes, shoulder sags forward, examiner holds the chin and head erect. If no symptoms, then in continuation.
  2. Examiner flexes patient's neck and holds the head down, if again no symptoms then in continuation.
  3. Examiner passively extends patients knee and dorsiflexes the foot.
Positive sign: Sciatic pain, impingement of dura and spinal cord or nerve roots.
 
LUMBAR SPINE
 
Brudzinski-Kernig Test
Tests: Neurodynamic dysfunction.
Patient's position: Supine.
Procedure: Hands cupped behind the head. Patient actively flex the head onto chest. Patient raises the extended leg with hip flexion until pain is felt, patient then flexes the knee.
Positive sign: Pain disappears.292
 
Farfan Torsion Test
Tests: Lumbar instability.
Patient's position: Prone.
Procedure: Examiner stabilizes ribs and spine by a hand and other hand on ilium.
Anteriorly pulls the ilium backward, results in rotation of spine on opposite side.
Positive sign: Reproduce all the symptoms in patient.
 
Quadrant Test
Tests: Joint dysfunction.
Procedure: Patient standing with examiner standing behind. Patient extends spine, patient holds the occiput on her/his shoulder and takes weight of head. Over pressure is applied, when patient side flexes and rotates.
Positive sign: Pain in the back and sometimes stress fracture.
 
Slump Test
Tests: Neurodynamic dysfunction.
Procedure
ST1: Supine lying
  • Cervical spine flexion
  • Thoracic and lumbar spine flexion
  • Hip flexion (90°)293
  • Knee extension
  • Ankle dorsiflexion.
ST2: Supine lying
  • Cervical spine flexion
  • Thoracic and lumbar flexion
  • Hip (90°), abduction
  • Knee extension
  • Ankle dorsiflexion.
ST3: Side lying
  • Cervical spine flexion
  • Thoracic and lumbar spine flexion
  • Hip flexion (20°)
  • Knee flexion
  • Ankle plantar flexion.
ST4: Long sitting
  • Cervical spine flexion, rotation
  • Thoracic and lumbar spine flexion
  • Hip flexion (90°)
  • Knee extension
  • Ankle dorsiflexion.
Positive sign: Reproduce the patient's symptoms, cause discomfort or pain on neurological tissues.
 
Straight Leg Raise Test
Tests: Neurodynamic dysfunction.
Patient's position: Supine lying.
Procedure: Stabilize the unaffected leg, patient actively raise the leg (hip flexion, with knee extension and ankle neutral).
294Positive sign: Pain and stretch below the range of 65°–70°.
 
SHOULDER JOINT
 
Anterior Drawer Test
Tests: Anterior shoulder instability.
Patient's position: Supine.
Procedure: Hold shoulder in 80°–120° abduction, 0–20° forward flexion and 0–30° lateral rotation. Perform flexion with stabilized scapula.
Positive sign: Click sound or/and apprehension.
 
Clunk Test
Tests: Ligament injury/tear of glenoid labrum.
Patient's position: Supine.
Procedure: Ask patient to abduct shoulder over his head. Apply anterior force to posterior aspect of humeral head, while lateral rotation.
Positive sign: Clunk or grinding sound and/or apprehension of instability present anteriorly.
 
Crank (Anterior Apprehension) Test
Tests: Anterior shoulder instability.
Patient's position: Supine.
Procedure: Slowly abduct the shoulder to 90° with lateral rotation.
Positive sign: Apprehension.295
 
Droparm Test/Codman's Test
Tests: Supraspinatus tendon rupture.
Patient's position: Sitting.
Procedure: Examiner on side, put one hand on shoulder girdle and other on forearm. Passively abduction of arm to 90° in prone. Patient lowers down the abducted arm.
Positive sign: Pain and lack of motor control.
 
Duga's Test
Tests: Shoulder dislocation.
Patient's position: Standing, both arms hanging by side.
Procedure: Patient is asked to touch the opposite shoulder by flexing the shoulder and elbow of the affected arm.
Positive sign: Patient is unable to touch the opposite shoulder.
 
Empty Can Test
Test: Pathology of supraspinatus tendon.
Patient's position: Sitting or standing.
Procedure: Shoulder abduction 90°; horizontal flexion 30° and medially rotate the thumb pointing downwards.
Positive sign: Weakness or reappearance of symptoms.296
 
Hamilton Ruler Test
Tests: Inferior shoulder instability.
Patient's position: Standing.
Procedure: Examiner places straight ruler over affected arm and checks whether the acromion process and lateral epicondyle are touched by the ruler at the same time or not.
Positive sign: If the ruler do not touch both at the same time, indicates instability.
 
Hawkins-Kennedy Test
Tests: Supraspinatus tendon impingement.
Patient's position: Sitting or standing.
Procedure: Ask the patient to forward flex shoulder to 90° and elbow flexion 90°. Apply medial rotation passively.
Positive sign: Reproduction of symptoms.
 
Jerk Test
Tests: Posterior shoulder instability.
Patient's position: Sitting.
Procedure: Hold shoulder in 90° forward flexion and medial rotation.
Apply longitudinal cephalad force (from head) to humerus and adduct the arm horizontally.
Positive sign: Sudden jerk or clunk.297
 
Neer Impingement Test
Tests: Biceps or supraspinatus tendon impingement.
Patient's position: Sitting or standing.
Procedure: Forward flex arm and medially rotate it passively.
Positive sign: Reappearance of symptoms.
 
Posterior Drawer Test
Tests: Posterior shoulder instability.
Patient's position: Supine.
Procedure: Place shoulder in 100°–120° abduction, elbow flexed to 120° and shoulder in 20°–30° forward flexion. Medial rotation and forward flexion of shoulder up to 60°–80° with scapula stabilized.
Positive sign: Apprehension and/or significant posterior displacement.
 
Speeds Test
Tests: Pathology of biceps tendon.
Patient's position: Sitting or standing.
Procedure: Elbow extension, forearm supination and shoulder forward flexion. Apply resistance when patient performs shoulder flexion.
Positive sign: Increased pain in bicipital groove.298
 
Sulcus Sign
Tests: Inferior shoulder instability.
Patient's position: Standing or sitting.
Procedure: Arm by side. Hold arm below elbow and pull distally.
Positive sign: Reappearance of symptoms and/or apprehension of sulcus under acromion.
 
ELBOW JOINT
 
Cozen's Test
Tests: Lateral epicondylitis.
Patient's position: Sitting or standing.
Procedure: Grip the patient's forearm distally and ask the patient to make a firm fist and passively flex the wrist.
Positive sign: Pain over lateral epicondyle and reappearance of symptoms.
 
Elbow Flexion Test
Tests: Cubital tunnel syndrome.
Patient's position: Sitting or standing.
Procedure: Elbow full flexion with extended wrist. Hold it for 5 minutes.
Positive sign: Tingling or paresthesia in ulnar nerve distribution.299
 
Jug Test
Test: Lateral epicondylitis.
Patient's position: Standing.
Procedure: Ask him to lift a jug full of water holding it from its mouth.
Positive sign: Pain and reappearance of symptoms.
 
Lateral Epicondylitis Test (Tennis Elbow)
Tests: Lateral epicondylitis.
Patient's position: Sitting or standing.
Procedure
Method 1: Passive elbow extension, forearm pronation and flexion fingers and wrist while palpating lateral epicondyle.
Method 2: Resist extension of middle finger distal to PIP joint.
Positive sign: Pain over lateral epicondyle and reappearance of symptoms.
 
Pinch Grip Test
Tests: Median (anterior interosseous) nerve intrapment.
Patient's position: Sitting or standing.
Procedure: Patient pinches the tip of index finger and thumb together.
Positive sign: Inability to pinch tip to tip.300
 
Valgus Stress Test
Tests: Stability of medial collateral ligament.
Patient's position: Sitting.
Procedure: Stabilize upper arm with elbow flexion in 20°–30° and lateral rotation of humerus in full range. Apply force while abducting forearm.
Positive sign: Reappearance of symptoms or increased laxity.
 
Varus Stress Test
Tests: Stability of lateral collateral ligament.
Patient's position: Sitting.
Procedure: Stabilize upper arm. Elbow flexion in 20°–30° and humerus in medial rotation.
Positive sign: Excessive laxity or reappearance of symptoms.
 
WRIST JOINT AND HAND
 
Finkelstein's Test
Tests: Tenosynovitis of abductor pollicis longus and extensor pollicis brevis tendons (de Quervain's tenosynovitis).
Patient's position: Sitting.
Procedure: Ask the patient, to make a fist with thumb inside. Move wrist into ulnar deviation passively.
Positive sign: Reappearance of symptoms.301
 
Liniburg's Test
Test: Tendon pathology between flexor pollicis longus and flexor indices.
Patient's position: Sitting.
Procedure: Flex thumb towards hypothenar eminence and extend index finger.
Positive sign: Limited extension and reappearance of symptoms.
 
Lunotriquetral Ballottement Test (Reagan's Test)
Tests: Stability of lunotriquetral ligament.
Patient's position: Sitting.
Procedure: Stabilize the triquetrum and lunate. Apply posterior and anterior glide.
Positive sign: Reappearance of symptoms crepitus or laxity.
 
Murphy's Sign
Tests: Lunate dislocation.
Patient's position: Sitting.
Procedure: Patients makes a fist.
Positive sign: 3rd metacarpal lines up with 2nd and 5th metacarpal.
 
