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Free board review book · Dr. Akash Garg

Physical Therapy Boards: NPTE Review

The complete book on one page. Use the button at the bottom right to save it as a PDF.

  1. Chapter 1: How the NPTE Works and How to Think Like the Exam
  2. Chapter 2: Musculoskeletal Foundations: Tissue, Kinesiology and the Spine
  3. Chapter 3: Musculoskeletal: The Upper Extremity
  4. Chapter 4: Musculoskeletal: The Lower Extremity and Gait
  5. Chapter 5: Neuromuscular Foundations: Neuroanatomy, Examination and Motor Control
  6. Chapter 6: Neuromuscular: Stroke, Brain Injury and Spinal Cord Injury
  7. Chapter 7: Neuromuscular: Progressive, Peripheral and Vestibular Disorders
  8. Chapter 8: Cardiovascular and Pulmonary Foundations: Physiology, Examination and Monitoring
  9. Chapter 9: Cardiovascular, Pulmonary and Lymphatic Conditions and Rehabilitation
  10. Chapter 10: Integumentary: Wounds, Burns and Skin
  11. Chapter 11: Other Systems and System Interactions
  12. Chapter 12: Therapeutic Modalities, Equipment and Devices
  13. Chapter 13: Safety, Professional Responsibilities and Evidence
  14. Chapter 14: Lifespan, Special Populations and Integrated Cases
Chapter 1 · Exam Strategy

How the NPTE Works and How to Think Like the Exam

The physical therapist licensing exam does not reward the student who memorized the most facts; it rewards the student who can read a short clinical story, see what the patient needs right now, and choose the safest, most effective next step. That is a learnable skill. This chapter explains how the exam is built, how its questions are written, the clinical models its authors think in, and a study plan that turns review time into points.

By the end of this chapter you can

  • Describe the format of the NPTE, including scored and pretest items, scenario and media items, and how the scaled score works.
  • Explain how the content outline crosses body systems and nonsystems areas with the clinical tasks of examination, evaluation and diagnosis and intervention.
  • Dissect a stem to find the patient, the setting and the task, and decode keywords such as first, best, most appropriate and least likely.
  • Apply priority and safety logic (medical stability, red flags, contraindications) to eliminate distractors.
  • Walk through the patient and client management model from examination to outcomes and place findings in the correct step.
  • Classify findings using the ICF: body structure and function, activity, participation, and environmental and personal factors.
  • Compare acute care, inpatient rehabilitation, skilled nursing, home health, outpatient and school based practice, and apply direct access and referral rules.
  • Build a spaced review plan with practice exams, a structured miss analysis, pacing targets and test anxiety strategies.

Section 1The structure of the licensing exam

What the exam is and who it serves

The National Physical Therapy Examination (NPTE) is the entry level licensing exam for physical therapists in the United States. It is developed and administered by the Federation of State Boards of Physical Therapy, an organization of the state licensing boards, and every state uses it as one requirement for licensure. A separate exam exists for physical therapist assistants. The purpose of a licensing exam is public protection: it asks whether a new graduate can practice safely and effectively at entry level. That purpose explains its personality. Questions favor safety, common conditions, sound clinical reasoning and the core of practice over rare trivia, and most questions put you in the role of a therapist making a decision about a real patient.

Passing the NPTE is necessary but not sufficient for a license. States also set their own requirements, which may include a jurisprudence exam on the state practice act, a background check and proof of graduation from an accredited program. Rules on registration, eligibility, scheduling, attempt limits and accommodations change, so the only reliable source is the current official candidate handbook. Read it early, because some steps (state approval of eligibility, accommodation requests) take weeks.

The testing experience

The NPTE is a computer based, multiple choice exam delivered at secure testing centers. It is long: the day is divided into several timed sections with a scheduled break, and most candidates describe it as an endurance event as much as a knowledge test. Each item is a stem followed by four options, and you choose the single best answer. There is no penalty for guessing, so you should never leave an item blank. Within a section you can flag items and return to them; once a section closes, you cannot go back. You will see a short tutorial before the first section, and the clock does not stop for breaks taken inside a section.

Most items are scenario items: a vignette with age, setting, diagnosis and findings that asks what to do or what a finding means. A minority are direct recall items. Media items add an image, graph, ECG strip, radiograph or short video (a gait pattern, a transfer) to interpret, and some items share a scenario but are scored independently.

Scored and pretest items

Not every item counts. A portion of each form is made up of pretest items: new questions being tried out so their statistics can be checked before they ever count toward a score. Pretest items look exactly like scored items and are mixed in among them, so you cannot tell which is which. The practical lesson is important for your nerves. When you meet a question that seems strange, ambiguous or far outside what you studied, it may well be a pretest item that will be discarded. Make your best choice, flag it if time allows, and move on without letting it shake your confidence.

Scaled scores

Different forms of the exam contain different items, and some forms are slightly harder than others. To be fair, raw scores are converted to a scaled score so that a given scaled score represents the same level of ability on every form. The NPTE reports scores on a scale of 200 to 800, and the passing standard is a scaled score of 600. Because of equating, the number of items you must answer correctly to reach 600 varies a little from form to form, which is why nobody can honestly tell you a fixed percentage to aim for. The passing standard is set by a criterion referenced process: expert panels judge how a minimally competent entry level therapist would perform. You are not competing with the other candidates on your test day.

The content outline: systems and nonsystems

The exam is built from a published content outline, a blueprint that sets how many items come from each area. Its organization is two dimensional. One dimension is content: the body systems and the nonsystems areas. The other is the clinical task being tested.

Content areaWhat it coversTypical tested decisions
MusculoskeletalSpine, upper and lower extremity, fractures, arthroplasty, gait, orthopedic surgerySpecial tests, mobilization choice, postoperative precautions, exercise progression
Neuromuscular and nervousStroke, spinal cord injury, traumatic brain injury, Parkinson disease, multiple sclerosis, peripheral nerves, vestibular, pediatricsLesion localization, functional prognosis, motor learning, balance and fall risk
Cardiovascular and pulmonaryHeart failure, myocardial infarction, COPD, restrictive disease, ECG, airway clearance, cardiac rehabVital sign responses, exercise termination, oxygen use, breathing techniques
LymphaticLymphedema, complete decongestive therapyStaging, bandaging, contraindications to compression
IntegumentaryPressure injury, venous and arterial ulcers, burns, wound careWound classification, debridement choice, dressing selection
Metabolic and endocrineDiabetes, thyroid disease, obesity, bone metabolismGlucose thresholds for exercise, hypoglycemia response
Gastrointestinal and genitourinaryReferred visceral pain, incontinence, pelvic health, renal diseaseScreening for referral, pelvic floor training
System interactionsMultisystem problems such as sepsis, cancer, deconditioning, pregnancy, complex older adultsIntegrating findings across systems, monitoring
NonsystemsEquipment and devices, therapeutic modalities, safety and protection, professional responsibilities, research and evidence based practiceDevice fit, modality parameters, infection control, ethics, statistics

Musculoskeletal and neuromuscular content together account for about half of the exam, which is why they receive the largest share of this book. Cardiovascular and pulmonary is the next largest system. The smaller systems still matter, because each item is worth the same; a candidate who skips integumentary or lymphatic review gives away points that are often easier to earn than difficult neurology items. Exact weights change when the outline is revised (it is updated periodically from a practice analysis survey of working therapists), so download the current version from the official source.

The clinical tasks

The second dimension is what you are asked to do with the content. The outline groups this into broad clinical tasks:

  • Examination: history, systems review and tests and measures. Questions ask which test to choose, how to perform it, or what a result shows.
  • Evaluation, differential diagnosis and prognosis: interpreting findings, identifying the likely condition or the movement system problem, recognizing when the problem is outside physical therapy, and predicting outcome.
  • Intervention: choosing, dosing, progressing and modifying treatment, including exercise, functional training, manual therapy, modalities, devices, education and discharge planning.
  • Foundational sciences: anatomy, physiology, pathology, pharmacology and exercise science that underpin the decisions above.

A single condition can be tested in all of these ways. Take a rotator cuff repair: one item asks which test detects a full thickness tear (examination), another asks what a weak lag sign means for prognosis (evaluation), and a third asks when active elevation may begin (intervention). As you study each condition later in this book, rehearse it across every task.

Every item sits in one cell of the blueprint Examination Evaluation,diagnosis Intervention Musculoskeletal Neuromuscular, nervous Cardiovascular, pulmonary Lymphatic, integumentary,endocrine, GI, GU, multi Nonsystems: devices,modalities, safety, ethics About half of all items Which test? What does it mean? What do I do? Foundational sciences (anatomy, physiology, pathology) run underneath every cell
Figure 1.1 The content outline crosses content areas (rows) with clinical tasks (columns). Musculoskeletal and neuromuscular rows carry about half the exam, but every cell is fair game, so rehearse each condition as an examination, an evaluation and an intervention question.
Board tip. When a question feels bizarre, remember that some items are unscored pretest items you cannot identify. Answer it with your best reasoning, flag it, and protect your time and confidence for the next item. One odd question never decides the exam.
Case. A candidate on a practice exam spends six minutes on a question about an unusual pediatric syndrome, then rushes the last ten items of the section and misses four easy ones on ankle sprain grading and blood pressure response to exercise.
Reasoning: Every item carries the same weight, and some odd items do not count at all. The best strategy is to make a reasoned choice on the hard item within about a minute and a half, flag it, and bank time for the common, high-yield items at the end. The tempting choice (keep working the hard item until certain) costs more points than it can earn. The safety point for test day is the same as for the clinic: do not let one difficult case consume the time owed to everyone else.

What the exam writers value

Items are written and reviewed by practicing clinicians and educators and anchored to entry level practice and current evidence. The same values recur: safety first (stability, red flags, precautions), function and the patient's goals over isolated impairments, current guidelines as the default answer, the least restrictive option that keeps the patient safe, and practice within scope, with appropriate delegation and referral.

Key point

The NPTE is a long, computer based exam of single best answer items, scored on a 200 to 800 scale with 600 as the passing standard. Pretest items are mixed invisibly among scored items. The blueprint crosses body systems and nonsystems content with the tasks of examination, evaluation and intervention, with musculoskeletal and neuromuscular content making up about half. Safety, function, evidence and scope are the values every item is written around.

Section 2Reading a physical therapy question

The three things every stem tells you

Before you look at the options, read the stem and find three things. Experienced test takers do this almost automatically; at first you should do it deliberately.

  1. The patient. Age, diagnosis, time since onset or surgery, comorbidities, medications, vital signs and current function. Every detail was put there for a reason, and the most important details are often the quiet ones: "two days after," "takes warfarin," "lives alone," "type 1 diabetes."
  2. The setting. Intensive care unit, acute hospital floor, inpatient rehabilitation facility, skilled nursing facility, home, outpatient clinic or school. The setting changes what is safe, what is realistic and what the goal of the visit is.
  3. The task. What exactly is being asked: the first action, the best intervention, the most likely diagnosis, the expected finding, the appropriate referral, the correct documentation, the parameter of a modality. Underline it mentally, then answer that question and not a different one.

A useful habit is to read the last sentence of the stem first, so you know the task, and then read the whole stem with that task in mind. In long vignettes this keeps you from drowning in details that do not bear on the question.

1. Read the last lineWhat is the task? 2. Read the stemPatient, setting, clues 3. Predict firstAnswer before options 4. Safety screenUnstable? Red flag?Contraindicated? 5. EliminateTrue but not asked,wrong step, absolutes 6. Last twoWhich comes first?Which is more specific? 7. CommitFlag if unsure, move on Keywords that change the answer FIRST, INITIAL: the earliest safe step BEST, MOST APPROPRIATE: all may help, pick top EXCEPT, LEAST, CONTRAINDICATED: flip the logic MOST LIKELY: the common cause wins
Figure 1.2 A seven step routine for every item. Notice where safety screening sits: after you have predicted an answer but before you start comparing options, so an unsafe option never survives to the final two.

Keywords that change the answer

Small words carry big weight. Item writers use a consistent vocabulary, and misreading one word is the most common source of avoidable error.

KeywordWhat it signalsHow to respond
First, initial, immediatelySequencing; several options may be correct eventuallyChoose the step that must precede the others, usually assessment or safety
Best, most appropriate, most effectiveMore than one option is reasonablePick the one most supported by evidence, most specific to the problem and most functional
Most likelyProbabilityChoose the common explanation that fits all the findings, not the exotic one that fits one
Except, least, not, contraindicatedNegative itemFind the one false or unsafe option; rephrase as "which one does not belong?"
Priority, primary concern, greatest riskRanking threatsLife and limb threats, then medical stability, then function
Expected, typicalNormal response or courseRecall the textbook pattern (for example, systolic pressure rises with exercise while diastolic stays roughly the same)
Should the therapistProfessional actionChoose the action within scope that protects the patient

Predict, then compare

Form an answer in your head before reading the options. If it is there, it is probably right, though you should still check the others; if it is not, reread the stem for the clue you missed. Prediction protects you from the most persuasive distractors.