Phalen's (Wrist Flexion) Test
Tests: Median nerve pathology, carpal-tunnel syndrome.302
Patient's position: Sitting.
Procedure: Place the hands together from its dorsal aspect with wrist in flexion. Hold it for one minute.
Positive sign: Tingling sensation in distribution.
 
Reverse Phalen's Test
Tests: Median nerve pathology.
Patient's position: Sitting.
Procedure: Place the palms of both hands together with wrist extension.
Positive sign: Tingling sensation over median nerve distribution.
 
Sweater Finger Sign
Tests: Rupture of flexor profundus tendon.
Patient's position: Sitting.
Procedure: Patient makes a fist.
Positive sign: Loss of flexion of DIP joint of one of the finger.
 
Thoment's Sign
Tests: Ulnar nerve paralysis.
Patient's position: Sitting or standing.
Procedure: Hold piece of paper between thumb and index finger. Pull the paper away.
Positive sign: As the paper is pulled away, the IP joint of thumb flexes.303
 
Tinel's Sign
Tests: Median nerve pathology, carpal-tunnel syndrome.
Patient's position: Sitting.
Procedure: Tap over carpal tunnel.
Positive sign: Tingling sensation or paresthesia over median nerve distribution.
 
Waston (Scaphoid Shift) Test
Tests: Instability of scaphoid.
Patient's position: Sitting.
Procedure: Stabilize the wrist is full ulnar deviation and slightly extended. Apply pressure to scaphoid tubercle by other hand (palmar aspect) and move wrist into radial deviation and slight flexion.
Positive sign: Pain and subluxation of scaphoid.
 
PELVIS
 
Anterior Gapping Test
Tests: Sprain of sacroiliac joint or ligaments.
Patient's position: Supine.
Procedure: Push right and left ASIS apart.
Positive sign: Reappearance of symptoms.
 
Gaenslen's Test
Tests: Sacroiliac joint involvement, hip pathology or L4 nerve root lesion.
304Patient's position: Side lying on normal side, with leg flexed against chest.
Procedure: Affected leg is hyper extended at hip and pelvis is stabilized by examiner.
Positive sign: Pain on SI joint, while performing movement.
 
Gillets Test
Tests: Sacroiliac joint dysfunction.
Patient's position: Standing.
Procedure: Palpate PSIS and sacrum. Patient performs hip flexion and knee on side to be tested (palpated), while standing on opposite leg. Repeat the test and compare both sides.
Positive sign: If the PSIS does not move downward to sacrum on side tested, it shows hypomobility of that side.
 
Hibb's Test
Tests: Movement of sacroiliac joint, stress of posterior sacroiliac ligament.
Patient's position: Prone.
Procedure: Pelvis is stabilized and patient performs 90° flexion on the knee, hip is medially rotated, while palpating sacroiliac joint on that side. Repeat the test and compare it with other side.
305Positive sign: Range of opening and quality of movement at each sacroiliac joint differ.
 
Laguere's Sign
Tests: Sacroiliac joint involvement, hip pathology.
Patient's position: Supine.
Procedure: Examiner flexes, abducts and laterally rotates the patient's hip to be tested. Over pressure is applied at end range. Pelvis is stabilized. Repeat the test on other side and compare both sides.
Positive sign: Pain on SI joint or hip.
 
Piedallu's Signs (Sitting Flexion)
Tests: Movement of sacrum on ilia.
Patient's position: Sitting.
Procedure: As the patient forward flexes, palpate the right and left PSIS.
Positive sign: Normal side moves higher than other, indicates hypomobility on that side.
 
Posterior Gapping Test
Tests: Sprain of posterior sacroiliac joint or ligament.
Patient's position: Side lying or supine.
Procedure: Push left and right ASIS towards each other.
Positive sign: Reappearance of symptoms.306
 
Standing Flexion
Tests: Movement of ilia on sacrum.
Patient's position: Standing.
Procedure: Palpate PSIS of both sides, while patient forward flexes the hip.
Positive sign: Normal side moves higher than affected side, indicates hypomobility on affected side.
 
Supine-to-Set (Long Sitting) Test
Tests: Pelvic torsion or rotation.
Patient's position: Supine.
Procedure: Note the level of inferior border of medial malleoli. Patient is asked to sit and changing position of malleoli is noted.
Positive sign: One leg moves up more than other.
 
HIP JOINT
 
Anterior Labral Tear Test
Tests: Ligament or labrum tear or injury.
Patient's position: Supine.
Procedure: Full flexion at hip, lateral rotation and full abduction. Examiner extends, medially rotates and adducts the hip.
Positive sign: Pain, reappearance of symptom with/without click.307
 
Ober's Sign
Tests: Tensor fasciae latae and iliotibial band contractures.
Patient's position: Side lying with lower leg flexed.
Procedure: Pelvis stabilized. Abduct and extend upper leg with knee extension or flexion to 90° passively and allow it to drop towards plinth.
Positive sign: Upper leg remains abducted and does not lower to plinth.
 
Patrick's Test (Faber's Test)
Tests: Hip joints and SI joint dysfunction, spasm of iliopsoas muscle.
Patient's position: Supine.
Procedure: Foot of test leg is placed on opposite knee. Slowly lower knee of test leg.
Positive sign: Pain or spasm, knee remains above the opposite leg.
 
Posterior Labral Tear Test
Tests: Ligament injury or labrum tear.
Patient's position: Supine.
Procedure: Full flexion at hip, adduction and lateral rotation. Examiner extends, abducts and laterally rotates the hip.
Positive sign: Resist extension of middle finger distal to PIP joint.308
 
Rectus Femoris Contracture Test
Tests: Rectus femoris contracture.
Patient's position: Supine.
Procedure: Knee flexed to 90° over edge of plinth. Patient takes other knee to chest.
Positive sign: Knee extends over edge of plinth.
 
Thomas Test
Tests: Hip flexion contracture.
Patient's position: Supine.
Procedure: Patient takes knee on to chest.
Positive sign: Opposite leg lifts off plinth.
 
Trendelenburg's Sign
Tests: Strength of hip abductors, stability of hip.
Patient's position: Standing.
Procedure: Patient is made to stand on one leg.
Positive sign: Pelvis on opposite side drops.
 
KNEE JOINT
 
Abduction (Valgus) Stress Test
Tests: Full knee extension ligament injury (ACL, MCL, POL, PCL), quadriceps and semimembranosus expansion.
Patient's position: Supine.
309Procedure: Ankle is stabilized and medial pressure is applied on knee joint at 0° and then at extension in 20°–30°.
Positive sign: Excessive movement is seen as compared to opposite knee.
 
Adduction (Varus) Stress Test
Tests: Full extension ligament injury (LCL), iliotibial band, biceps femoris tendon.
Patient's position: Supine.
Procedure: Ankle is stabilized, lateral pressure is applied on knee joint at 20° and then extension at 20°–30°.
Positive sign: Excessive movement is seen as compared to opposite knee.
 
Anterior Drawer Test
Tests: Ligament injury (ACL, POL, MCL), iliotibial band, posteromedial and posterolateral capsules.
Patient's position: Supine with 45° hip flexion and 90° knee flexion.
Procedure: Foot is stabilized, posteroanterior force is applied on tibia.
Positive sign: Movement of tibia, move than 6 mm on femur.310
 
Apley's Test
Tests: Compress for meniscus injury and distraction for ligamentous injury.
Patient's position: Prone with 90° knee flexion.
Procedure: Medial and lateral rotation of tibia, first with distraction and then with compression.
Positive sign: Pain.
 
Brush Test
Tests: Mild effusion.
Patient's position: Long sitting.
Procedure: Stroke the patella on medial side, below joint line upto suprapatellar pouch two to three times and stroke down lateral side of patella by using opposite hand.
Positive sign: Fluid travels to medial side and bulge appears.
 
External Rotation Recurvatum Test
Tests: Posterolateral rotatory stability in knee extension.
Patient's position: Supine.
Procedure: Place the knee in 30° flexion and hold the heel. Extend knee slowly while palpating the knee's posterolateral aspect.
Positive sign: Excessive hyperextension and lateral rotation can be palpated.311
 
Fairbank's Apprehension Test
Tests: Patellar subluxation or dislocation.
Patient's position: Supine.
Procedure: 30° flexion at knee and relaxed quads. Lateral glide to patella passively.
Positive sign: Excessive movement.
 
Hughston Plica Test
Tests: Inflammation of suprapatellar plica.
Patient's position: Supine.
Procedure: Knee is medially rotated and flexed. Applying medial glide on patella and medial femoral condyle is palpated. Extend and flex knee passively.
Positive sign: Popping of plica band over femoral condyle, tenderness.
 
Lachman's Test
Tests: Ligament injury (ACL, POL), arcuate-popliteus complex.
Patient's position: Supine with 0–30° knee flexion.
Procedure: Femur is stabilized and posteroanterior force on tibia is applied.
Positive sign: Soft end feel or excessive movement.
 
McMurray Test
Tests: Medial meniscus and lateral meniscus injury.
312Patient's position: Supine.
Procedure: Complete knee flexion.
Test medial meniscus: Knee lateral rotation and 90° extension passively, while palpating joint line.
Test lateral meniscus: Test is repeated with medial rotation at knee.
Positive sign: Click or a snap.
 
Posterior Drawer Test
Tests: Ligament injury (ACL, POL, PCL), arcuate popliteus complex.
Patient's position: Supine.
Procedure: 45° flexion at hip and 90° flexion at knee with feet on plinth.
Positive sign: Posterior drop of tibia.
 