The anatomy of a distractor

Wrong options are not random. They are built to catch predictable mistakes, and once you recognize the types you eliminate them faster.

  • True but irrelevant. The statement is correct medicine but does not answer this task. A stem asking for the first action after a fall may offer an excellent strengthening exercise; true, useful, not first.
  • Right action, wrong time. Correct for a later phase (resisted exercise two days after a tendon repair) or an earlier one (passive range of motion only, when the patient is ready for strengthening).
  • Right idea, wrong patient. Appropriate for a different diagnosis or setting, such as a home exercise program for a patient in the ICU.
  • Overreach. An action outside physical therapist scope (adjusting a medication dose, ordering imaging where not permitted, diagnosing a medical disease) or outside entry level competence.
  • Absolutes and extremes. "Always," "never," "complete bed rest," "discontinue all exercise." Real practice rarely works in absolutes, so these options are usually wrong unless they describe a true contraindication.
  • Passive or modality heavy choices when the patient needs active, functional work. Modalities are adjuncts; they are rarely the best answer when an active intervention is available.

When two options remain, ask: which one is more specific to the problem described, which one is more functional, which one comes earlier in the logical sequence, and which one is safer? Usually one of these questions breaks the tie.

Priority and safety logic

Many items are really ranking problems. When the stem describes a patient who could be harmed, the hierarchy below almost always decides the answer.

RankPriorityExamples in a stem
1Life threatening emergencyUnresponsive, no pulse, chest pain with diaphoresis, signs of stroke, anaphylaxis, autonomic dysreflexia: stop, call for help, begin the emergency protocol
2Airway, breathing, circulation and abnormal vital signsSpO2 falling below about 88 to 90 percent, systolic pressure dropping with exercise, new arrhythmia, severe dyspnea
3Red flags requiring referralSaddle anesthesia, unexplained weight loss with night pain, signs of deep vein thrombosis, fever with spinal pain
4Precautions and contraindicationsHip precautions, weight bearing limits, sternal precautions, modality contraindications
5Examination before interventionAssess what has changed before acting; you cannot treat what you have not measured
6Function and patient goalsTask specific training, independence, return to valued roles
7Comfort and impairment level carePain modalities, isolated range of motion, general conditioning

When a stem reports a change in status (new confusion, sudden pain, calf swelling, falling oxygen saturation) or gives abnormal values, the answer usually involves stopping or modifying the activity and assessing or reporting, not pushing on with the plan.

Board tip. In "first" questions, the answer is often "assess" or "ask," but not always. If the danger is already clear (a patient who has stopped breathing, a patient sliding to the floor), act first. Check whether the stem has already given you the assessment data; if it has, a choice that repeats that assessment is a distractor.

Common traps

Do not add information the stem does not give, and do not change a reasoned answer without a specific clue. Avoid the impressive specialist technique when a standard, well supported one fits entry level practice. Let the setting shape the answer, and never treat numbers as decoration: a Berg score of 38, an ankle brachial index of 0.6 or a platelet count of 15,000 each changes the answer.

Case. A 72 year old man on postoperative day 2 after a right total knee arthroplasty is seen in the acute hospital for gait training. While walking with a rolling walker he reports new shortness of breath and sharp chest pain on inspiration; heart rate is 118 and SpO2 is 89 percent on room air. Which action should the therapist take first? Options: continue gait with closer guarding, have him sit and rest and then resume, return him to bed, stop activity and notify the medical team immediately while monitoring him.
Reasoning: The patient is two days after lower limb joint replacement, a classic risk window for venous thromboembolism. Sudden dyspnea, pleuritic chest pain, tachycardia and desaturation suggest pulmonary embolism, a medical emergency. Continuing gait is unsafe. Rest and resume treats this as fatigue. Returning him to bed is part of the answer but is incomplete because it delays medical evaluation. The best answer is to stop, keep him seated or supported, stay with him, monitor vital signs and notify the medical team (activating the emergency response if he deteriorates). The safety point: new cardiopulmonary symptoms during activity mean stop and report, never push through.
Key point

Read every stem for the patient, the setting and the task, preferably reading the final sentence first. Predict an answer before reading the options, then eliminate distractors that are true but irrelevant, mistimed, wrong for this patient, beyond scope or written in absolutes. Use the priority ladder (emergency, vital signs, red flags, precautions, examination, function, comfort) to break ties, and treat any change in status or abnormal number as a signal to stop, assess and report.

Section 3The patient and client management model and the ICF

Why the model matters on the exam

Physical therapy practice in the United States is organized around the patient and client management model: a cycle of examination, evaluation, diagnosis, prognosis, intervention and outcomes. Many exam items are really asking "which step are we in?" An option can be the right action in the wrong step. If a question asks what the therapist should do when a patient arrives for the first visit, the answer lies in examination; if it asks what to conclude from the findings, it lies in evaluation; if it asks how long recovery will take, it lies in prognosis. Recognizing the step narrows the options immediately.

ExaminationHistory, systems review,tests and measures EvaluationClinical judgment DiagnosisMovement system label PrognosisExpected level, time,plan of care, goals InterventionCoordination, education,procedural interventions OutcomesFunction, participation reexamine each visit Refer outat any step
Figure 1.3 The patient and client management model. Examination gathers data, evaluation interprets it, diagnosis names the problem, prognosis sets goals and the plan, intervention carries it out, and outcomes are measured. Reexamination loops back at every visit, and referral can leave the cycle at any point.

The steps one by one

Examination has three parts. The history collects demographics, the chief complaint, onset and course, past medical and surgical history, medications, social history, living environment, prior and current function and the patient's goals. The systems review is a brief screen of the cardiovascular and pulmonary (heart rate, respiratory rate, blood pressure, edema), integumentary (skin integrity, color, scar), musculoskeletal (gross symmetry, strength, range, height and weight) and neuromuscular (gross coordinated movement such as balance, gait and transfers) systems, plus communication, affect, cognition, language and learning style. Its purpose is to find problems that need further testing or referral. Tests and measures are the specific, chosen procedures (goniometry, manual muscle testing, special tests, balance scales, gait speed) used to confirm or refute hypotheses.

Evaluation is the thinking step: a dynamic process of making clinical judgments from the examination data. It weighs the severity, chronicity, stability and complexity of the problem and leads to a diagnosis. Evaluation is also where the therapist decides whether the problem belongs in physical therapy at all.

Diagnosis in physical therapy labels the problem at the level of the movement system and function. It is not a substitute for a medical diagnosis; a therapist may describe "impaired joint mobility and motor function associated with a shoulder disorder," while the physician's diagnosis is "adhesive capsulitis." Physical therapists do diagnose within their scope, and in direct access settings they also screen for conditions that need medical diagnosis.

Prognosis is the predicted optimal level of improvement and the time needed to reach it. It is written into the plan of care, which includes the goals, the expected frequency and duration of visits, the interventions planned and the discharge plan. Good goals are functional and measurable; a common framework names the Audience, Behavior, Condition, Degree and expected time ("Patient will ambulate 150 feet on level surfaces with a single point cane and supervision within 2 weeks").

Intervention is broader than procedures. It includes coordination, communication and documentation (case management, communication with the team, discharge planning), patient and client instruction (education of the patient, family and caregivers), and procedural interventions (therapeutic exercise, functional training, manual therapy, airway clearance, integumentary repair, devices and equipment, modalities).

Outcomes are the results of care, measured with valid instruments: change in impairments, activity, participation, risk reduction, patient satisfaction and quality of life. Outcomes justify continuing care and support the discharge decision. Reexamination occurs throughout care to judge progress and modify the plan. Discharge occurs when goals are met; discontinuation occurs when care ends before goals are met (the patient declines, the condition changes, or further benefit is not expected).

Case. A 45 year old woman refers herself to an outpatient clinic with neck pain. During the history she mentions that she has had difficulty swallowing for two weeks and that her neck pain wakes her at night regardless of position. Which is the most appropriate next step?
Reasoning: This is the examination step, and the systems review and history have turned up findings (dysphagia, constant night pain unrelated to position) that are not explained by a mechanical neck problem and may signal a serious condition. The best answer is to complete a focused screen and refer her to a physician, documenting the reason, before or alongside any treatment. Beginning cervical manipulation, prescribing a home program or reassuring her are tempting because neck pain is common, but each skips the evaluation decision that the problem may be outside physical therapy. The safety point: screening is part of every examination, not only direct access visits.

The International Classification of Functioning, Disability and Health

The ICF, published by the World Health Organization, is the framework that physical therapy uses to describe health and disability. It replaced older, linear disablement models (pathology leading to impairment, then functional limitation, then disability). The ICF is biopsychosocial: function and disability result from an interaction between a health condition and contextual factors, and the arrows run in both directions.

  • Health condition: the disease, disorder, injury or state (stroke, total hip arthroplasty, pregnancy).
  • Body functions and structures: physiological functions and anatomical parts. Problems here are impairments (decreased knee flexion range, weakness of hip abductors, impaired sensation, reduced vital capacity).
  • Activity: the execution of a task by the individual. Problems are activity limitations (cannot climb stairs, needs assistance for bed to chair transfer, walks slowly).
  • Participation: involvement in a life situation. Problems are participation restrictions (cannot return to work as a mail carrier, cannot attend church, cannot care for grandchildren).
  • Environmental factors: the physical, social and attitudinal environment (stairs at home, supportive spouse, insurance coverage, workplace accommodations). They can be facilitators or barriers.
  • Personal factors: features of the individual that are not part of the health condition (age, coping style, education, motivation, fear of movement).
Health conditione.g. left MCA stroke Body functions andstructuresImpairment: R weakness ActivityLimitation: needs helpon stairs ParticipationRestriction: cannotreturn to teaching Environmental factors3 steps at entry, family Personal factorsAge 58, highly motivated all arrows run both ways
Figure 1.4 The ICF model with a stroke example. Impairments, activity and participation interact with each other and with the environment and the person. A barrier such as entry steps can turn a mild activity limitation into a major participation restriction.
FindingICF categoryWhy
Shoulder flexion 0 to 95 degreesBody function and structure (impairment)A measure of a body part's function
Grip strength 40 percent of the other sideBody function and structure (impairment)Strength is a body function
Gait speed 0.6 m/sActivityWalking is a task performed by the person
Needs moderate assistance for sit to standActivity limitationExecution of a task
Unable to coach his child's soccer teamParticipation restrictionInvolvement in a life role
Bathroom on the second floor, no railingEnvironmental factor (barrier)Physical environment
High fear avoidance beliefsPersonal factorPsychological feature of the person, not the disease
Supportive employer offering light dutyEnvironmental factor (facilitator)Social and attitudinal environment
Board tip. The most tested ICF distinction is activity versus participation. If it describes doing a task (walking, dressing, lifting, transferring), it is activity. If it names a role in a life situation (worker, parent, student, churchgoer, golfer in a weekly league), it is participation. Range of motion, strength, pain, sensation and endurance are body functions.

Using the ICF in clinical reasoning

The ICF is not just vocabulary. It guides goal setting and outcome selection. Long term goals should be written at the activity and participation levels because those are what matter to patients and payers; impairment goals support them. Outcome measures can also be mapped: goniometry and dynamometry measure impairments, the Timed Up and Go and 6 minute walk test measure activity, and many self report questionnaires capture activity and participation. When a stem asks which goal is "most appropriate" for a plan of care, the functional, measurable, patient centered goal tied to the patient's stated priority is usually the answer.

Case. A 66 year old retired carpenter with Parkinson disease tells the therapist that his main goal is to get back to building furniture with his grandson in the garage workshop. Examination shows a gait speed of 0.8 m/s, a Berg Balance Scale score of 44 out of 56 and reduced trunk rotation. Which long term goal best reflects his priorities?
Reasoning: Begin with the ICF level of what the patient values: a participation goal (working in his workshop), supported by activity and impairment goals. "Increase trunk rotation by 15 degrees" is an impairment goal, valid but not the long term priority. "Improve Berg score to 50" is a measurable balance goal but is not his life role. The best answer is a measurable participation level goal, such as safely standing and working at a workbench for 30 minutes with no loss of balance while completing a woodworking task, within a stated time frame. Safety point: include the balance and fall risk element, because the workshop has tools and obstacles.
Key point

The patient and client management model runs from examination (history, systems review, tests and measures) through evaluation, diagnosis, prognosis and plan of care, to intervention and outcomes, with reexamination throughout and referral possible at any step. Identifying the step an item is asking about eliminates many options. The ICF describes function as an interaction of the health condition with body functions and structures, activity and participation, shaped by environmental and personal factors; activity is doing a task, participation is filling a life role.

Section 4Clinical decision rules and setting differences

Screening for referral: treat, treat and refer, or refer

Every examination ends with one of three decisions. The therapist can treat (the problem is within physical therapy and no concerning findings exist), treat and refer or consult (physical therapy is appropriate, but another finding needs a provider's attention, such as elevated blood pressure in a patient with knee pain), or refer without treating (the presentation suggests a medical condition that must be addressed first). Some situations are emergencies and call for immediate activation of emergency services rather than a routine referral.

Screening uses the whole history. Classic red flags include a history of cancer, unexplained weight loss, constant pain unchanged by position or rest, night pain that wakes the patient and does not ease, fever or chills, recent infection or immunosuppression, progressive neurological deficit, bowel or bladder changes, saddle anesthesia, pain out of proportion to the injury, and symptoms that do not follow a musculoskeletal pattern (for example, shoulder pain that increases with exertion and eases with rest, which could be cardiac). Yellow flags are psychosocial factors (fear avoidance, catastrophizing, depression, job dissatisfaction) that predict a slower recovery; they do not call for referral by themselves but do change how you treat.

History and systems review Signs of an emergency? Red flags suggesting anon-musculoskeletal cause? Secondary finding needinganother provider? Call emergencyservices, stay Refer beforetreating Treat and referor consult Treat, reexamine each visit yesyesyesnonono rescreen ifstatus changes chest pain, stroke signs,cauda equina, anaphylaxis
Figure 1.5 The screening sequence that ends every examination. The order matters: emergencies are recognized before red flags, red flags before secondary concerns, and the loop back means screening repeats whenever status changes.

Clinical prediction and decision rules

A clinical prediction rule (also called a clinical decision rule) combines a small set of findings to estimate the probability of a diagnosis, the need for imaging, or the likelihood of responding to a treatment. Rules are judged by their validation: a rule that has only been derived in one sample is weaker than one that has been validated in new patients and tested for impact. The exam expects you to know the major rules and how to apply them.

RulePurposeCore contentWhere taught in this book
Ottawa ankle and foot rulesNeed for radiographs after ankle injuryBone tenderness at the posterior edge or tip of either malleolus, base of fifth metatarsal or navicular, or inability to bear weight four steps immediately and in the clinicChapter 4
Ottawa knee ruleNeed for knee radiographsAge 55 or older, isolated patellar tenderness, fibular head tenderness, cannot flex to 90 degrees, cannot bear weight four stepsChapter 4
Canadian C-spine ruleNeed for cervical imaging in alert, stable trauma patientsHigh risk factors, low risk factors that allow testing, active rotation 45 degrees each wayChapter 2
Wells criteria for DVTProbability of deep vein thrombosisCancer, immobilization, recent surgery, tenderness along deep veins, whole leg swelling, calf asymmetry over 3 cm, pitting edema, collateral veins, prior DVT, minus 2 if another diagnosis is as likelyChapter 8
Lumbar manipulation ruleLikely rapid response to thrust manipulationFive criteria; 4 of 5 strongly predicts successChapter 2
Cervical radiculopathy clusterDiagnosis of cervical radiculopathySpurling, distraction, upper limb tension test, rotation under 60 degreesChapter 2

On the Wells DVT score, the commonly used two level version calls DVT likely at a score of 2 or more and unlikely at 1 or less. A patient with a likely score should not be exercised or treated with manual techniques to that limb until medically cleared; the physician will typically order a D-dimer or duplex ultrasound. Homans sign is no longer considered a reliable test and should not be used to rule DVT in or out.

The settings of practice

The same diagnosis looks different in each setting, and the exam expects you to know what is realistic and safe where the patient is. The table summarizes the defining features; detailed payer rules vary and change, so learn the principles rather than memorizing billing codes.

SettingTypical patient and focusFeatures the exam tests
Intensive care and acute hospitalMedically ill or postoperative; focus on early mobility, safety, preventing complications and recommending discharge dispositionCheck the chart and lab values before treating; lines, tubes, drains and monitors; orthostatic hypotension; vital sign limits; discharge recommendation (home, home with services, inpatient rehabilitation, skilled nursing)
Inpatient rehabilitation facilityMedically stable patient who needs and can tolerate intensive interdisciplinary rehab (stroke, spinal cord injury, brain injury, major multiple trauma, amputation)Must be able to participate in intensive therapy, commonly described as about 3 hours a day at least 5 days a week; needs at least two therapy disciplines, one being PT or OT; close physician supervision; regular team conferences
Skilled nursing facilityPatient who needs daily skilled nursing or rehabilitation but cannot tolerate or does not need intensive rehab; also long term care residentsLower intensity than inpatient rehab; under traditional Medicare, coverage generally follows a qualifying inpatient hospital stay; goals often aim at return home or at the safest level of function
Home healthPatient who is homebound and needs intermittent skilled careHomebound means leaving home requires considerable and taxing effort or the help of a person or device, with absences infrequent, short or for medical care or religious services; home safety assessment; caregiver training; standardized start of care assessment
Outpatient clinicAmbulatory patient, orthopedic, sports, neurologic, pelvic health, vestibularDirect access and screening; plan of care certification and periodic progress reports for many payers; home exercise programs; return to work and sport
Early intervention (birth to 3)Infants and toddlers with developmental delay or disabilityFederal Part C services; Individualized Family Service Plan (IFSP); services in the natural environment (home, daycare); family centered
School (3 to 21)Students with disabilitiesFederal Part B services; Individualized Education Program (IEP); services must be educationally relevant; least restrictive environment; Section 504 plans cover students who need accommodations but not special education
Hospice and palliative careLife limiting illnessComfort, safety, energy conservation, caregiver training, positioning; goals shift from restoration to quality of life
Board tip. In school based practice, the test of whether a service belongs in the IEP is whether it helps the child access and benefit from education. Gait training to reach the classroom and the cafeteria fits; improving hamstring flexibility for its own sake does not. In early intervention, the family is the focus and services happen in natural settings, written into an IFSP rather than an IEP.

Acute care specifics that recur on the exam

In the hospital, review the chart before every session: orders (activity, weight bearing, precautions), vital sign trends, laboratory values and the nursing report, looking for a reason not to treat today, such as new fever, an acute hemoglobin drop, a very low platelet count, new chest pain, an unstable arrhythmia or a dangerous glucose level (Chapter 8 gives the values). Patients with arterial or central lines, chest tubes, urinary catheters or nasogastric tubes can usually be mobilized; plan the route of the lines and protect them during transfers.

Discharge recommendation is a classic acute care item. Consider the patient's current function, prior level of function, expected trajectory, tolerance for intensity, caregiver support and the home environment. A patient who needs moderate assistance, can tolerate several hours of therapy and has a good prognosis after a stroke fits inpatient rehabilitation; a frail patient who needs similar help but tolerates only short sessions fits skilled nursing; a patient who is safe with supervision and has help at home may go home with home health services if homebound, or with outpatient therapy if not.

Scope, direct access and supervision

Each state's practice act defines what physical therapists may do and how. Across the country, patients may now see a physical therapist without a physician referral (direct access), but many states attach provisions such as a time limit or visit limit after which a referral or physician involvement is required, and some payers require referral for payment even where the law does not. Medicare does not require a physician referral to begin evaluation, but it does require a plan of care certified by a physician or other allowed practitioner. Know the principle, and on the exam assume that a therapist practicing under direct access carries the full responsibility to screen for conditions requiring medical care.

Supervision of support personnel is tested often. The physical therapist performs the initial examination and evaluation, establishes the diagnosis, prognosis and plan of care, performs reexaminations, and writes the discharge summary; these cannot be delegated. The physical therapist assistant may provide selected interventions within the plan of care, adjust interventions within the plan (progressing repetitions or resistance as the plan allows), collect data and document progress, but may not perform evaluations, change the plan of care or discharge the patient. The PT decides what to delegate based on the patient's stability and complexity and the assistant's competence. Aides and technicians are not licensed; they perform nonskilled tasks (preparing the treatment area, assisting with transfers under direct supervision) and may not provide skilled interventions independently. Supervision levels (general, direct, direct personal) vary by state and payer.

TaskPTPTAAide
Initial examination and evaluationYesNoNo
Establish or change plan of care, goalsYesNoNo
Reexamination, discharge evaluationYesNo (may contribute data)No
Interventions within the plan of careYesYes, as delegatedNonskilled tasks only, directly supervised
Progress interventions within plan parametersYesYesNo
Recognize a change in status and stopYesYes, then notify the PTYes, then notify the PT
Case. A 58 year old man with a history of prostate cancer treated three years ago comes to an outpatient clinic under direct access with low back pain that started gradually a month ago, is worse at night, and is not changed by position. He has lost weight without trying. Which action is most appropriate?
Reasoning: History of cancer, age over 50, unexplained weight loss and constant night pain unaffected by position form a red flag cluster for spinal metastasis. The correct decision is to refer to a physician before starting treatment, communicating the findings. Beginning a trial of directional preference exercise, mobilization, or a two week trial of care before referring are tempting because back pain is usually mechanical, but a history of cancer is the single most important red flag for malignancy in back pain. If new neurological signs such as leg weakness or bladder changes appear, the referral becomes urgent.
Key point

Every examination ends in treat, treat and refer, refer, or emergency action, decided by red flags and the overall pattern. Know the major clinical prediction rules and what each predicts. Match care to setting: acute care is about stability, early mobility and disposition; inpatient rehab requires the ability to tolerate intensive interdisciplinary therapy; skilled nursing offers lower intensity skilled care; home health requires homebound status; school services must be educationally relevant. Direct access increases the duty to screen, and evaluation, plan of care changes and discharge are never delegated to an assistant.

Section 5A study plan that works

How memory works, and why cramming fails

Two findings from learning science should shape your plan. The first is the spacing effect: material reviewed several times with gaps between reviews is remembered far longer than the same material studied in one block. Each time you return to a topic just as it begins to fade, the memory is rebuilt more durably. The second is the testing effect (retrieval practice): trying to recall information, as in answering questions or flashcards, strengthens memory more than rereading or highlighting. Rereading creates a feeling of familiarity that is easily mistaken for knowledge; retrieval shows you what you can actually produce under pressure.

A third principle, interleaving, matters for an exam that mixes topics. Practicing mixed sets (a stroke item, then a knee item, then a lab value item) is harder than practicing one topic at a time, but it trains the skill the exam actually demands: recognizing what kind of problem you face. Blocked practice is fine when you first learn a topic; interleaved practice should dominate the final weeks.

100%50%0% 013714Days since first study Recall Spaced retrieval One study session dots = review points
Figure 1.6 A schematic forgetting curve. After one session, recall falls fast. Each retrieval review (dots) restores it, and the decline after each review is slower, so the gaps between reviews can widen. The shape is illustrative, not data from a particular study.

Building the calendar

Most candidates do best with a structured plan of about 8 to 12 weeks of dedicated review after graduation, adjusted for their starting point and other obligations. A plan that is realistic and followed beats an ambitious plan abandoned in week three. A practical structure:

  1. Baseline (week 1). Take a full length, timed practice exam under realistic conditions. The score matters less than the profile: which systems and which tasks are weakest.
  2. Content building (weeks 2 to 7). Work through the systems in order of weight and weakness, starting with musculoskeletal and neuromuscular. For each topic: read the chapter, make or use flashcards, then do a mixed question set the same day and a review set two to three days later.
  3. Integration (weeks 8 to 10). Shift to mixed, timed question blocks and a second full length practice exam. Revisit weak topics identified by miss analysis.
  4. Final phase (last 7 to 10 days). A final full length exam about a week before test day, then light, targeted review of high-yield tables (special tests, lab values, nerve lesions, modality parameters). No new major topics in the last two days.

Analyzing your misses

Doing questions without studying the misses wastes most of their value. Keep a miss log with the topic, the type of error and the fix. Classifying errors shows patterns that rereading never would.