Posterior Sag Test
Tests: Ligament injury (PCL, POL, ACL)
Patient's position: Supine.
Procedure: 45° flexion at hip and 90° flexion on knee with feet on plinth.
Positive sign: Tibia drops posteriorly.
 
Slocum Test for Anterolateral Rotatory Instability
Tests: Ligament injury (ACL, PCL, LCL and cruciate), iliotibial band.
Patient's position: Supine.
313Procedure: 45° flexion at hip and 90° flexion at knee, foot is placed in 30° medial rotation and stabilized, posteroanterior force is applied on tibia.
Positive sign: Excessive movement on lateral side, when compared with other knee.
 
Slocum Test for Anterolateral Rotary Instability
Tests: Ligament injury (MLC, POL, ACL)
Patient's position: Supine.
Procedure: 45° hip flexion, 90° knee flexion, foot is placed in 15° lateral rotation and stabilize it. Then posteroanterior force is applied on tibia.
Positive sign: Excessive movement on medial side, when compared with other knee.
 
ANKLE JOINT AND FOOT
 
Anterior Drawer Test
Tests: Medial and lateral ligament integrity.
Patient's position: Prone.
Procedure: Flexion at knee, posteroanterior force is applied on talus with dorsiflexion on ankle and then plantar flexion.
Positive sign: If movement on one side only (ligament on the affected side). If excessive anterior movement (both ligaments are affected).314
 
Squeeze Test of Leg
Tests: Syndesmosis injury (fracture, contusion or compartment syndrome).
Patient's position: Supine.
Procedure: Examiner grasps leg at mid calf level and squeezes the tibia and fibula together.
Positive sign: Pain in the lower leg.
 
Talar Tilt
Tests:
Abduction: Integrity of deltoid ligament.
Adduction: Integrity of calcaneofibular ligament and also anterior talofibular ligament.
Patient's position: Prone, supine or side lying.
Procedure: Flexion at knee. Talus is tilted in adduction and abduction and foot is in neutral position.
Positive sign: Excessive movement.
 
Thompson's Test
Tests: Achilles tendon rupture.
Patient's position: Prone.
Procedure: Feet is placed over edge of plinth and then calf muscle is squeezed.
Positive sign: Absence of plantar flexion.315
 
MUSCULOSKELETAL PATHOLOGIES
 
ACHONDROPLASIA
It is a condition which occurs because of failure of normal ossification of bones, specially the long bones, turning into dwarfism. It is a disease with autosomal dominant inheritance, but may also occur by a fresh gene mutation.
 
Clinical Features
Flat nose, short limbs, lumbar lordosis, large skull with bulged vault and forehead, stubby fingers
 
ALBERS-SCHöNBERG DISEASE
Also known as marble bone disease or osteoporosis. This is a disorder in which the bone are brittle but dense and there is poor formation of protein matrix. It may result due to immobilisation, hormonal imbalance, nutritional deficiency.
 
Clinical Features
Fracture resulting by minimal injury or pressure, weak bone, reduced gaps between bone.
 
ANKYLOSING SPONDYLITIS
This is a chronic disease showing progressive inflammatory stiffening of joint. The SI joint is the first to be involved, the manubrio-sternal, hip and knee joints may also be involved. This mainly 316affects the age group of 15–30 years. M:F—10:1. There may occur cartilage destruction and synovitis.
 
Clinical Features
Pain and stiffness (early morning), deformity of hip and spine (kyphosis), peripheral joints may also be involved, i.e. shoulder hip and knee.
 
ARTHROGRYPOSIS MULTIPLEX CONGENITA
It is a nonprogressive condition in which the infant born with multiple deformities, joint stiffness and soft tissues contractures.
Types:
Neurogenic—Due to degeneration of anterior horn cells in certain segments of spinal cord.
Myogenic—Due to replacement of muscles by fibrofatty tissue.
 
Clinical Features
Flexion, abduction at hips, flexion at knees, equinovarus feet, congenital hip dislocation, joint contractures, genu recurvatum, calcaneovalgus feet, web skins.
 
BAKER'S CYST
This is associated with rheumatoid arthritis and osteoarthritis. There occurs a cyst or a mass or a fluid filled sac at back of knee joint.317
 
Clinical Features
Popliteal bursa gets distended, associated with herniation of synovial membrane of knee joint.
 
BURSITIS
This is the inflammation of bursa. This occurs because of bacterial infection or mechanical irritation. Because of which the bursitis may be infective or irritative caused by excessive pressure or friction. Also sometimes due to gouty deposit.
 
Clinical Features
Pain, swelling, redness, reduced joint range of motion.
 
CONGENITAL TALIPES EQUINOVARUS (CTEV)
This is the commonest congenital feet deformity also known as clubfoot. The etiology is unknown, hence two types: Idiopathic and secondary. The talus neck gets angulated facing downwards and medially, i.e. in inversion.
 
Clinical Features
Postural equinovarus, as age increases difficulty in walking, head is small in size, bilateral foot deformity, creases on back of heel, foot is slight convex. 318
 
CARPAL-TUNNEL SYNDROME
This syndrome occurs when the median nerve gets compressed while passing through flexor retinaculum. The causes of this may be inflammatory, post-traumatic, endocrine, idiopathic. The patient affected is usually middle aged.
 
Clinical Features
Numbness, tingling, clumsiness in carrying fine movements, absent in pulse conduction.
 
COMPARTMENT SYNDROME
A rise in pressure in compartments containing muscles, bones, vessels, fascia, because of any reason may affect the blood supply to nerves and muscles resulting in compartment syndrome. This injury leads to swelling resulting into reduced blood supply, further resulting in muscle ischemia.
 
Clinical Features
Necrosis, nerve damage, fibrosis, contractures gangrene.
 
CONGENITAL DISLOCATION OF HIP
This is the sudden dislocation of hip occurring before, during or after the birth. This is one of the commonest disorders in western countries. The factors responsible for this are hereditary, trauma, breech malposition, hormonal changes during pregnancy. F:M—6:1.319
 
Clinical Features
Asymmetry creases on groin, reduces range of motion on the affected side, click sound is heard everytime when movement occurs, child walks with a peculiar gait, i.e. Trendelenburg or waddling gait.
 
DE QUERVAIN'S DISEASE
It results because of inflammation of the tendon sheath of abductor pollicis longus and extensor pollicis brevis at place where it crosses styloid process of radius.
 
Clinical Features
Tenderness on radial styloid process, pain aggravates by adducting the thumb.
Thickened sheath can be palpated.
 
DUPUYTREN'S CONTRACTURE
This is a condition occurring due to the flexion deformity of one or more fingers because of thickening and shortening of palmar aponeurosis. The etiology is unknown, but it can be hereditary. The ring finger is commonly affected.
 
Clinical Features
Thickening felt at bases of ring and little finger, flexion deformity of fingers.320
 
FIBROSITIS
This is the inflammation of the fibrous tissue. There are nodules (firm) mostly on trapezius and spinal muscles. The nodules are mainly the trigger points, respond to ultrasonic therapy and local steroids.
 
Clinical Features
Tenderness, nodules (small, firm), pain, affected movement, reduced range of motion.
 
FIBROMYALGIA
This is disorder which is rheumatological and non-articular in nature associated with joint and myofascial pain. The etiology and pathology is unknown, but it can occur itself or with some other condition.
 
Clinical Features
Pain, tenderness, fatigue, disturbed sleep, anxiety, depression, morning stiffness.
 
GOLFER'S ELBOW (MEDIAL EPICONDYLITIS)
This is the condition in which there is inflammation at the origin of flexor tendon, i.e. at the medial epicondyle of the humerus.
 
Clinical Features
Pain, tenderness, swelling, reduced range of motion. 321
 
MYOSITIS OSSIFICANS
In this there is formation of hematoma around a joint due to fracture or severe soft tissue injury, mainly around elbow. It may also be congenital.
 
Clinical Features
Pain, tenderness, stiffness of joint.
 
OSTEOARTHRITIS
This is a degenerative joint disorder mainly affecting the articular cartilage of the joint. It may affect any age group after adolescent. Mainly affects the large joint and the weight bearing joints. Female are more affected than male.
 
Clinical Features
Pain, tenderness, swelling, morning stiffness, reduced range of motion, joint effusion.
 
OSTEOCHONDRITIS
This is the disorder in which there is inflammation of the joint and the cartilages. It may occur due to compression, fragmentation or separation of piece of bone. The various or common types of osteochondritis are:
 
Perthes' Disease
Also known as coxaplana, pseudocoxalgia.
Mainly affects the femoral head or femoral epiphysis affecting the young boys. Occurs due 322to recurrent episodes of ischemia and necrosis. The bone becomes soft and fragmented due to which it appears larger than original size.
 
Osgood-Schlatter Disease
Mainly affect the tibial tubercle seen in teenage boys. Results in detachment of small cartilage, due to vigorous physical activity.
 
Osteochondritis Dissecans
Mainly seen in adult boys. In this, there is separation of fragment of bone and cartilage into a joint. The commonest site are the capitulum of humerus and medial femoral condyle.
 
Scheuermann's Disease
Mainly affects the vertebral bodies resulting in degeneration of the intervertebral disc into vertebral end plate. Can also lead to kyphosis.
 