Error typeWhat happenedFix
Knowledge gapDid not know the fact or conceptStudy the topic, make a flashcard, retest in 2 to 3 days
Misread the stemMissed "except," "first," a key number or the settingSlow the first read; read the last sentence first; underline the task mentally
Reasoning errorKnew the facts but chose a mistimed or less safe optionReview priority logic; write out why each wrong option is wrong
Second guessingChanged a right answer to a wrong oneChange answers only for a specific misread clue
Time pressureRushed at the end of a sectionPractice pacing checkpoints; move on from hard items sooner
FatigueAccuracy falls late in long sessionsBuild stamina with full length practice; plan breaks and food

For every missed question, write one sentence explaining why the right answer is right and one explaining why your answer was wrong. Also review a sample of questions you answered correctly but guessed; a lucky guess is a hidden knowledge gap.

Board tip. Practice exam scores are most useful as trends and profiles, not as precise predictions. Different practice sources vary in difficulty. Watch whether your weakest systems are improving and whether your errors are shifting from knowledge gaps toward fewer, careless misreads; that pattern means you are close to ready.

Pacing on test day

Work out your per item time budget from the current handbook's section length and time limit, and set checkpoints (for example, where you should be at the quarter, half and three quarter marks of each section). A comfortable target leaves a few minutes at the end of each section for flagged items. Hard items should get a reasoned choice and a flag, not an open ended struggle. Answer every item before time expires, because there is no penalty for guessing.

Confirm the test center, travel time, identification and room rules days ahead, sleep well, and plan a familiar breakfast and a snack for the break.

Test anxiety

Some anxiety improves performance; too much narrows attention and blocks retrieval. Well supported strategies include simulation (at least two full length timed practice exams, including the break), slow breathing with a longer exhale to reduce sympathetic arousal, reappraisal of arousal as readiness rather than danger, brief expressive writing about worries before the test, and a reset routine after a hard item (breathe out, relax the shoulders, read the next stem fresh).

Candidates who have a diagnosed condition that affects testing may request testing accommodations through the official process, which requires documentation and time. Start early. If anxiety is severe or longstanding, a counselor or physician can help, and that help is a sign of good judgment, not weakness.

Case. A new graduate scores below the passing range on her first full length practice exam. Her miss log shows strong musculoskeletal performance, weak cardiopulmonary and integumentary performance, and a large number of misses labeled "misread the stem," most in the last third of each section. Which change to her plan is most likely to raise her score?
Reasoning: Start with the error profile. Two problems are present: knowledge gaps in two systems, and a reading and stamina problem that appears late in sections. The best plan addresses both: targeted content review of cardiopulmonary and integumentary topics with spaced retrieval, plus timed full length practice to build stamina and a deliberate stem reading routine. Rereading all of her musculoskeletal notes is tempting because it feels productive, but it targets her strength. Taking many more untimed questions does not fix the late section misreads. Rescheduling the exam immediately may help but does not by itself fix either problem. The general lesson: let your data, not your comfort, decide where study hours go.

Using this book's companion exams and flashcards

Each chapter of this book ends with ten "Check yourself" questions; treat them as a first retrieval pass on the day you read the chapter, and revisit them a few days later. The companion practice exams and flashcard decks on the same site are built to match the chapters. Use them this way:

Use flashcards for facts that must be automatic (nerve roots, special test positives, lab ranges, modality parameters), reviewing only the cards due each day; topic sets in tutor mode during content building; mixed timed exams in exam mode during integration, followed by miss analysis; and the glossary tables as a quick self test with the right column covered.

Key point

Learning lasts when it is spaced, retrieved and interleaved. Start with a timed baseline exam, build content in order of weight and weakness, shift to mixed timed practice, and finish with a final full length exam about a week before test day. Keep a miss log that classifies each error and fixes the cause. Plan pacing checkpoints, never leave an item blank, manage anxiety with simulation, breathing and reappraisal, and use the companion flashcards and exams for daily retrieval rather than rereading.

The chapter in one breath

  • The NPTE is a long, computer based exam of four option, single best answer items, reported on a 200 to 800 scale with 600 as the passing standard; check the current candidate handbook for logistics.
  • Unscored pretest items are mixed invisibly among scored items, so a strange item deserves a reasoned guess and a flag, not panic.
  • The content outline crosses body systems and nonsystems areas with examination, evaluation and diagnosis, and intervention; musculoskeletal and neuromuscular content make up about half.
  • For every stem, identify the patient, the setting and the task; read the final sentence first and predict before you look at options.
  • Keywords such as first, best, most likely and except change the answer; distractors are often true but irrelevant, mistimed, beyond scope or absolute.
  • The priority ladder runs emergency, vital signs, red flags, precautions, examination, function, comfort; a change in status means stop, assess and report.
  • The patient and client management model moves from examination (history, systems review, tests and measures) to evaluation, diagnosis, prognosis and plan of care, intervention and outcomes.
  • In the ICF, impairments are body function and structure problems, activity is doing a task, participation is filling a life role, and environmental and personal factors shape all three.
  • Every exam ends in treat, treat and refer, refer or emergency; know the major clinical prediction rules and the red flags that override them.
  • Settings differ: inpatient rehab requires tolerance for intensive interdisciplinary therapy, home health requires homebound status, and school services must be educationally relevant.
  • The PT alone performs evaluations, sets and changes the plan of care and discharges; the PTA delivers and progresses interventions within the plan.
  • Study with spaced retrieval, interleaved timed practice and a miss log, and train pacing and anxiety control before test day.

Words worth knowing

TermWhat it means
NPTEThe National Physical Therapy Examination, the entry level licensing exam for physical therapists in the United States.
Scaled scoreA raw score converted to a common scale so that results mean the same thing across exam forms of slightly different difficulty.
Pretest itemA new, unscored question mixed among scored items to gather statistics before it is used for scoring.
Content outlineThe published blueprint that sets how many items come from each content area and clinical task.
NonsystemsContent not tied to one body system: equipment and devices, modalities, safety, professional responsibilities, research.
Patient and client management modelThe cycle of examination, evaluation, diagnosis, prognosis, intervention and outcomes that structures physical therapy care.
EvaluationThe clinical judgment step in which examination findings are interpreted to reach a diagnosis and plan.
PrognosisThe predicted optimal level of improvement and the time needed to reach it.
Plan of careThe documented goals, interventions, frequency, duration and discharge plan established by the physical therapist.
ICFThe International Classification of Functioning, Disability and Health, a biopsychosocial model of health and disability.
ImpairmentA problem in body function or structure, such as weakness, limited range or reduced sensation.
Activity limitationDifficulty executing a task or action, such as walking, dressing or transferring.
Participation restrictionDifficulty with involvement in a life situation or role, such as work, school, parenting or recreation.
Red flagA finding that suggests a serious medical condition requiring referral or urgent care.
Yellow flagA psychosocial factor, such as fear avoidance or catastrophizing, that predicts slower recovery.
Clinical prediction ruleA validated combination of findings that estimates the probability of a diagnosis, outcome or treatment response.
Direct accessThe ability of patients to see a physical therapist without a physician referral, as allowed by state law.
HomeboundA requirement for home health coverage: leaving home takes considerable and taxing effort, and absences are infrequent or short.
IEPIndividualized Education Program, the plan for special education and related services for a student aged 3 to 21.
IFSPIndividualized Family Service Plan, the family centered plan for early intervention from birth to age 3.
Retrieval practiceStrengthening memory by actively recalling information, as with practice questions and flashcards.
Miss logA record of missed practice questions classified by topic and error type, used to target review.

Check yourself

A candidate meets a question on a rare genetic disorder she has never studied. What is the best approach?
Answer. Make a reasoned choice quickly, flag it and move on. It may be an unscored pretest item, every item carries equal weight, and time is better spent on items she can answer. Never leave it blank, because there is no penalty for guessing.
A stem asks for the "first" action when a patient becomes diaphoretic, short of breath and reports chest pressure during cycle ergometry. What should the therapist do?
Answer. Stop the exercise and activate the emergency response while staying with and monitoring the patient. These are signs of possible myocardial ischemia, an emergency; continuing, reducing the workload or scheduling a physician visit all delay care.
Classify each finding by ICF category: knee extension lag of 10 degrees; unable to climb stairs without a rail; unable to return to work as a firefighter.
Answer. Extension lag is a body function and structure impairment, stair climbing difficulty is an activity limitation, and inability to work as a firefighter is a participation restriction.
During the history, a patient reports that her husband drives her everywhere and she cannot manage the four steps into her home. Which part of the ICF does the steps detail represent?
Answer. An environmental factor acting as a barrier. The physical environment interacts with her activity limitations and must shape the plan and discharge recommendations.
Which step of the patient and client management model includes setting the expected frequency and duration of care?
Answer. Prognosis, which is expressed in the plan of care along with goals, planned interventions and the discharge plan.
A physical therapist assistant notices that a patient's goals have been met and the patient has plateaued. Which task can the assistant not perform?
Answer. The discharge reexamination and the decision to discharge, as well as changing the plan of care. The PTA should report findings to the supervising PT, who reexamines and decides.
An 80 year old woman after a hip fracture needs moderate assistance for transfers, tolerates only 30 minutes of activity at a time, and lives alone. Which discharge recommendation from acute care is most appropriate?
Answer. A skilled nursing facility. She needs daily skilled rehabilitation but cannot tolerate the intensive therapy required in inpatient rehabilitation, and she is not safe to go home alone.
A school based therapist is asked to add hamstring stretching to a student's IEP to improve flexibility. The student walks independently throughout the school. What is the key principle?
Answer. School based services must be educationally relevant, helping the student access and benefit from education. Flexibility work without an educational impact does not belong in the IEP; it may be addressed through outpatient care.
On the two level Wells criteria, what score makes deep vein thrombosis "likely," and what should a therapist do with that result?
Answer. A score of 2 or more. The therapist should hold exercise and manual treatment to the limb and refer for medical evaluation (typically D-dimer or duplex ultrasound). Homans sign is not reliable and should not be used.
A student's miss log shows that most errors come from changing correct answers to incorrect ones. What should she change?
Answer. Change an answer only when she identifies a specific clue that she misread, not because of a vague second thought. First reasoned answers are more often right than changes driven by doubt.
Chapter 2 · Musculoskeletal

Musculoskeletal Foundations: Tissue, Kinesiology and the Spine

Every orthopedic decision on the exam, from how soon a repaired tendon can be loaded to which way to glide a stiff joint and whether a patient with neck pain needs imaging, rests on a few foundations: how tissues heal, how joints move, and how to examine the spine without missing something dangerous. This chapter builds those foundations and then applies them to the cervical, thoracic, lumbar and sacroiliac regions, where clinical prediction rules, classification systems and safety screening are tested heavily.

By the end of this chapter you can

  • Describe the inflammatory, proliferative and remodeling phases and match loading to each, applying Wolff law and Davis law.
  • Read a stress strain curve and explain how tendon, ligament, bone and cartilage respond to load and immobilization.
  • Apply planes and axes, open and closed kinetic chain concepts, the convex concave rule, the length tension relationship and lever classes.
  • Screen the cervical and thoracic spine for red flags and cervical arterial dysfunction, and apply the Canadian C-spine rule.
  • Distinguish cervical radiculopathy from cervical myelopathy using test clusters, and recognize thoracic outlet syndrome and whiplash grades.
  • Classify low back pain with treatment based classification, identify directional preference and centralization, and recognize stenosis, spondylolisthesis and radiculopathy.
  • Use the sacroiliac provocation cluster correctly.
  • Select mobilization grades, apply manipulation contraindications, and progress motor control and McKenzie based exercise toward return to function.

Section 1Tissue healing and loading

The three overlapping phases

Soft tissue healing after injury or surgery proceeds through three overlapping phases. Their timelines vary with tissue type, blood supply, age, nutrition, smoking, diabetes and medications such as systemic corticosteroids, so the numbers below are typical ranges, not rules. What the exam tests is the biology of each phase and the type of loading that fits it.

The inflammatory phase begins immediately and lasts roughly the first 3 to 7 days. Vasoconstriction and clotting stop bleeding; then vasodilation and increased permeability bring plasma proteins and white cells to the area. Neutrophils arrive first, followed by macrophages, which clear debris and release growth factors that drive the next phase. The cardinal signs are redness, heat, swelling, pain and loss of function. Clinically, pain is felt before end range, at rest or with any stress. The goals are to protect the tissue, control edema and pain, and maintain motion in neighboring regions. Complete rest is not the goal; gentle, pain free movement within protected limits reduces stiffness and supports circulation.

The proliferative phase (also called repair or fibroplasia) overlaps inflammation and runs from about day 3 to about week 3 to 6. Fibroblasts lay down type III collagen, a thin, weak, randomly arranged collagen, along with new capillaries (angiogenesis) and granulation tissue. Wound contraction by myofibroblasts draws the edges together. The new tissue is fragile, and tensile strength is low. Controlled, low load stress now begins to orient the new fibers; too much load disrupts them and restarts inflammation.

The remodeling phase (maturation) begins at about week 3 and continues for months to more than a year. Type III collagen is gradually replaced by stronger type I collagen, fibers align along lines of stress, cross links form and the scar shrinks and strengthens. Even after a year, a ligament or tendon scar typically regains only a portion of its original tensile strength. Progressive loading, specific to the demands the patient will face, is the stimulus that drives this alignment.

Healing phases overlap; loading follows the biology Injury Day 3 Wk 1 Wk 3 Wk 6 Mo 6 1 yr+ Inflammatory Proliferative: type III collagen Remodeling: type I collagen aligns Protect, control edema,gentle pain free motion Controlled low load,guide fiber orientation Progressive, task specificloading toward full demand
Figure 2.1 The phases of soft tissue healing overlap rather than switch on and off. Loading should match the dominant biology: protection and gentle motion while inflammation dominates, controlled low load while fragile type III collagen is laid down, and progressive specific loading as type I collagen remodels.

Mechanical behavior: the stress strain curve

Connective tissues are viscoelastic: their response depends on how fast and how long they are loaded. On a stress strain (load deformation) curve for tendon or ligament, the first segment is the toe region, where crimped collagen fibers straighten with little force. The elastic (linear) region follows; deformation is proportional to load and fully recoverable when the load is removed. Beyond the yield point lies the plastic region, in which some fibers fail and deformation is permanent (a clinical sprain or strain). At the ultimate failure point the tissue ruptures. The slope of the elastic region is the stiffness (Young modulus).

Two viscoelastic properties are used in treatment. Creep is continued elongation under a constant load over time; it is why a low load, long duration stretch is more effective than a brief forceful one at producing lasting length change. Stress relaxation is the decline in internal force when tissue is held at a constant length; it is the principle behind serial casting and static progressive splinting. Tissues are also stiffer when loaded quickly, and warm tissue deforms more readily than cold tissue, which is why heat combined with prolonged stretch is effective.

Strain (deformation) Stress (load) Toecrimpstraightens Elasticrecoverable Plasticpermanentdeformation Yield point Failure physiologic loadingmicrofailure: sprainrupture
Figure 2.2 A schematic stress strain curve for tendon or ligament. Daily activity stays in the toe and elastic regions. Loading past the yield point causes permanent deformation (a sprain or strain), and the ultimate failure point is a complete tear.

How specific tissues respond

TissueBlood supply and healingResponse to loadResponse to immobilization
TendonRelatively poor blood supply, slow healing; repaired tendon is weakest around weeks 1 to 3 after repairProgressive loading increases stiffness and strength; heavy slow and eccentric loading help tendinopathyLoss of stiffness and strength; adhesions in sheathed tendons (flexor tendons of the hand)
LigamentExtra-articular ligaments (MCL) heal well; intra-articular ligaments (ACL) bathed in synovial fluid heal poorlyControlled stress improves collagen alignment and strengthRapid loss of strength at the insertion sites; recovery takes many months
BoneWell vascularized; heals with true bone, not scarRemodels along lines of stress (Wolff law); weight bearing and impact increase densityDisuse osteopenia within weeks
Articular cartilageAvascular, aneural; nourished by synovial fluid through cyclic loading; limited intrinsic repair; full thickness defects fill with weaker fibrocartilageIntermittent compression and motion pump nutrients and maintain matrixThinning, softening and loss of proteoglycans; constant compression damages it
MuscleRich blood supply; satellite cells regenerate fibers; large injuries form scarHypertrophy and strength gains with progressive overloadAtrophy within days, greatest in antigravity muscles; shortened position causes loss of sarcomeres
MeniscusOuter third (red zone) vascular and repairable; inner (white zone) avascularLoad sharing across the kneeLoss of tensile strength

Bone healing

Fracture healing follows its own phases. In indirect (secondary) healing, typical of fractures treated with casts or flexible fixation, a hematoma and inflammation form in the first days, a soft callus of fibrocartilage bridges the gap over the next few weeks, a hard callus of woven bone replaces it (often visible on radiographs by 4 to 8 weeks), and remodeling into lamellar bone continues for months to years. Rigid fixation allows direct (primary) healing without callus. Fracture timelines and weight bearing status are covered in Chapter 4.

Wolff law states that bone adapts its density and architecture to the loads placed on it: bone is laid down where stress is applied and resorbed where it is absent. This explains osteoporosis with bed rest or spinal cord injury and the use of weight bearing and impact exercise to build bone. Davis law is the soft tissue counterpart: soft tissues remodel according to the demands placed on them, lengthening under sustained tension and shortening when kept slack. A patient whose knee is kept flexed in bed develops shortened hamstrings and posterior capsule; prolonged low load positioning can reverse it.

Board tip. Wolff law is for bone, Davis law is for soft tissue. The SAID principle (specific adaptation to imposed demands) generalizes both: the tissue adapts to the specific type, direction and magnitude of load. When a question asks how to strengthen a healing tendon or build bone density, the answer is progressive, specific loading, not rest.

Protected motion and progressive loading

Modern rehabilitation favors protected early motion over immobilization whenever the repair allows. Controlled motion reduces adhesions, maintains cartilage nutrition, limits atrophy and helps align new collagen. Protection means respecting the limits the surgeon or the tissue sets: range limits (for example, after a rotator cuff repair), load limits (weight bearing status), speed (slow before fast), and direction (avoiding the motion that stresses the repair). Within those limits, loading is progressed by one variable at a time, guided by the patient's response during and over the 24 hours after a session. Pain that is mild, settles quickly and does not increase the next morning is generally acceptable; pain that lingers, increasing swelling, or loss of motion means the load was too much.

Case. A 34 year old recreational soccer player is 10 days after a grade II sprain of the medial collateral ligament of the left knee. Swelling has decreased, and she has pain only at end range valgus stress. Which intervention is most appropriate now? Options: strict immobilization in a locked brace, high velocity cutting drills, controlled range of motion and progressive closed chain strengthening in a hinged brace that blocks valgus, or ultrasound alone.
Reasoning: At 10 days she is entering the proliferative phase, when new type III collagen is fragile but benefits from controlled stress. The MCL is extra-articular and heals well with protected motion. Strict immobilization causes ligament insertion weakness and stiffness. Cutting drills load the ligament far beyond what immature collagen tolerates. Ultrasound alone is a passive adjunct. The best answer is protected motion with progressive loading in a valgus protecting brace. The safety point: pain or swelling that increases over the next 24 hours means the load was too much.
Key point

Healing moves through overlapping inflammatory, proliferative and remodeling phases; immature type III collagen is gradually replaced by aligned type I collagen under the influence of progressive load. Tissues are viscoelastic, so low load, long duration stretch uses creep and stress relaxation. Bone follows Wolff law and soft tissue follows Davis law: both adapt to the loads applied. Protected early motion within the tissue's limits, progressed by symptom response, beats prolonged immobilization.

Section 2Kinesiology essentials

Planes, axes and the language of motion

Motion is described from anatomical position: standing, facing forward, arms at the sides with palms forward. Each plane of motion has a perpendicular axis around which the motion occurs.

PlaneDivides the body intoAxisMotions
SagittalRight and leftMediolateral (frontal, coronal)Flexion and extension, dorsiflexion and plantarflexion, anterior and posterior pelvic tilt
Frontal (coronal)Front and backAnteroposterior (sagittal)Abduction and adduction, lateral flexion of the trunk, radial and ulnar deviation, eversion and inversion (in part)
Transverse (horizontal)Top and bottomVertical (longitudinal)Internal and external rotation, horizontal abduction and adduction, trunk rotation, pronation and supination of the forearm

Open and closed kinetic chain

In an open kinetic chain (OKC) exercise the distal segment moves freely in space (a seated knee extension, a biceps curl). In a closed kinetic chain (CKC) exercise the distal segment is fixed against a surface and the proximal segments move over it (a squat, a push up, a step up). The distinction matters for joint loading and for which muscles work.

FeatureOpen chainClosed chain
Distal segmentFreeFixed or weight bearing
Muscle activityOften isolated, concentric and eccentric of one groupMultiple joints and muscle groups, cocontraction
Joint forcesShear forces dominate; tibial translation with knee extensionCompressive forces dominate; joint approximation increases stability
Proprioceptive inputLowerHigher, more functional
Knee example after ACL reconstructionKnee extension from 90 to 45 degrees limits anterior tibial shear on the graft early onSquats and leg press from 0 to about 60 degrees limit graft strain
Typical useIsolating a weak muscle, when weight bearing is restrictedFunctional training, balance, joint stability

Open chain knee extension pulls the tibia anteriorly in the last 30 to 40 degrees, straining the ACL, so early ACL rehab favors closed chain work and limits open chain extension to a protected arc.

Arthrokinematics and the convex concave rule

Osteokinematics describes the movement of the bones (flexion, abduction). Arthrokinematics describes what the joint surfaces do: roll (new points on one surface meet new points on the other, like a tire rolling), glide or slide (one point on one surface contacts new points on the other, like a skidding tire), and spin (rotation around a fixed point, like the radial head in pronation). Most joints combine roll and glide.

The convex concave rule predicts the direction of glide. When a convex surface moves on a fixed concave surface, it rolls in the direction of the bone's movement but glides in the opposite direction. When a concave surface moves on a fixed convex surface, roll and glide occur in the same direction as the bone movement. Joint mobilization uses this rule: to restore a lost motion, the therapist glides the moving bone in the direction its surface should glide.

Convex on concave: opposite Concave on convex: same Glenoid (concave) Humeral head(convex) Shaft moves up Roll up Glide down Abduction needs aninferior glide Femoralcondyles(convex) Tibial plateau(concave) Tibia movesanteriorly Glide anterior Open chain extension: anterior tibial glide anterior is to the left
Figure 2.3 The convex concave rule. Left: in shoulder abduction the convex humeral head rolls up but glides down, so a stiff shoulder lacking abduction is mobilized with an inferior glide. Right: in open chain knee extension the concave tibia glides anteriorly, the same direction the bone moves.
Joint (moving surface)RuleTo increaseGlide the moving bone
Glenohumeral (convex humerus)OppositeAbduction, flexionInferior (abduction); posterior and inferior (flexion)
GlenohumeralOppositeExternal rotation; internal rotationAnterior; posterior
Hip (convex femur)OppositeFlexion and internal rotation; extension and external rotationPosterior; anterior
Tibiofemoral, open chain (concave tibia)SameFlexion; extensionPosterior; anterior
Talocrural (convex talus)OppositeDorsiflexion; plantarflexionPosterior; anterior
Radiocarpal (convex carpals)OppositeWrist flexion; extensionDorsal; volar
Humeroulnar (concave ulna)SameFlexion; extensionDistraction is the main technique, the ulna follows its trochlear notch
Metacarpophalangeal and interphalangeal (concave phalanx)SameFlexion; extensionVolar; dorsal

Close packed, loose packed and capsular patterns

In the close packed position the joint surfaces are maximally congruent and the capsule and ligaments are taut, so the joint is most stable and least able to be mobilized; it is also the position in which joints are typically injured by high loads and in which stability tests are often done. In the loose packed (resting) position the capsule is most lax, and joint play is greatest, so it is where mobilization usually begins. A capsular pattern is the characteristic proportional loss of motion when the whole capsule is involved (arthritis, adhesive capsulitis); a noncapsular pattern suggests a more local problem such as a ligament adhesion, internal derangement or extra-articular lesion.

JointClose packedResting (loose packed)Capsular pattern
GlenohumeralFull abduction and external rotationAbout 55 degrees abduction, 30 degrees horizontal adductionExternal rotation, then abduction, then internal rotation
HipExtension, internal rotation, abductionAbout 30 degrees flexion, 30 degrees abduction, slight external rotationFlexion, abduction and internal rotation; sources differ on order, internal rotation often most limited
KneeFull extension with tibial external rotationAbout 25 degrees flexionFlexion much more than extension
TalocruralMaximal dorsiflexionAbout 10 degrees plantarflexion, midway inversion and eversionPlantarflexion more than dorsiflexion
HumeroulnarExtensionAbout 70 degrees flexion, 10 degrees supinationFlexion more than extension
Cervical spineFull extensionMidway between flexion and extensionLateral flexion and rotation equally limited, then extension

Length tension, force velocity and insufficiency

The force a muscle can produce depends on its length. Active tension is greatest near resting length, where actin and myosin overlap optimally; at short lengths the filaments crowd and overlap, and at long lengths few cross bridges can form. Passive tension from connective tissue and the protein titin rises as the muscle is stretched beyond resting length. Total tension is the sum, which is why a muscle on stretch can still resist strongly even as its active force falls.