OSTEOMALACIA
Occurs due to deficiency of vitamin D, i.e. due to poor nutrition, lack of various types of vitamin D. Due to this, there is softening of bone, because of incomplete calcification. Due to which they become weak and get easily fractured. Mainly seen in long bones.323
 
Clinical Features
Soft fragmented bone, pain, tenderness, swelling, redness, difficulty in weight bearing.
 
OSTEOMYELITIS
This occurs due to infection of the bones by the micro-organisms. This results into destruction of bone and production of inflammatory cells and exudates. Seen commonly because of open fracture or joint surgery. The infection may also spread to other parts of body.
 
Clinical Features
Pain, tenderness, swelling, weight loss, fever.
 
PAGET'S DISEASE
This is a disease characterized by excessive tendency of bony breakdown, gets thickened and spondy. Tibia is affected most commonly. Diseases mostly affects after 40 year of age. This occurs due to osteoclast dysfunction.
 
Clinical Features
Dull pain, thickening of the affected bone.
 
POLYARTERITIS NODOSA
This is a vasculitic syndrome in which, the various size of arteries are attacked by the rogue immune 324cells causing inflammation and necrosis. All the organs or parts of the body supplied by blood or arteries are affected due to impaired blood supply.
 
Clinical Features
Fever, renal failure, hypertension, neuritis, weight loss, muscle and joint pain, skin lesion.
 
POLYMYALGIA RHEUMATICA
This is a vasculitic syndrome, symptoms usually begin at or over the age of 50 and mainly affects women. This is associated with fever, generalized pain and stiffness.
 
Clinical Features
Loss of vision, involvement of cranial arteries, migraines, stroke.
 
POLYMYOSITIS
This is an autoimmune, inflammatory disease of muscle. It causes progressive weakness of skeletal muscle. It has an unknown etiology. The muscles of pelvis, hip and shoulder girdle are mainly affected. The disease occurs sometimes with a skin rash over the body and is known as dermatomyositis.
 
Clinical Features
Pain, tender to touch, difficulty in weight bearing.325
 
RHEUMATOID ARTHRITIS
This is an autoimmune disorder affecting several joints at same times. There is destruction of articular cartilage, capsule, ligament and tendons, leads to deformity. The joints are symmetrically affected. There are nodules, the disease is common in young to middle aged women.
 
Clinical Features
Pain, swelling, morning stiffness, loss of movement and function.
 
SPONDYLOLISTHESIS
This is the forward displacement of one vertebral body over the vertebral body below it, commonly seen in L5/S1, the displacement may be severe, causes compression of cauda equina.
  1. Dysplastic: Congenital
  2. Isthmic: Fatigue fracture of the pars interarticularis due to overuse
  3. Degenerative: Osteoarthritis
  4. Traumatic: Acute fracture
  5. Pathological: Weakening of the pars intra–articularis by a tumor, osteoporosis, tuberculosis or Paget's disease.
 
Clinical Features
Pain, tenderness, difficulty in bending, sitting and lying down, affected movement.326
 
SPONDYLOLYSIS
This is the defect in the pars interarticularis of the lumbar vertebrae resulting due to fatigue fracture. It can be both uni and bilateral and it may or may not progress to spondylolisthesis.
 
Clinical Features
Pain, difficulty in bending, affected movement.
 
SPONDYLOSIS
This occurs due to degeneration and narrowing of the intervertebral discs which leads to the formation of osteophytes at joint margin and arthritic changes of the facet joint, the cervical joints are commonly affected. The spinal canal causes dysfunction of all four limbs and may be the bladder also. The vertebral artery may also be involved.
 
Clinical Features
Neck pain, stiffness, radiating pain to upper limbs, vertigo.
 
SYSTEMIC LUPUS ERYTHEMATOUS
This is a chronic inflammatory autoimmune connective tissue disorder. It involves the skin, joint and internal organs. Amongst the affected people, 90 percent are women.327
 
Clinical Features
Anemia, hypertension, vasculitis, renal disease, pleurisy, alopecia, polyarthritis vasculitis, butterfly rash on face, Raynaud's disease.
 
SYSTEMIC SCLEROSIS
This is an autoimmune disorder of the connective tissue that causes increase in metabolism of collagen. Excessive collagen deposits damage the microscopic blood vessels in skin and other organs and leads to fibrosis and degeneration. Middle age women are most commonly affected.
 
Clinical Features
Edema of hands and feet. Alterations of facial features are dry, shiny, tight, skin contractures and finger deformities.
 
TENNIS ELBOW
Also known as lateral epicondylitis, affecting the common extensor origin due to the inflammation of the lateral epicondyle.
 
Clinical Features
Pain, tenderness, affected movement of extension.
 
TENOSYNOVITIS
This is the inflammation of the synovial lining of the tendon sheath caused due to mechanical 328irritation or infection. It may also occur due to overuse and repetitive movements.
 
Clinical Features
Pain, tenderness, swelling, redness affected movement and function.
 
THORACIC OUTLET SYNDROME
It is characterized by compression of neurovascular bundle comprising of subclavian artery/vein, axillary artery/vein and brachial plexus at the thoracic outlet (space between first rib, clavicle and scalene muscles). Causes include hypertrophy of the existing muscles or due to any other cause like trauma, congenital, etc.
 
Clinical Features
Pain, weakness, edema, pallor, paresthesia, venous engorgement, cyanosis involving mainly neck, any affected side shoulder and upper extremity.
 
GRADES OF SPRAIN AND TREATMENT
Grade I—Minimal pain and disability, weight bearing not affected.
Grade II—Moderate pain and disability, weight bearing difficult.
Grade III—Severe pain, swelling and dislocation, no weight bearing possible. 329
 
TREATMENT
 
Prices
P—Prevention from further injury
R—Rest to the part
I—Icing
C—Compression
E—Elevation of the part
S—Support.
 
STAGES OF FRACTURE HEALING
 
HEMATOMA FORMATION
  • Duration: Less than 7 days
  • Essential features: Deposition of blood at the site of fracture, which sensitizes the precursor cells.
 
CELLULAR PROLIFERATION
  • Duration: Up to two to three weeks
  • Essential features: It has two substages:
    1. Endosteal cellular proliferation—formation of cells in endosteam
    2. Periosteal cellular proliferation—formation of cells on surface of medullary cavity.
 
STAGE OF CALCIFICATION
This stage includes deposition of lime salt, mainly calcium and phosphorus.330
 
NEW BONE FORMATION
  • Duration: Up to 4 to 12 weeks
  • Essential features: It has three substages:
    1. Stage of callus formation: Deposition appears as slit callus, it occurs after two to three weeks of trauma.
      Callus—It is a new bone formation/calcification which bridges the fracture site, responsible for healing of fracture.
    2. Stage of consolidation:
      • This stage is characterized by more callus formation which bridges the fracture site.
      • The callus appears to be firm or hard on palpation. This callus consolidates on parent bone.
    3. Crossing of trabecular pattern:
      • The trabecular pattern of the fractured bone gets disturbed.
      • It requires 8–10 weeks for slit alignment of trabecular pattern.
      • This alignment is not anatomically satisfactory.
      • It appear to be slit deformed as normal one. The bone gets bended.
      • To correct it, next stage occurs.
 
REMODELING STAGE
  • Duration: One to two years
  • Essential features: It occurs till the correction of bending.331
  • After 6 month, 90 percent bone is formed.
    Note
    1. Angulation and over-riding is not accepted since:
      • It has longer period of remodeling.
      • Movement of limb is affected.
      • Bone may be fixed in rotated position.
    2. When fracture is united on bending with remodeling in few months, it is accepted.
    3. One of the very important clinical findings of mature union is—no pain on applying angulation force.
    4. Radiological criteria to suggest mature union are:
      • Callus formation
      • Crossing of trabeculae formation
      • Remodeling.
 
FRACTURES WITH EPONYMS
 
BARTON'S FRACTURE
It is the fracture of distal articular surface of the radius which extends to either its anterior or posterior cortical. It is thus divided into two types:
  1. Volar Barton's fracture (anterior marginal type).
  2. Dorsal Barton's fracture (posterior marginal type).
This type of fracture is treated by closed manipulation and by a plaster cast. If it fails, the open reduction and internal fixation is done.332
 
COLLES' FRACTURE
It is defined as the fracture at the distal end of the radius, at its corticocancellous junction with typical displacement in adults such as:
  1. Dorsal tilt
  2. Dorsal displacement
  3. Fragment impaction
  4. Lateral tilt
  5. Lateral displacement
  6. Supination.
 
Common Injuries Associated Colles' Fracture
  • Fracture of the styloid process of ulna
  • Rupture of the ulnar collateral ligament
  • Rupture of the interosseous radioulnar ligament, resulting radioulnar subluxation.
 
Treatment
It is mainly treated conservatively. Undisplaced type of fracture is immobilized in a below-elbow plaster cast for six weeks. Displaced fractures are treated by manipulative reduction and immobilization in Colles’ cast.
 
GALEAZZI FRACTURE—DISLOCATION
This is characterized by fracture of the lower third of the radius with dislocation or subluxation of the distal radioulnar joint. The most common cause is fall on outstretched hand.
333It shows a typical displacement, i.e. the radius fracture is angulated medially and anteriorly. The distal radioulnar joint is disrupted which results in dorsal dislocation of the distal end of the ulna.
Treatment: In children, it is treated with closed reduction in a conservative manner. In elder persons, it is mostly treated by open reduction and internal fixation of radius with a plate.
 