Muscle length Tension Resting length Active Passive Total Too short: filamentsoverlap, activeinsufficiency Long: passivetensiondominates Optimal overlap
Figure 2.4 The length tension relationship. Active force peaks near resting length, passive tension rises steeply as the muscle is lengthened, and total tension is their sum. A two joint muscle shortened across both joints works on the far left of the active curve (active insufficiency).

Active insufficiency occurs when a muscle that crosses two or more joints is shortened across all of them at once and cannot generate enough force to complete the motion: the hamstrings cannot fully flex the knee when the hip is already extended, and the finger flexors make a weak fist when the wrist is flexed. Passive insufficiency occurs when a two joint muscle is lengthened across both joints and its passive tension stops motion at the other end: tight hamstrings limit hip flexion when the knee is extended (the basis of the straight leg raise for hamstring length), and the rectus femoris limits knee flexion when the hip is extended (the Ely test). Tenodesis uses passive insufficiency deliberately: in a person with C6 tetraplegia, active wrist extension pulls the finger flexors taut and closes the hand for grasp, which is why finger flexors are not stretched over an extended wrist in these patients.

The force velocity relationship states that concentric force falls as shortening speed rises, isometric force is intermediate, and eccentric force exceeds isometric and rises with lengthening speed up to a plateau. Eccentric work therefore produces the highest forces at the lowest metabolic cost, and it is also the type most associated with delayed onset muscle soreness.

Muscle actions and roles

A concentric contraction shortens the muscle while it produces force; an eccentric contraction lengthens it under load (the quadriceps controlling descent into a squat or down stairs); an isometric contraction produces force without a change in length. Isokinetic exercise holds velocity constant with a machine that matches resistance to the force produced. A force couple is two or more muscles pulling in different directions to produce rotation: the upper trapezius, lower trapezius and serratus anterior upwardly rotate the scapula, and the deltoid and rotator cuff together elevate the arm while keeping the humeral head centered.

Levers and torque

Torque equals force multiplied by the perpendicular distance from the axis to the line of force (the moment arm). Muscle torque must overcome resistance torque, which is why the same weight feels heavier when held at arm's length and why a long lever arm is used to progress resistance (straight arm versus bent arm raises). The mechanical advantage is the ratio of the force arm to the resistance arm; a value above 1 favors force, below 1 favors speed and range of motion.

First classSecond classThird class ERAxis ERAxis ERAxis A between E and RNeck extensorsbalancing the head R between A and EHeel raise: axis atmetatarsal headsFavors force E between A and RBiceps flexing elbow,most common in bodyFavors speed, range E effort (muscle), R resistance (load), A axis
Figure 2.5 The three lever classes. The middle element names the class (axis, resistance, effort for first, second, third). Most muscles work as third class levers, trading force for speed and range of motion.
Board tip. Remember "ARE 1 2 3": the element in the middle is the Axis for first class, the Resistance for second class and the Effort for third class. For any torque question, ask what happens to the moment arm: moving a weight farther from the joint, lengthening a lever, or a cane held in the hand opposite a painful hip (which reduces the torque the hip abductors must produce) all change torque without changing the force itself.
Case. A 52 year old woman with adhesive capsulitis of the right shoulder has 80 degrees of active and passive abduction and markedly limited external rotation. The therapist plans joint mobilization to improve external rotation. Which glide is most appropriate?
Reasoning: The humeral head is convex moving on a concave glenoid, so it glides opposite to the direction of its roll. External rotation rolls the head posteriorly, so it must glide anteriorly. A posterior glide would be the choice for internal rotation, and an inferior glide is the choice for abduction (which she also needs, and which is a reasonable second technique). Some clinicians argue that a posterior glide also improves external rotation in capsulitis, and research is mixed, but the exam expects the convex concave rule unless the stem says otherwise. Safety point: avoid aggressive high grade techniques while the shoulder is highly irritable (the painful freezing stage).
Key point

Each plane has a perpendicular axis. Closed chain exercise emphasizes compression, cocontraction and function; open chain isolates muscles and increases shear. A convex surface glides opposite to the bone's movement and a concave surface glides the same way, which sets the direction of mobilization. Joints are most stable close packed and most mobile in the resting position, and a capsular pattern signals whole capsule involvement. Active force peaks at resting length; two joint muscles show active insufficiency when shortened and passive insufficiency when lengthened. Torque depends on the moment arm, and most muscles are third class levers.

Section 3Examination of the cervical and thoracic spine

Screening first

Neck pain is usually benign and mechanical, but the cervical spine sits next to the spinal cord, the vertebral and carotid arteries and the upper airway, so the exam weights screening heavily. Before any test that loads the neck, the therapist screens for fracture (after trauma), upper cervical ligamentous instability, cervical arterial dysfunction, cervical myelopathy, and nonmusculoskeletal sources such as cancer, infection and cardiac referral.

ConcernClues in the stemAction
Cervical arterial dysfunction (vertebrobasilar or internal carotid)The "5 Ds and 3 Ns": dizziness, diplopia, dysarthria, dysphagia, drop attacks; nystagmus, nausea, numbness (often facial); also new severe headache or neck pain unlike any before, recent neck trauma, ptosis or pupil changesNo manual therapy; urgent medical referral, emergency if signs are active
Upper cervical instabilityRheumatoid arthritis, Down syndrome, long term corticosteroid use, recent trauma; occipital headache, a feeling that the head is heavy, bilateral or quadrilateral paresthesia, lump in the throatAvoid end range and manipulation; ligament tests only if safe; refer
FractureTrauma with high risk features of the Canadian C-spine ruleImmobilize, imaging before examination
MyelopathyBilateral hand clumsiness, gait imbalance, upper motor neuron signsRefer for surgical opinion; no manipulation
Malignancy or infectionHistory of cancer, weight loss, constant night pain, fever, immunosuppressionRefer
Cardiac referralNeck, jaw or left arm pain brought on by exertion and relieved by restStop, emergency or medical referral

Upper cervical ligament integrity tests include the Sharp-Purser test (with the head slightly flexed, the examiner stabilizes C2 and glides the head posteriorly; a clunk or reduction of symptoms suggests atlantoaxial instability from transverse ligament laxity) and the alar ligament stress test (side bending or rotating the head while palpating the C2 spinous process, which should move immediately). Screening for cervical arterial dysfunction is now framed as a clinical reasoning process built on history and risk factors; positional tests such as sustained end range rotation have poor accuracy and should not be relied on alone.

Imaging after trauma: the Canadian C-spine rule

The Canadian C-spine rule decides whether an alert (Glasgow Coma Scale 15), stable adult trauma patient needs cervical radiographs. It is highly sensitive, so a patient who clears it has a very low probability of a clinically important injury.

1. Any high risk factor? Age 65 or olderDangerous mechanism (fall from height, axial load,high speed or rollover crash) · Limb paresthesias 2. Any low risk factor that allows testing? Simple rear end collision · Sitting in the EDAmbulatory at any time · Delayed onset of painNo midline cervical tenderness 3. Actively rotates 45 degreesto the left and to the right? Radiography No imagingneeded yesnononeyesyesunable
Figure 2.6 The Canadian C-spine rule for alert, stable adults after trauma. Any high risk factor means imaging. Without one, a low risk factor allows active rotation to be tested; rotating 45 degrees each way clears the patient without imaging.

Nerve root levels

RootDermatomeMyotomeReflex
C5Lateral upper arm over the deltoidShoulder abduction, elbow flexionBiceps (C5, C6)
C6Lateral forearm, thumb and index fingerWrist extension, elbow flexionBrachioradialis (C5, C6)
C7Middle fingerElbow extension, wrist flexion, finger extensionTriceps (C7)
C8Ring and little fingers, distal medial forearmFinger flexion, thumb extensionNone commonly tested
T1Medial forearm and elbowFinger abduction and adduction (interossei)None

Remember that cervical roots exit above the vertebra of the same number (the C6 root exits between C5 and C6), and C8 exits between C7 and T1. A C5 to C6 disc herniation therefore affects the C6 root. The C7 root is the most commonly involved in radiculopathy, followed by C6.

Cervical radiculopathy versus myelopathy

Cervical radiculopathy is compression or irritation of a nerve root, usually in the intervertebral foramen by a disc herniation in younger adults or by uncovertebral and facet osteophytes in older adults. It causes unilateral arm pain in a dermatomal pattern, paresthesia, and lower motor neuron signs in that root's distribution: myotomal weakness and a diminished reflex. Resting the hand on the head often eases symptoms (shoulder abduction sign).

The Wainner test item cluster diagnoses cervical radiculopathy with four tests: a positive Spurling test (extension, side bending and gentle compression toward the symptomatic side reproduces arm symptoms), a positive distraction test (lifting the head relieves symptoms), a positive upper limb tension test A (median nerve bias: scapular depression, shoulder abduction, forearm supination, wrist and finger extension, shoulder external rotation, elbow extension, then contralateral cervical side bending), and cervical rotation toward the involved side of less than 60 degrees. Three of four positive gives a moderate shift toward the diagnosis, and all four positive a large one (positive likelihood ratio about 30). The upper limb tension test A is the most sensitive single test, so a negative result helps rule radiculopathy out, while Spurling is the most specific and helps rule it in.

Cervical myelopathy is compression of the spinal cord itself, usually by degenerative spondylosis narrowing the central canal in people over 50. It causes upper motor neuron signs below the level: bilateral hand numbness and clumsiness (difficulty with buttons and handwriting), a broad based, unsteady gait, hyperreflexia, clonus, a positive Hoffmann sign (flicking the middle finger distal phalanx causes thumb and index flexion), a positive Babinski sign, an inverted supinator sign (tapping the brachioradialis tendon produces finger flexion instead of the expected response) and sometimes the Lhermitte sign (neck flexion sends an electric sensation down the spine). A five item cluster (gait deviation, positive Hoffmann, inverted supinator sign, positive Babinski, age over 45) helps: one or fewer positive makes myelopathy unlikely, three or more makes it very likely. Myelopathy is a contraindication to cervical manipulation and needs medical referral.

Radiculopathy Myelopathy Vertebral bodyVertebral body Osteophyte orlateral disc Exiting root Foramen narrowed on one side Unilateral dermatomal pain, weakmyotome, reduced reflex (LMN) Central disc Thick ligament Cord flattened Bilateral clumsy hands, gaitataxia, hyperreflexia (UMN) Axial view, anterior at top
Figure 2.7 Root versus cord. Narrowing of one intervertebral foramen compresses an exiting root and produces lower motor neuron signs in one arm (radiculopathy). Narrowing of the central canal flattens the cord and produces upper motor neuron signs below the level (myelopathy), which contraindicates manipulation.

Neck pain classification and other conditions

Current neck pain practice guidelines classify patients by the dominant impairment: neck pain with mobility deficits (treated with thoracic and cervical mobilization or manipulation and exercise), neck pain with movement coordination impairments (commonly after whiplash; education, active exercise, deep neck flexor training), neck pain with headaches (cervicogenic headache; manual therapy and exercise) and neck pain with radiating pain (radiculopathy; mechanical intermittent traction combined with exercise, neural mobilization). A six item prediction rule for thoracic manipulation in neck pain (recent onset under 30 days, no symptoms below the shoulder, looking up not painful, low fear avoidance, reduced upper thoracic kyphosis, cervical extension under 30 degrees) was not well supported in later validation, but thoracic manipulation remains a reasonable option for mechanical neck pain.

Cervicogenic headache is unilateral, starts in the neck, is provoked by neck postures and shows reduced C1 to C2 rotation on the flexion rotation test.

Whiplash associated disorders follow acceleration and deceleration injury and are graded by the Quebec Task Force system.

GradeFindingsImplication
0No neck complaint, no physical signsReassure
INeck pain, stiffness or tenderness only; no physical signsEducation, stay active
IINeck complaint with musculoskeletal signs (reduced range, point tenderness)Active exercise, manual therapy, education; avoid prolonged collar use
IIINeck complaint with neurological signs (weakness, reflex or sensory change)Neurological monitoring, consider referral
IVFracture or dislocationMedical and surgical management

Thoracic outlet syndrome is compression of the brachial plexus (neurogenic, by far the most common), subclavian vein or subclavian artery at the interscalene triangle, the costoclavicular space or beneath the pectoralis minor. Neurogenic symptoms most often follow the lower trunk (C8, T1: medial forearm and ulnar hand). The Adson test (head extended and rotated toward the tested side with a deep breath while the radial pulse is monitored) targets the scalenes, the costoclavicular (military brace) test the space between clavicle and first rib, the Wright hyperabduction test the pectoralis minor, and the Roos elevated arm stress test (arms at 90 degrees abduction and external rotation, opening and closing the hands for 3 minutes) reproduces symptoms. Pulse changes occur in many healthy people, so reproduction of symptoms is more meaningful than pulse loss.