MONTEGGIA'S FRACTURE—DISLOCATION
It is defined as ‘ fracture of upper third of the ulna with dislocation of the head of radius.’ Most common cause is fall on outstretched hand with forearm forced in excessive pronation.
 
Types
  1. Extension type: Extension type is commoner with the ulna fracture angulates anteriorly and the radial head dislocates anteriorly.
  2. Flexion type: Flexion type indicates that the ulna fracture angulates posteriorly and the radial head dislocates posteriorly.
 
Treatment
Since, it is very unstable injury, it redisplaces frequently even if it has been reduced once. After proper reduction, close watch is kept by weekly check X-rays for initial three to four weeks.
334Open reduction and internal fixation using a plate is performed in case where a reduction is not possible or if redisplacement occurs.
 
SMITH'S FRACTURE
It is also seen as reverse of Colles’ fracture where the distal fragment displace ventrally and tilts ventrally.
It is important to differentiate it from the commoner Colles’ fracture which occurs at the same site.
It is treated by closed reduction and plaster cast immobilization for six weeks.
 
BENNETT'S FRACTURE—DISLOCATION
It is a type of an oblique intra-articular fracture of the base of the first metacarpal with subluxation or dislocation of the metacarpal.
Most common cause is longitudinal force applied to the thumb.
 
Treatment
As being an intra-articular fracture it requires accurate reduction and reduction, otherwise it leads to incongruity of the articular surface and may prone the bone for osteoarthritis.
Mostly used methods are:
  • Closed manipulation and plaster cast.335
  • Closed reduction and percutaneous fixation under X-ray control using an image intensifier.
  • Open reduction and internal fixation with a K-wire or a screw.
 
MALLET FRACTURE
  • It is also called as mallet finger or baseball finger.
  • This fracture is the result of sudden passive flexion of the distal interphalangeal joint, which causes avulsion of extensor tendon of the distal interphalangeal (DIP) from its insertion at the base of the distal phalanx. Sometimes the avulsion is associated with fragment of bone with it.
  • It shows the clinical feature of slight flexion of distal phalanx.
  • Treatment of this fracture is by immobilizing the DIP joint in hyperextension with help of an aluminium splint or plaster cast.
 
ROLADO'S FRACTURE
This is the fracture of base of the first metacarpal, extra-articularly. Being an extra-articular fracture, its perfect reduction is not as important as in Bennett's fracture dislocation.
It is treated clinically by reduction and immobilization in a thumb spica for three weeks.336
 
BUMPER FRACTURE
It is actually the fracture of condyle of tibia.
Mechanism of injury is direct trauma to the upper end of tibia, or an indirect force more often results in unicondylar (by a varus/valgus bending force) or infracondylar fracture (by a hyperextension force).
Bumper fracture is more accurately the fracture of the lateral condyle of the tibia, when the bumper of a motorcar strikes the lateral side of the knee.
 
Treatment
It is treated clinically by reduction under anesthesia, followed by below knee skin traction for three weeks. The knee is mobilized as the fracture becomes stickly, few cases need open reduction and joint reconstruction.
 
MUSCULOSKELETAL ASSESSMENT
Reg. No.
Name
Age/sex
Date of admission
Address
Occupation
Referred by (consultant) and hospital
Consultant's probable diagnosis
Type of operation/illness
337Date of discharge
Discharge summary
Instructions for physiotherapist
History of present illness
Past medical history
Drug history:
Current medication
Steroids
Anticoagulants
allergies.
ADL activity
Personal history
Social history
Family history.
 
ON OBSERVATION
Attitude of limb
Facial expression
Deformity
Posture:
Lying
Sitting
Standing.
Pain:
Type
Onset
Nature
Radiation
Intensity
Aggravating factor
Relieving factor338
Severity
Associated symptoms.
 
ON PALPATION
Temperature
Tenderness
Edema—pitting/non-pitting
Inflammatory signs
Muscle wasting
Contractures.
 
ON EXAMINATION
Range of movement:
Active
Passive.
Joint effusion measurement
Muscle girth
Limb length
End feel:
Capsular
Noncapsular.
Differential test
Gait assessment
MMT
Neurological test:
Dermatomes
Reflexes
Myotomes.
Special tests
Investigations—Blood/X-ray/CT scan/MRI.

MiscellaneousCHAPTER 6

  • Diagnostic/electrodiagnostic testing
  • National immunization schedule
  • Proprioceptive neuromuscular facilitation (PNF)
  • Common sports injuries
  • Types of aphasia
  • Gait
  • Levels of amputations
  • Abbreviations
  • Normal reference/lab values
340
 
DIAGNOSTIC/ELECTRODIAGNOSTIC TESTING
 
COMPUTED TOMOGRAPHY (CT)
Imaging procedure where detailed information is obtained from thin section in collimated X-rays.
 
Indications
  • Evaluation of bony structure, especially cortical bone.
  • Useful for diagnosis in compound fracture, dislocations, stress fracture and spinal pathologies.
  • Structural evaluation of lung, mediastinal pathologies.
  • Structural analysis of intracranial lesions.
  • Evaluation and comparison of the normal organ and abdominal tissues.
 
Contraindications
  • Restless patient
  • Pregnancy.
 
MAGNETIC RESONANCE IMAGING (MRI)
Cross sectional image is formed by certain atomic nuclei, which possess unpaired protons or neutrons, possess an inherent spin. Positive charged nucleus generates a small magnetic field 341around itself, when it spins. Those signals emitted by the nuclei are measured and reconstructed by computer to create an image of soft tissue and bone.
T1—Images show anatomical detail with fluid being dark and fat being bright.
T2—Images show soft tissue pathology much better with fluid being bright.
 
Advantages
  • Noninvasive.
  • Give high intrinsic contrast.
  • No bony or air defect.
  • No known biological hazards.
  • Sagittal, transverse imaging are possible.
  • It does not involve the use of ionizing radiation.
 
Disadvantages
  • Patients may produce artifacts, because imaging time is long.
  • Expansive.
  • Require trained technical staff.
  • Patient with a cardiac pacemaker, brain aneurysm clip or other metallic implants with the exception of those attached to the bone, i.e. prosthetic joints cannot be scanned.342
 
ULTRASOUND
Based on piezo-electric effect which is the property of certain substances to convert electrical energy to sound energy.These are the active portions of the ultrasonic transducers. Can be used to examine a broad range of soft tissue structures.
 
Advantages
  • Noninvasive.
  • Cost-effective.
  • Widely available.
  • Also used in wards.
  • Does not involve the use of ionizing radiation and can therefore be safely used in a pregnant women.
 
Disadvantages
  • Limited in thorax.
  • Cannot image the bone.
  • Limited use in the abdomen when there is gaseous distension.
 
RADIOGRAPHY
Oldest imaging technique, formed by exposure to short wavelengths of X-rays that pass through the body and hit a photographic receptor placed behind the patient body.343
 
USES
  • In dentistry
  • Mammography
  • Chest examinations
  • Diagnosis of fractures.
Hollow organ can be visualized by filling them with a radiopaque substances. These block the X-rays and visualize the structures.
Angiography: Visualization of the blood vessels.
Arthrography: Visualize the degenerations of the joints.
Discography: Visualize the disc pathology.
Myelography: Visualize the compressive lesions of the spinal cord and cauda equine.
Tenography: Visualize the tendon pathology and ligaments ruptures.
 
ELECTROENCEPHALOGRAPHY (EEG)
Electroencephalography examines by means of scalp electrode the spontaneous electrical activity of the brain. Tiny electrical potentials, which recorded, amplified and displayed on either 8 or 16 channels of a pen recorder. Mainly used in diagnosis of coma, epilepsy and certain forms of encephalitis.
 
ELECTROMYOGRAPHY (EMG)
Electromyography is a technique used in studying the electrical activity of the muscles for the 344diagnosis of neuromuscular disease. Used in the diagnosis of a broad range of myopathies and neuropathies.
 
NERVE CONDUCTION STUDIES (NCV)
Recording technique of a peripheral nerve impulses at same location, which may distant from the site from where the propagating action potential is induced in that peripheral nerves. Mainly used in the diagnosis of nerve entrapments, peripheral neuropathies, motor and sensory nerve damage and multifocal motor neuropathies.
 
EVOKED POTENTIALS (EP)
An electrical response recorded from the brain, the spinal cord or the peripheral nerve that is evoked by various external stimuli such as visual (e.g. flashing the light), auditory (click sound), somatosensory (electrical stimulation), etc. The recording electrodes are placed over the scalp, neck or spine surface, which vary depending on the type of stimulus modality to be tested. Mainly used for detecting multiple sclerosis, brainstem and cerebellopontine angle lesions, various cerebral metabolic disorders in infants and children.345
 
NATIONAL IMMUNIZATION SCHEDULE
Time
Vaccine
Birth
BCG and OPV zero dose (for institutional deliveries)
6 weeks
BCG (if not given at birth) DPT-1 and OPV-1
10 weeks
DPT-2 and OPV-2
14 weeks
DPT-3 and OPV-3
9 months
Measles
18-24 months
DPT and OPV (1 booster)
5 years
DT
10 year and 16 years
TT
For pregnant women
Early in pregnancy TT-1, after 1 month TT-2
 
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)
 
TECHNIQUE
To strengthen muscles:
  1. Slow reversals
  2. Repeated contractions
  3. Rhythmic stabilizations
To gain relaxation/lengthening of muscles:
  1. Hold—relax
  2. Contract—relax
  3. Rhythmic stabilizations
346To improve coordination
  1. Slow reversals
  2. Repetitive movements.
 
COMMON SPORTS INJURIES
 
SHOULDER JOINT AND ARM
Rotator cuff tear
Javelin throwers, swimmers, volleyball players, baseball players
Glenohumeral
Gymnasts, weight lifters, ballers
Glenohumeral
Boxers, hockey players dislocation
 
ELBOW AND FOREARM
Medial epicondylitis — Golf players
Lateral epicondylitis — Tennis players
Valgus extension — Javelin throwers
 
WRIST AND HAND
Tendon ligament
Volleyball players, basketball players, boxers
Ulnar tunnel syndrome
Cyclist
Carpel-tunnel syndrome
Rock-climbers, tennis players, golf players
347
 
HIP AND THIGH
Quadriceps and hamstring injuries—Runners
Adductor injuries—Horse riders
Fracture of pelvis/hip-dislocation—Footballers
 
KNEE AND LEG
Collateral ligament injury—Footballers
Meniscal injury—Footballers, kabaddi players
Cruciate ligament injury—Long-jumpers
Knee dislocation—Kick boxers
IT band syndrome—Long and high jumpers
Compartment syndrome—Runners and cyclists
 
ANKLE AND FOOT
Sprain—Basketball player, footballers, baseball players
Achilles tendonitis and bursitis—Runners
TA rupture—Runners, footballers
Metatarsalgia—Runners
Stress fracture—Walkers348
 
TYPES OF APHASIA
Fluency
Comprehension
Repetition
1.
Global
2.
Isolation
+
3.
Broca's
+
4.
Transcortical motor
+
+
5.
Wernicke's
+
6.
Transcortical sensory
+
+
7.
Conduction
+
+
8.
Normal
+
+
+
– Absent, + present
 
GAIT
 
GAIT TERMINOLOGY
Traditional
Rancho los amigos
Stance phase
Heel strike
Initial contact
Foot flat
Loading response
Mid stance
Mid stance
Heel off
Terminal stance
Toe off
Preswing
Swing phase
Acceleration
Initial swing
Mid swing
Mid swing
Deceleration
Terminal swing
349
 
GAIT ASSESSMENT
Under the headings of:
  • Type of gait patterns and variations
  • Length of step and width of base
  • Abnormal leg movements
  • Instability
  • Associated postural movements
  • Identification of cause
  • Energy requirement in given pattern
  • Determination of the functional ambulation capacities.
 
ABNORMAL GAIT
Antalgic/Painful—Stance face on the affected leg is shorter than that on the non-affected leg.
Atherogenic/Stiff hip or knee—Patient lifts the entire leg higher than normal to clear the ground because of stiff hip or knee.
Ataxic/Drunkers—Staggering and unsteadiness. Patient walks with a wide base and swings the leg unnecessarily and irregularly.
High stepping/Foot drop/Slapping—More of the hip and knee flexion to clear the ground.
Lordotic—Walking with increased lumber lordosis.
Hemiplegic/Circumductory—Rigid lower limb is stiffly dragged sideways and forwards in semi- circular fashion.
350Spastic—Toes scraping the floor with pelvis lifting from side to side.
Scissoring—Crossed leg pattern, walk on toes, overactive arms to maintain balance, pelvic waddle.
Shuffling (Parkinsonian, Festinant, Festinating gait)—Walking on toes but rapid shuffling steps, increased in cadence, lack of heel strike and toe off, decreased arm swing.
Jaunty—Jerky and dancing pattern.
Waddling—Oscillatory pattern.
Kinesia paradoxa—Run better than walks.
Tandem walking—Heel-to-toe pattern.
Gluteal—Leaning of the trunk to the affected side.
Antalgic/Limping—Patient does not put his complete weight on the affected lower limb, step length is very small.
Calcaneal—Patient walks on the heel.
Hand to knee/Quadriceps—Knee has to be forcibly extended during heel strike and this is done by placing hand on thigh at midstance.
Talus/Equinous/Toe—Walks on toes.
Valgus—Walks on medial border of the foot and knock knee is present.
Varus—Patient walks on the lateral border of the foot and associated bow leg is present.351
 
LEVELS OF AMPUTATIONS (FIGS 6.1 AND 6.2)
Fig. 6.1: Levels of amputation in lower limb
352
Fig. 6.2: Levels of amputation in upper limb
353
 