In the thoracic spine, think first of visceral referral: cardiac (left chest, arm, jaw, interscapular), gallbladder (right scapula), kidney (flank), aortic dissection (tearing interscapular pain). Minimal trauma in an older adult suggests an osteoporotic compression fracture; a young adult with morning stiffness over 30 minutes that improves with exercise and reduced chest expansion suggests ankylosing spondylitis.

Board tip. Lower motor neuron signs at one level in one arm point to the root; upper motor neuron signs (Hoffmann, Babinski, clonus, hyperreflexia, gait ataxia), especially bilateral, point to the cord. A patient can have both: an LMN sign at the level of compression and UMN signs below it.
Case. A 61 year old man reports neck stiffness and six months of gradually worsening numbness in both hands, dropping coins and difficulty buttoning his shirt. He has started to walk with his feet farther apart. Reflexes are brisk in both arms and legs, and the Hoffmann sign is positive bilaterally. What is the most appropriate action?
Reasoning: Bilateral hand clumsiness, a widened gait, hyperreflexia and positive Hoffmann signs form an upper motor neuron picture: cervical spondylotic myelopathy, not radiculopathy (which is unilateral with lower motor neuron signs) or carpal tunnel syndrome (no gait change or reflex change). The correct action is referral to a physician for imaging and a surgical opinion, with documentation of the findings. Cervical manipulation and traction are tempting for a stiff neck but are inappropriate; manipulation is contraindicated. Safety point: progressive myelopathy can cause permanent loss of function, so it should not be watched through a long trial of conservative care.
Key point

Screen the neck for fracture, ligament instability, cervical arterial dysfunction, myelopathy and nonmusculoskeletal sources before treating. The Canadian C-spine rule decides imaging after trauma. Radiculopathy is unilateral with lower motor neuron signs in one root (Spurling, distraction, upper limb tension test A and limited rotation form the cluster), while myelopathy produces bilateral upper motor neuron signs and needs referral. Classify neck pain by its dominant impairment, grade whiplash with the Quebec system, interpret thoracic outlet tests by symptom reproduction, and remember visceral referral to the thoracic spine.

Section 4Examination and management of the lumbar spine and sacroiliac region

Red flags in low back pain

Most low back pain is nonspecific and has a favorable course, and imaging is not recommended in the absence of red flags. The examination therefore begins by excluding the small number of serious causes.

ConditionKey featuresAction
Cauda equina syndromeSaddle anesthesia, urinary retention (often with overflow incontinence), fecal incontinence, bilateral or progressive leg weaknessEmergency referral
MalignancyPrior cancer (strongest single predictor), age over 50, unexplained weight loss, no improvement after a month, constant night painPhysician referral
Vertebral fractureOlder age, prolonged corticosteroid use, osteoporosis, significant traumaReferral for imaging
Spinal infectionFever, intravenous drug use, recent infection or procedure, immunosuppressionUrgent referral
Abdominal aortic aneurysmOlder male smoker, pulsing abdominal mass, deep back or abdominal pain unaffected by movementEmergency if symptomatic
Inflammatory spondyloarthropathyOnset before 40, morning stiffness over 30 minutes, improves with exerciseRheumatology referral

Screen psychosocial risk as well (for example with the STarT Back tool, which stratifies risk of persistent disability), and track outcomes with the Oswestry Disability Index.

Lumbar radiculopathy and neural tension tests

Lumbar roots exit below the pedicle of the vertebra of the same number (the L4 root exits between L4 and L5). Because the common posterolateral disc herniation hits the root that is traversing the disc on its way down, an L4 to L5 posterolateral herniation compresses the L5 root and an L5 to S1 herniation compresses S1. A less common far lateral herniation at L4 to L5 catches the exiting L4 root.

L4L5Sacrum (S1) L4 root exitsbelow L4 pedicle L5 root exitsbelow L5 pedicle PosterolateralL4-5 herniationhits L5 root Pedicle Dural sac withcauda equina Patient's leftPatient's right Posterior view, posterior elements removed; discs shaded blue
Figure 2.8 Why an L4 to L5 posterolateral disc herniation causes an L5 radiculopathy. The L4 root has already exited above the disc, while the L5 root is still traveling down past it. Viewed from behind, the patient's left is on the viewer's left.
RootDermatomeMyotomeReflex
L2Anterior upper thighHip flexionNone reliable
L3Anterior thigh to medial kneeKnee extensionPatellar (L3, L4)
L4Medial leg and medial malleolusAnkle dorsiflexionPatellar (L4)
L5Lateral leg and dorsum of foot, great toeGreat toe extension, hip abductionMedial hamstring (inconsistent)
S1Lateral foot, little toe, soleAnkle plantarflexion and eversion, hip extensionAchilles (S1)

The straight leg raise is positive when it reproduces radicular leg pain between about 30 and 70 degrees; it is sensitive for disc related radiculopathy, so a negative test helps rule it out. The crossed straight leg raise (raising the uninvolved leg reproduces pain in the involved leg) is specific and helps rule it in. The slump test adds trunk and neck flexion; release of neck flexion that eases symptoms confirms neural tension. The prone knee bend (femoral nerve tension) tests the L2 to L4 roots.

Treatment based classification

The treatment based classification (TBC) system sorts patients with low back pain into subgroups that respond to different treatments. The classic version, still widely tested, has four categories.

CategoryFindings that point to itTreatment
ManipulationSymptoms under 16 days, no symptoms distal to the knee, low work fear avoidance score (under 19), lumbar hypomobility, at least one hip with more than 35 degrees of internal rotation; 4 of 5 predicts rapid successThrust manipulation and range of motion exercise
StabilizationAge under 40, straight leg raise over 91 degrees, aberrant movements, positive prone instability test; frequent recurrencesMotor control and trunk strengthening
Specific exerciseDirectional preference: centralization with repeated extension (most common), with flexion, or a lateral shift that needs correctionRepeated movements in the preferred direction
TractionSigns of nerve root compression with peripheralization during extension or a positive crossed straight leg raise, no centralizationMechanical traction with extension exercise (evidence limited)

A shortened two item version of the manipulation rule (symptoms under 16 days and no symptoms below the knee) is also used. The prone instability test is done with the patient prone, trunk on the table and feet on the floor; posterior to anterior pressure provokes pain, and the test is positive when the pain disappears as the patient lifts the legs and contracts the back extensors. The updated TBC reframes care by goal: symptom modulation for highly irritable patients, movement control for those with moderate irritability and motor control deficits, and functional optimization for low irritability patients ready for full loading.

Centralization is the movement of referred symptoms from distal to proximal toward the spine during repeated movements or sustained positions. It is a strong good prognostic sign. Peripheralization, symptoms spreading distally, means that direction should be avoided for now. Pain in the back may increase as leg symptoms centralize; that is still a good response.

Board tip. Centralization always wins over local back pain: if repeated extension reduces calf pain to buttock pain while back pain rises slightly, continue extension. If symptoms move farther down the leg, stop that direction.

Stenosis and spondylolisthesis

Lumbar spinal stenosis narrows the central canal or lateral recesses, usually through disc degeneration, facet hypertrophy and ligamentum flavum thickening in older adults. It produces neurogenic claudication: buttock and leg pain, numbness or heaviness with standing and walking that eases with sitting or flexion (flexion widens the canal and foramina). Patients lean forward on a shopping cart. Helpful findings include age over about 48, bilateral symptoms, leg pain worse than back pain, pain while walking or standing and relief with sitting. A two stage treadmill test separates stenosis from other causes: symptoms begin sooner when walking level than walking on an incline (the incline flexes the trunk).

FeatureNeurogenic claudicationVascular claudication
ReliefSitting or bending forward, not standing stillStanding still, any position
Uphill walking or cyclingBetter tolerated (trunk flexed)Worse, symptoms at the same workload
Pulses and skinNormalDiminished pulses, low ankle brachial index, cool, hairless skin
Pain qualityBurning, numbness, variable distanceCramping in the calf at a consistent distance

Management emphasizes flexion based exercise, manual therapy to the spine and hips, cycling or body weight supported treadmill walking, and conditioning; surgery is considered for progressive deficits or failed conservative care.

Spondylolysis is a defect (often a stress fracture) of the pars interarticularis, most often at L5, common in adolescent athletes who repeatedly extend and rotate (gymnastics, diving, football linemen, cricket bowlers). An oblique radiograph shows a "collar on the Scotty dog." Spondylolisthesis is the forward slip of one vertebra on the one below. Isthmic spondylolisthesis follows bilateral pars defects, usually L5 on S1 in younger people; degenerative spondylolisthesis occurs with intact pars from facet arthritis, usually L4 on L5 in older women. The Meyerding grade describes slip as a percentage of the vertebral body width below: grade I up to 25 percent, II 26 to 50, III 51 to 75, IV 76 to 100, and V (spondyloptosis) beyond 100 percent. A palpable step off may be felt. Treatment avoids end range extension early, emphasizes trunk stabilization and hamstring flexibility, and may include bracing and activity modification for an acute pars fracture in an adolescent.

The sacroiliac joint

Sacroiliac pain is felt over the posterior superior iliac spine and buttock, typically below L5, and can refer to the thigh. Single SI tests are unreliable, so the exam expects the Laslett provocation cluster:

  • Distraction: supine, posterolateral pressure on both anterior superior iliac spines gaps the front of the joints.
  • Thigh thrust: supine with the hip flexed to 90 degrees, a posterior force along the femur shears the SI joint.
  • Compression: side lying, downward force on the iliac crest.
  • Sacral thrust: prone, posterior to anterior force on the sacrum.
  • Gaenslen test: one hip flexed to the chest while the other leg drops off the table into extension, tested on both sides.

Two of the first four positive, or three or more of all tests, supports SI joint pain; all negative makes it unlikely. The cluster works best once a discogenic source has been excluded (no centralization).

Case. A 28 year old warehouse worker has had low back pain for 8 days after lifting. Pain stays above the knee, his work fear avoidance score is 12, spring testing shows lumbar hypomobility, and his right hip internal rotation is 40 degrees. There are no red flags. Which intervention is most likely to produce rapid improvement?
Reasoning: He meets all five criteria of the manipulation clinical prediction rule (symptoms under 16 days, no symptoms distal to the knee, fear avoidance work score under 19, hypomobility, hip internal rotation over 35 degrees), which strongly predicts a fast response to lumbopelvic thrust manipulation followed by range of motion exercise. Stabilization exercise fits a younger patient with aberrant movements and a positive prone instability test; traction fits nerve root compression with peripheralization; bed rest is never the answer. Safety point: screening for red flags must precede manipulation, and it was negative here.
Case. A 71 year old woman reports bilateral buttock and thigh heaviness after walking two blocks, relieved when she sits or leans on a shopping cart. Foot pulses are strong, and she can ride a stationary bike for 30 minutes without symptoms. Which exercise approach is most appropriate?
Reasoning: Symptoms relieved by flexion and sitting, tolerance of cycling and normal pulses point to neurogenic claudication from lumbar spinal stenosis, not vascular claudication. Flexion widens the canal, so flexion based exercise, cycling and walking with a slightly forward lean (or body weight supported treadmill) are appropriate, combined with hip and spine mobility work. Repeated extension in standing narrows the canal and is likely to aggravate symptoms. Safety point: new bladder changes or progressive weakness would require urgent referral.
Key point

Exclude cauda equina syndrome, cancer, fracture, infection and aneurysm before treating low back pain. Lumbar roots exit below their pedicle, so a posterolateral L4 to L5 disc compresses L5. The straight leg raise rules radiculopathy out and the crossed straight leg raise rules it in. Treatment based classification matches patients to manipulation, stabilization, directional exercise or traction, and centralization is a good sign. Stenosis improves with flexion and differs from vascular claudication. Grade spondylolisthesis by Meyerding, and diagnose SI pain with a provocation cluster, not single tests.

Section 5Manual therapy and therapeutic exercise for the spine

Joint mobilization grades

Joint mobilization is a passive, skilled movement of a joint at a speed the patient can stop. The two grading systems the exam uses describe where in the available range the movement occurs and how large it is.