ABBREVIATIONS
AAA
Abdominal aortic aneurysm
Ab
Antibody
ABG
Arterial blood gas
ABPA
Allergic bronchopulmonary aspergillosis
ACBT
Active cycle of breathing technique
ACE
Angiotensin-converting-enzyme
ACT
Activated clotting time
ACTH
Adrenocorticotropic hormone
AD
Autogenic drainage
ADH
Anti-diuretic hormone
ADL
Activities of daily living
A-aDO2
Alveolar-arterial oxygen gradient
ADR
Adverse drug reaction
AE
Air entry
AEA
Above elbow amputation
AF
Atrial fibrillation or a febrile
AFB
Acid fast bacilli
AFO
Ankle foot orthosis
Ag
Antigen
AGN
Acute glomerulonephritis
AHRF
Acute hypoxemic respiratory failure
Ai
Aortic insufficiency
AIDS
Acquired immunodeficiency syndrome
AKA
Above knee amputation
AL
Acute leukemia
ALD
Alcoholic liver disease354
ALI
Acute lung injury
AMBER
Advance multiple beam equalization radiography
AML
Acute myeloid leukemia
AP
Anteroposterior
APACHE
Acute physiology and chronic health evaluation
A-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 saturated
AVAS
Absolute visual analog scale
AVF
Arteriovenous fistula
AVR
Aortic valve replacement
AVSD
Atrioventricular septal defect
AXR
Abdominal X-ray
B/slab
Back slab
BCG
Bacille Calmette-Guerin
BDI
Baseline and transition dyspnea index
BE
Bacterial endocarditis/barium enema/base excess
BEA
Below elbow amputation
BiPAP
Bilevel positive airway pressure
BIVAD
Biventricular device355
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
Consistent with
Ca
Carcinoma
CABG
Coronary artery-bypass graft
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 hip
CF
Cystic fibrosis
CFA
Cryptogenic fibrosing alveolitis356
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/cytomegalovirus
CNS
Central nervous system
CO
Carbon monoxide
CO
Cardiac output
CO2
Carbon dioxide
COAD
Chronic obstructive airways disease
CoP
Completion of plaster
COPD
Chronic obstructive pulmonary disease
CP
Cerebral palsy
CPAP
Continuous positive airway pressure
CPM
Continuous passive movement
CPN
Community psychiatric nurse
CPP
Cerebral perfusion pressure
CPR
Cardiopulmonary resuscitation
Crash team
Cardiac arrest team
CRF
Chronic renal failure
CRP
C-reactive protein
CRP
Conditioning rehabilitation program 357
CRQ
Chronic respiratory disease questionnaire
C-section
Cesarean section
CSF
Cerebrospinal fluid
CT
Computed tomography
CVA
Cerebrovascular accident
CVI
Cerebrovascular incident
CVP
Central venous pressure
CVS
Cardiovascular system
CVVHF
Continuous veno-venous hemofiltration
CXR
Chest X-rays
D and C
Dilation and curettage
D/C
Discharge
D/W
Discussed with
DBE
Deep breathing exercises
DDD
Degenerative disc 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
Dl
Deciliter
DLCO
Diffusing capacity for carbon monoxide 358
DM
Diabetes mellitus
DMARD
Disease modifying anti-rheumatic drug
DMD
Duchenne muscular dystrophy
DN
District nurse
DNA
Deoxyribonucleic acid/did not attend
DOA
Dead on arrival/date of admission
DSA
Digital subtraction angiography
DTs
Delirium tremens
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
ETT
Exercise tolerance test
EMG
Electromyography
ENT
Ear, nose and throat
EOR
End of range
Ep
Epilepsy
EPAP
Expiratory positive airway pressure
EPP
Equal pressure points359
ERCP
Endoscopic retrograde, cholangiopancreatography
ERV
Expiratory reserve volume
ESR
Erythrocyte sedimentation rate
ESRF
End stage renal failure
ETCO2
End-tidal carbon dioxide
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
Ft
Feet
FVC
Forced vital capacity
FWB
Full weight bearing
G
Gram
GA
General anesthetic
Gaw
Airway conductance
GBS
Guillain-Barré syndrome360
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
H+
Hydrogen ion
H2
Hydrogen
HASO
Hip abduction spinal orthosis
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 antigen361
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
Hz
Hertz
IABP
Intra-aortic 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
IDDM
Insulin dependent diabetes mellitus
IF
Interferential therapy
Ig
Immunoglobulin
IHD
Ischemic heart disease
ILD
Interstitial lung disease
IM
Intramedullary
IM/im
Intramuscular
IMA
Internal mammary artery
IMV
Intermittent mandatory ventilation
INH
Inhalation
INR
International normalized ratio
IPAP
Inspiratory positive airway pressure
IPPB
Intermittent positive pressure breathing362
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
J
Joule
JVP
Jugular venous pressure
KAFO
Knee ankle foot orthosis
KCO
Transfer coefficient
KO
Knee orthosis
KPa
Kilopascal
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 test363
LFT × 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
M
Meter
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
Medical collateral ligament
MCV
Mean corpuscular volume
MDI
Multidisciplinary team
MDI
Metered dose inhaler
ME
Metabolic equivalents/myalgic encephalomyelitis
MEFV
Maximum expiratory flow volume
METs
Metabolic equivalents
MHz
Megahertz
MI
Myocardial infraction
MIFV
Maximum inspiratory flow volume364
ML
Middle lobe
MM
Muscle
MMAD
Mass median aerodynamic diameter
mmHg
Millimeter of mercury
MMV
Mandatory minute volume
MND
Motor neuron disease
MOW
Meals on wheels
Mph
Miles per hour
MRI
Magnetic resonance imaging
MRSA
Methicillin-resistant staphylococcus aureus
Ms
Millisecond
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
Non-accidental injury
NBI
No bony injury
NBL
Non-directed bronchial lavage
NBM
Nil by mouth
NCPAP
Nasal continuous positive airway pressure
NEEP
Negative end expiratory pressure365
NEPV
Negative extra-thoracic pressure ventilation
NFR
Note for resuscitation
NG
Nasogastric
NH
Nursing home
NICU
Neonatal intensive care unit
NIDDM
Non-insulin dependent diabetes mellitus
NIPPV
Non-invasive intermittent positive pressure ventilation
NITU
Neonatal intensive care unit
NIV
Non-invasive ventilation
Nm
Nanometer
Nmol
Nanomole
NMR
Nuclear magnetic resonance
NO
Nitric oxide
NOF
Neck of femur
NOH
Neck of humerus
NP
Nasopharyngeal
NPA
Nasopharyngeal airway
NPV
Negative pressure ventilation
NR
Nodal rhythm
NREM
Non-rapid eye movement
NSAID
Non-steroidal anti-inflammatory drug
NSR
Normal sinus rhythm
NWB
Non-weight bearing
O/E
On examination
O2
Oxygen
OA
Oral airway/osteoarthritis366
OB
Obliterative bronchiolitis
Occ
Occasional
OD
Over dose
Oe
Objective examination
OGD
Oesophagogastroduodenoscopy
OHFO
Oral high-frequency oscillation
Oi
Oxygen index
°JACCOL
No jaundice, anemia, clubbing, cyanosis, edema
°LKKS
No liver, kidney, kidney, spleen
OLT
Orthotopic liver transplantation
OPD
Outpatient department
ORIF
Open reduction and internal fixation
OT
Occupational therapist
PR
Per rectum
PA
Posteroanterior
PA
Pernicious anemia/posteroanterior/pulmonary artery
PACO2
Partial pressure of carbon dioxide in alveolar 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 blood367
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
Pressure-controlled inverted ratio ventilation
PCP
Pneumocystis carinii pneumonia
PCPAP
Periodic continuous positive airway pressure
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 and reactive to light and accommodation
PFC
Persistent fetal circulation368
PFO
Persistent foramen ovale
PFY
Patellofemoral 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 record
POP
Plaster of Paris
PPIVM
Passive physiological intervertebral movement
PROM
Passive range of movement
PS
Pressure support/pulmonary stenosis
PTB
Pulmonary tuberculosis
PTCA
Percutaneous transluminal coronary angioplasty
PTFE
Polytetrafluoroethylene
PTT
Partial thromboplastin time
PU
Passed urine
PVC
Polyvinyl chloride
PVD
Peripheral vascular disease
PVH
Periventricular hemorrhage369
PVL
Periventricular leukomalacia
PVR
Pulmonary vascular resistance
PWB
Partial weight-bearing
Px
Prescribing
QOL
Quality of life
R/O
Removal of
RA
Rheumatoid arthritis/room air
RAP
Right atrial 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
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
RS
Respiratory system
RSV
Respiratory syncytial virus
RTA
Road traffic accident
RV
Residual volume
RVF
Right ventricular failure
SC
Subcuticular
SA
Sinoatrial370
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
SH
Social history
SHO
Senior house officer
SIJ
Sacroiliac joint
SIMV
Synchronized intermittent mandatory ventilation
SL
Sublingual
SLAP
Superior labrum, anterior and posterior
SLE
Systemic lupus erythematosus
SMA
Spinal muscular atrophy
SN
Swedish nose
SNAG
Sustained natural apophyseal glide
SOA
Swelling of ankle
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 stick371
SR
Sinus rhythm
SRAW
Specific airway resistance
SS
Social services
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
SW
Social worker
SWT
Shuttle walk test
T21
Trisomy 21 (Down's syndrome)
TA
Tendon of Achilles
TAA
Thoracic aortic aneurysm
TAH
Total abdominal hysterectomy
TAR
Total ankle replacement
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 arteriogram372
TFT
Thyroid function test
TGA
Transposition of 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
Trans urethral resection of prostate
TV
Tidal volume
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
mm
Micrometer
URTI
Upper respiratory tract infection373
ms
Microsecond
USS
Ultrasound scan
UTI
Urinary tract infection
V
Ventilation
V/p shunt
Ventricular peritoneal shunt
V/Q
Ventilation-perfusion ratio
VA
Alveolar ventilation/alveolar volume
VAD
Ventricular assist device
VAS
Visual analog 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
W
Watt
W/R
Ward round
WBC
White blood count
WCC
White cell count
WOB
Work of breathing
ZEEP
Zero end expiratory pressure374
 
OTHER 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—assisted
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
Δ —diagnosis
—circumduction
!!—parallel
—abdomen
H—head
Frh—forehead
N—neck
B—back
T—trunk
S—side
Abd—abdomen
P—pelvis
Shbl—shoulder blades
Sh—shoulder
A—arm
Elb—elbow
Wr—wrist
Hnd—hand375
Fing—fingers
L—leg
K—knee
Hl—heel
F—feet
Ank—ankle
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
Add—adduction
U—upward.
S—sideways
376
 
NORMAL REFERENCE/LAB VALUES
 
HEMATOLOGY
Male
Female
Units
Activated partial thromboplastics time APTT (PTTK)
35-45
35-45
Seconds
ESR
Westergren
Wintrobe
 
0-10
0-7
 
0-20
0-14
 
mm/lst hr
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
%
Mean corpuscular hemoglobin
MCH
28-32
28-32
Pg
Mean corpuscular hemoglobin concentration
MCHC
31-36
31-36
G/dl or %
Mean corpuscular volume
MCV
78-98
78-98
FL
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 count
0.5-2.0
0.5-2.0
%
Serum iron
80-180
60-160
Ug/dl
Serum feritin
16-300 (mean 50)
12-160 (mean 18)
Ug/ml
Total iron binding capacity
Tibc
250-450
250-450
Ug/dl
Total leukocyte
TLC
4000-11000
4000-11000
Million/cumm count
Transferring saturation
30-35
30-35
%
377
 
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
5-40
U/l aminotransferase SGOT
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
Creatinine clearance
70-120
ml/min
S fatty acid
Total 9-15
mmol/l
B glucose fasting
65-100
mg/dl
B glucose PP
<140
mg/dl (postprandial 2 hours)
S lactate dehydrogenase LDH
50-150
Units/L
S lipids total
400-800
mg/dl
S phosphatase acid
1-5
2-10
Ka units/dl units/L
Prostatic fraction
Up to 4
units/L378
S phosphatase alkaline
40-100
4-12
units/L Ka units/dl
S proteins total
Albumin
Globulin
A/g ratio
5.5-8
3.5-6.0
2.0-3.5
1.5:1-3:1
gm/dl
gm/dl
gm/dl
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
Values are only for adults and depending on testing methods used.
 
OTHER BODY FLUIDS
 
Urine Examination
Urine examination
24 hr volume
600-1800 ml
Specific gravity
urine (random)
1.003-1.030
Protein excretion
24 hr urine
<150 mg/day
Protein, qualitative
urine
negative
Glucose excretion
24 hr urine
50-300 mg/day
Glucose qualitative
urine (random)
negative
Porphobilinogen
urine (random)
negative
Urobilinogen
24 hr urine
1.0-3.5 mg/day
 
Stool Examination
Coproporphyrin
400-1000 mg/day
Fecal fat excretion
<6.0 g/day
Occult blood
negative (<2 ml blood/day)
Urobilinogen
40-200 mg/day
379
 
Cerebrospinal Fluid (CSF)
Normally cerebrospinal fluid is clear, colorless and faintly alkaline.
Production
100 ml/day
CSF volume
120–150 ml
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
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%
380
 
NOTES
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Index
Page numbers followed by f refer to figure
AAbduction stress test Abductordigiti minimi hallucis pollicisbrevis longus Abnormalbreath sounds ECG findings gait Acetazolamide Acetylcysteine Achondroplasia Aciclovir Acute respiratory distress syndrome Adduction stress test Adductorbrevis hallucis longus magnus pollicis Adenosine Adventitious sounds Aerosol therapy Albendazole Albers-Schönberg disease Alendronate , Alfentanil Allopurinol Alphabetical listing of muscles Alprazolam Alternateheel-to-knee test nose-to-finger test Alternative method of postural drainage Alzheimer's disease Ambulatory manual breathing unit bag Aminophyline Amiodarone Amitriptyline Amlodipine Amoxicillin Ampicillin Anconeus Ankle joint Ankylosing spondylitis Anterioraspect of neck and carotid sinus border ofleft lungs right lung cerebral artery , cord syndrome drawer test , , gapping test labral tear test Apgar scoring method Apley's test Arachnoiditis Arterialblood gas classification of respiratory failure pressure supply of cerebral hemi- sphere Arthrogryposis multiplex congenita Ascending tracts Aspirin Atelectasis of lung Atenolol Atracurium Atropine Auscultation Axillary nerve Azathioprine BBaclofen Baker's cyst Barton's fracture Basal ganglia Beclomethasone Bell's palsy Bendrofluazide Bendroflumethiazide Bennett's fracture Benzhexol Bicepsbrachii femoris Biphasic positive airway pressure Bloodurea nitrogen values Body volume Brachialis Brachioradialis Breath sounds Broca's dysphasia Bronchial asthma Bronchiectasis Bronchitis Bronchopulmonary segments Brown-Sequard syndrome Brudzinski-Kernig test Brush test Budesonide Bulbar palsy Bumper fracture Bursitis CCalcitonin Captopril Carbamazepine Cardiacindex output Cardiorespiratory monitoring Carpal-Tunnel syndrome Celecoxib Cellular proliferation Centralcord syndrome venous pressure Cerebralpalsy perfusion pressure Cerebrospinal fluid Cervical spine , , Charcot-Marie-tooth disease Chloramphenicol Chloroquine Chlorpromazine Chronic obstructive pulmonary disease Ciclosporin Ciprofloxacin Circular arteriosus Clofazimine Clomipramine Clonidine Clunk test Codeine phosphate Codman's test Cold therapy Colles’ fracture Commonmusculoskeletal tests peroneal nerve sports injuries Compartment syndrome Computed tomography Congenitaldislocation of hip lung cyst talipes equinovarus Continuouspassive motion positive airway pressure Contrast bath Controlled mechanical ventilation Coproporphyrin Coracobrachialis Coronal section of brain Corpus callosum Cozen's test Cranial nerves Crank test Cryotherapy Cystic fibrosis DDapsone De Quervain's disease Deep tendon reflexes Dermatomes Descending tracts Dexamethasone Diaphragm , Diazepam Diclofenac Didanosine Digoxin Dihydrocodeine Diltiazem Disseminated encephalo- myelitis Distraction test Dobutamine Donepezil Dopamine Dornase alfa Dorsal interossei , Dosulepin Dothiepin Doxapram Doxycycline Droparm test Duga's test Dupuytren's contracture EEfavirenz Ejection fraction Elbow , and forearm flexion test joint , Electrodiagnostic testing Electroencephalography Electromyography Emphysema Empyema Enalapril Erythromycin Etidronate Evoked potentials Expiratory reserve volume Extensorcarpi radialisbrevis longus carpi ulnaris digiti minimi digitorum brevis longus hallucis longus indicis pollicisbrevis longus External rotation recurvatum test FFaber's test Fairbank's apprehension test Farfan torsion test Femoral nerve Fentanyl Ferrous sulphate Fibromyalgia Fibrositis Finger-to- finger test nose test Finkelstein's test Flexorcarpiradialis ulnaris digiti minimi brevis digitorumaccessorius brevis longus profundus superficialis hallucis brevis Flucloxacillin Forced expiratory techniques Frusemide Functional residual capacity Furosemide GGabapentin Gaenslen's test Gait terminology Galeazzi fracture Gastrocnemius Gatifloxacin Gemellusinferior superior Gentamicin Gillets test Glasgow coma scale Gliclazide Gluteusmaximus medius minimus Golfer's elbow Gracilis Guillain-Barré syndrome HHaloperidol Hamilton ruler test Hawkins-Kennedy test Heart rate Heel-Shin test Hematoma formation Hemiplegia Hemothorax Heparin Hibb's test High frequency ventilation Hip joint , Hoffmann reflex Horner's syndrome Hughston plica test Huntington's disease Hydrocephalus Hydrocortisone IIbuprofen Iliacus Iliocostaliscervicis lumborum thoracis Inflammation of pleura Infrared radiation Infraspinatus Inspiratorycapacity reserve volume Insulin Intercostalisexterni interni Intermittentmandatory ventilation pneumatic compression positive pressure breathing Interspinalis Intertransversarii Intracranial pressure Iontophoresis Ipratropium Ischiocavernosus Ishihara's chart Isoniazid Isosorbide mononitrate JJacksonion march Jerk test Joint position sense Jug test KKetamine Knee joint , LLachman's test Lactulose Laguere's sign Laser therapy Lateralcricoarytenoid decubitus epicondylitis test Latissimus dorsi Levator scapulae Levels of amputation inlower limb upper limb Lidocaine Lignocaine Liniburg's test Liquid paraffin Lisinopril Location of normal breath sounds Longissimuscapitis cervicis thoracis Longuscapitis colli Lowermotor neuron quarter screen Lumbar spine Lungabscess capacities function test volumes and capacities Lunotriquetral ballottement test MMagnetic resonance imaging Mallet fracture Manualchest clearance technique hyperinflation muscle testing grading McMurray test Medial epicondylitis Meloxiam Meningitis Metformin Methotrexate Methyldopa Metronidazole Mid sagittal section of brain Midazolam Middle cerebral artery , Modified Ashworth scale for grading spasticity Monteggia's fracture Morphine Motor neuron disease Multifidus Multiple sclerosis Murphy's sign Muscular dystrophy Musculocutaneous nerve Myasthenia gravis Myositis ossificans Myotomes NNaproxen National Immunization Schedule Neer impingement test Nerve conduction studies Neuromuscular electrical stimulation Neutrophil New bone formation Noninvasive ventilation Norfloxacin OOber's sign Obturatorexternus internus nerve Omeprazole Ondansetron Opponensdigiti minimi pollicis Origination of nerve Orphenadrine Osgood-Schlatter disease Osteoarthritis Osteochondritis dissecans Osteomalacia Osteomyelitis Oxybutinin Oxytetracycline PPaget's disease Palmar interossei Palmaris longus Palpation of pulses Pancuronium Paracetamol Paraffin wax bath Patrick's test Pectineus Pectoralismajor minor Pelvis Penicillin-G Peripheral nervous system Peroneusbrevis longus tertius Perthes’ disease Pethidine Phalen's test Phenytoin Piedallu's signs Pinch grip test Piriformis Piroxicam Plantar interossei Plantaris Pleural rub Pleurisy Pneumonia Pneumothorax Poliomyelitis Polyarteritis nodosa Polycythemia Polymyalgia rheumatica Polymyositis Popliteus Positive end expiratory pressure Posteriorcerebral artery , cord syndrome drawer test , gapping test labral tear test sag test Postpolio syndrome Postural drainage Prednisolone Pressure controlled ventilation Pronatorquadratus teres Propranolol Proprioceptive neuromus- cular facilitation Prothrombin time Pseudobulbar palsy Psoasmajor minor Pulmonaryartery pressure edema embolism tuberculosis QQuadrant test , Quadratusfemoris lumborum Quinine RRadial nerve Radioulnar joint Ramipril Ranitidine Rapidly alternating movement Readings of chest X-rays Reagan's test Rectusabdominis capitisanterior lateralis posterior major posterior minor femoris contracture test Red blood cells Respiratoryfailure pathologies rate volumes and capacities Reverse Phalen's test Rheumatoid arthritis Rhomboidmajor minor Rifampicin Right cerebral hemisphere Rolado's fracture Romberg's test , SSacral sparing Salbutamol Salcatonin Sarcoidosis Sartorius Scalenusanterior medius posterior Scapula Scheuermann's disease Sciatic nerve Semispinaliscapitis cervicis thoracis Sensoryaphasia assessment ataxia loss Serratus anterior Sharpened Romberg's test Sharp-Purser test Short wave diathermy Shoulder joint , Skin sensation test , , , , , , -Sleep apnea Slump test , Smith's fracture Speeds test Spinalcord tracts muscular atrophis Spleniuscapitis cervicals Spondylolisthesis Spondylolysis Spondylosis Spurling's test Squeeze test of leg Stages ofcalcification fracture healing Standing flexion Stethoscope position Straight leg raise test Strength duration curve Streptokinase Streptomycin Stroke volume Subscapularis Subtalar joint Sulcus sign Sulfasalazine Superficial reflexes Superior oblique Supine-to-set test Supraspinatus Sweater finger sign Synchronized intermittent mandatory ventilation Systemiclupus erythematous sclerosis TTalar tilt Tennis elbow , Tenosynovitis Tensor fasciae latae Teresmajor minor Tetracycline Theophylline Thomas test Thoment's sign Thompson's test Thoracicand lumbar spine outlet syndrome spine Thoracolumbar spine Tibial nerve Tibialisanterior posterior Tidal volume Timolol Tinel's sign Tinidazole Tizanidine Tolterodine Totaliron binding leukocyte lung capacity Tracheal bifurcation Tracheostomies Tramadol Transcutaneous electrical nerve stimulation Transverse myelitis Transversus abdominis Trapezius Trazodone Trendelenburg's sign Triceps brachii Trigeminal neuralgia Trihexyphenidyl Types ofaphasia goniometer nebulizer nerve tracheostomy tube UUlnar nerve Ultraviolet radiations Upperlimb tension test motor neuron quarter screen Uric acid Urobilinogen VValgus stress test , Vancomycin Varus stress test Vastusintermedius lateralis medialis Vecuronium Venous blood Ventilation/perfusion Verapamil Vital capacity WWaston test Wernicke's dysphasia Whirlpool bath White blood cells Wristflexion test joint and hand ZZalcitabine Zidovudine