Start of rangeRestricted limitAnatomicallimit Ismall, beginning of range IIlarge, midrange, short of limit IIIlarge, up to the limit IVsmall, at the limit Vthrust, high velocity, low amplitude Grades I, II:pain, jointnutritionIII, IV:stiffness
Figure 2.9 Maitland grades by position in the available range and amplitude. Grades I and II stay short of resistance and are used for pain; grades III and IV reach into resistance and are used for stiffness; grade V is a thrust.
SystemGradeDescriptionMain use
Maitland (oscillation)ISmall amplitude at the beginning of rangePain, highly irritable joints
MaitlandIILarge amplitude within the range, not reaching the limitPain, maintain joint nutrition
MaitlandIIILarge amplitude up to the limit of available rangeStiffness, increase motion
MaitlandIVSmall amplitude at the limit of available rangeStiffness, increase motion
MaitlandVHigh velocity, low amplitude thrust at the end of available rangeManipulation
Kaltenborn (sustained)ISmall distraction that only neutralizes joint compression ("loosen")Pain relief, used with gliding
KaltenbornIITakes up the slack in the capsule ("tighten")Pain, assess joint play
KaltenbornIIIStretches the capsule beyond the slackIncrease motion

Oscillations run at about one to three per second for 30 to 60 seconds and are repeated. Begin in the resting position for irritable joints, glide according to the convex concave rule or distract perpendicular to the treatment plane, and stabilize the proximal segment.

Effects are both mechanical (stretching capsule, restoring glide) and neurophysiological (spinal and descending pain inhibition, reduced guarding), which is why a thoracic thrust can ease neck pain.

Thrust manipulation: indications, contraindications and precautions

Thrust manipulation (Maitland grade V) is a high velocity, low amplitude movement, often accompanied by an audible cavitation (which is not required for benefit). It has good evidence for acute low back pain in patients who fit the prediction rule, for mechanical neck pain (particularly thoracic thrust) and for cervicogenic headache. The decision to thrust is a risk benefit judgment; rare but serious adverse events, especially with cervical thrust, make screening essential.

Contraindications (do not thrust)Precautions (modify, use caution or gentler grades)
Fracture, malignancy or infection of the spineOsteopenia or mild osteoporosis
Cauda equina syndrome, myelopathy, progressive neurological deficitRadiculopathy with stable neurological signs
Cervical arterial dysfunction, vertebrobasilar insufficiency signsAnticoagulant therapy or bleeding disorder
Upper cervical ligament instability (rheumatoid arthritis, Down syndrome, recent trauma)Pregnancy, hypermobility, connective tissue disorders
Severe osteoporosis, bone disease, acute inflammatory arthritisSevere pain, high irritability, psychological dependence on passive care
No consent, unclear diagnosisPrior spinal surgery at the level, long term corticosteroids
Board tip. Mobilization grades I and II for pain, III and IV for stiffness, V is a thrust. If a stem describes a joint that is painful before resistance is felt, choose a low grade; if resistance comes before pain, a higher grade is appropriate. Manual therapy works best combined with active exercise, so the best answer is rarely manual therapy alone.

Motor control training

People with recurrent low back pain often show delayed activation of the transversus abdominis and atrophy or poor activation of the lumbar multifidus, and people with neck pain show poor endurance of the deep neck flexors (longus colli and longus capitis) with overactivity of the sternocleidomastoid and anterior scalenes. Motor control training first teaches isolated activation of the deep muscles, then integrates it into posture and function.

  • Abdominal drawing in maneuver: gently draw the lower abdomen in without moving the spine or holding the breath; a pressure biofeedback unit under the abdomen in prone (starting near 70 mmHg) should drop a few mmHg with a correct contraction.
  • Multifidus: palpated contraction in prone or side lying, progressed to quadruped arm and leg lifts (bird dog).
  • Craniocervical flexion test and training: supine with a pressure unit under the neck inflated to 20 mmHg, the patient nods to raise the pressure in steps of 2 mmHg up to 30 mmHg, holding each for 10 seconds without superficial muscle substitution.
  • Progression: supine bridges, side planks, curl ups (the classic "big three" emphasize trunk endurance with low spinal load), then standing, lifting, and sport or work specific tasks with a neutral spine.

General exercise works about as well as specific motor control training for many with chronic low back pain; progressive, functional active exercise is the key.

McKenzie principles

Mechanical Diagnosis and Therapy, developed by Robin McKenzie, uses repeated movements and sustained positions to classify spinal pain into three mechanical syndromes.

SyndromeFeaturesManagement
DerangementMost common; symptoms change with repeated movement, centralize in one direction and peripheralize in another; may have a lateral shiftRepeated movements in the direction that centralizes; correct a lateral shift first
DysfunctionPain only at end range of a shortened, adaptively changed tissue; no lasting change with repeated movementRegular end range stretching in the painful direction to remodel tissue
PosturalIntermittent pain only with sustained end range positions (slumped sitting); no loss of motionPostural correction and education

The typical extension progression for a posterior derangement is prone lying, prone on elbows, prone press ups, then standing extension. A lateral shift (the trunk displaced away from the painful side in most cases) is corrected before extension. When extension peripheralizes symptoms, it stops; flexion or lateral movements are explored instead.

Return to function

Current guidelines recommend staying active, reassuring education (including pain neuroscience education for persistent pain), exercise, and manual therapy combined with exercise; passive modalities and rest are not primary care. For fear of movement, graded activity (quota based increases regardless of pain) and graded exposure (gradual confrontation of feared movements) reduce disability, and work conditioning or hardening prepares the return to work.

Case. A 40 year old office worker has chronic neck pain and forward head posture. During the craniocervical flexion test she cannot hold 24 mmHg for 10 seconds without the sternocleidomastoid contracting visibly. Which intervention is most appropriate to begin?
Reasoning: The test shows poor endurance and control of the deep neck flexors with superficial substitution. The best start is low load craniocervical flexion training at the pressure she can hold correctly (22 mmHg), progressing in 2 mmHg steps, combined with postural and scapular exercises. Heavy resisted neck flexion with a head lift trains the superficial muscles she already overuses. Cervical thrust manipulation alone ignores the motor control deficit. Collars weaken the muscles further. Safety point: screen for cervical arterial dysfunction and myelopathy before any manual therapy added to the plan.
Key point

Maitland grades I and II treat pain, III and IV treat stiffness and V is a thrust; Kaltenborn grades describe sustained distraction from loosening to stretching. Thrust manipulation helps selected patients but is contraindicated with fracture, malignancy, infection, cauda equina syndrome, myelopathy, arterial dysfunction and ligament instability. Motor control training targets the transversus abdominis, multifidus and deep neck flexors before integration into function. McKenzie classifies derangement, dysfunction and postural syndromes, using the direction that centralizes. Active care, education and graded activity lead the return to function.

The chapter in one breath

  • Soft tissue heals through overlapping inflammatory, proliferative (type III collagen) and remodeling (type I collagen) phases, and loading should match each phase.
  • Tissues are viscoelastic: low load, long duration stretch uses creep and stress relaxation; bone follows Wolff law and soft tissue follows Davis law.
  • Protected early motion beats immobilization whenever the repair allows; symptom response over 24 hours guides progression.
  • A convex surface glides opposite to bone movement and a concave surface glides the same way, which sets mobilization direction.
  • Closed chain work emphasizes compression and function; open chain isolates muscles and increases shear; most muscles are third class levers.
  • Two joint muscles show active insufficiency when shortened and passive insufficiency when lengthened; tenodesis uses the latter for grasp.
  • Screen the neck for fracture (Canadian C-spine rule), ligament instability, cervical arterial dysfunction and myelopathy before manual therapy.
  • Radiculopathy gives unilateral lower motor neuron signs (Wainner cluster); myelopathy gives bilateral upper motor neuron signs and needs referral.
  • Lumbar roots exit below their pedicle, so a posterolateral L4 to L5 herniation affects L5; the crossed straight leg raise rules radiculopathy in.
  • Treatment based classification matches patients to manipulation, stabilization, directional exercise or traction; centralization predicts a good outcome.
  • Stenosis improves with flexion; grade spondylolisthesis with Meyerding; diagnose SI pain with the provocation cluster.
  • Maitland grades I to II for pain, III to IV for stiffness, V is a thrust; pair manual therapy with motor control and graded active exercise.

Words worth knowing

TermWhat it means
Proliferative phaseThe healing phase, from about day 3 to week 6, when fibroblasts lay down weak type III collagen and new capillaries.
Remodeling phaseThe long healing phase in which type III collagen is replaced by aligned, stronger type I collagen.
CreepGradual elongation of tissue under a constant load over time.
Stress relaxationDecline in internal tension when tissue is held at a constant length.
Wolff lawBone remodels its density and structure according to the loads placed on it.
Davis lawSoft tissue remodels according to the demands placed on it, lengthening under sustained tension.
Convex concave ruleA convex surface glides opposite to bone movement; a concave surface glides in the same direction.
Close packed positionThe joint position of maximal congruence and ligament tension, with the least joint play.
Capsular patternA characteristic proportional loss of motion when the entire joint capsule is involved.
Active insufficiencyInability of a multijoint muscle to produce enough force when shortened across all its joints.
Passive insufficiencyLimitation of motion by a multijoint muscle that is fully lengthened across all its joints.
RadiculopathyDysfunction of a nerve root, causing dermatomal symptoms and lower motor neuron signs.
MyelopathyDysfunction of the spinal cord, causing upper motor neuron signs below the level of compression.
Cervical arterial dysfunctionCompromise of the vertebral or internal carotid arteries that can mimic neck pain and contraindicates manipulation.
Thoracic outlet syndromeCompression of the brachial plexus or subclavian vessels between the neck and the axilla.
CentralizationMovement of referred symptoms toward the spine with repeated movement, a favorable prognostic sign.
Neurogenic claudicationLeg symptoms with walking or standing from spinal stenosis, relieved by sitting or flexion.
SpondylolisthesisForward slip of one vertebra on the one below, graded by Meyerding from I to V.
Cauda equina syndromeCompression of the lumbosacral roots causing saddle anesthesia and bladder or bowel dysfunction; an emergency.
Derangement syndromeThe McKenzie category in which symptoms change and centralize with repeated movement in one direction.

Check yourself

Which type of collagen predominates in the proliferative phase, and why does it matter for exercise?
Answer. Type III collagen, which is thin, weak and randomly oriented. Controlled low loads help align it, but high loads can disrupt it and restart inflammation.
A patient has a stiff knee lacking flexion. Using the convex concave rule, which direction should the tibia be glided?
Answer. Posteriorly. The concave tibia moves on the convex femur, so it glides in the same direction as the bone movement during flexion.
Why does a person with C6 tetraplegia avoid stretching the finger flexors with the wrist extended?
Answer. To preserve tenodesis. Slight tightness of the finger flexors lets active wrist extension close the fingers passively for functional grasp.
A 70 year old is alert after a low speed rear end collision and has no midline tenderness. Does the Canadian C-spine rule allow testing without imaging?
Answer. No. Age 65 or older is a high risk factor, so radiography is indicated regardless of the low risk features.
Which tests make up the cervical radiculopathy cluster, and which single test is best for ruling radiculopathy out?
Answer. Spurling, distraction, upper limb tension test A and ipsilateral rotation under 60 degrees. The upper limb tension test A is the most sensitive, so a negative result helps rule it out.
A patient has weak great toe extension and numbness over the dorsum of the foot. Which root, and which disc level is most likely if the herniation is posterolateral?
Answer. The L5 root, most likely from a posterolateral L4 to L5 disc herniation, which compresses the traversing L5 root.
During repeated prone press ups, a patient's calf pain moves up to the buttock while low back pain rises. Should extension continue?
Answer. Yes. Symptoms are centralizing, a favorable response, even though central back pain has increased.
How do you distinguish neurogenic from vascular claudication on a stationary bike?
Answer. Neurogenic claudication is usually tolerated on a bike because the trunk is flexed, while vascular claudication produces calf pain at a consistent workload regardless of posture and eases with simply stopping.
What does a Meyerding grade III spondylolisthesis mean?
Answer. The upper vertebra has slipped forward 51 to 75 percent of the width of the vertebral body below.
A patient's shoulder is painful before any resistance is felt during passive motion. Which mobilization grades are appropriate?
Answer. Grades I and II, which stay short of resistance and are used for pain relief. Grades III and IV are for stiffness when resistance is felt before pain.
Chapter 3 · Musculoskeletal

Musculoskeletal: The Upper Extremity

The upper extremity questions on the NPTE rarely ask you to name a muscle; they hand you a patient with a painful arc, a weak grip or a numb ring finger and ask what is wrong, what to test next and what is safe to do this week. Shoulder pathology, postoperative protocols, elbow and hand injuries and peripheral nerve lesions form a large and predictable block of the musculoskeletal content. This chapter organizes that block around the decisions you will make on the exam and in clinic.

By the end of this chapter you can

  • Describe scapulohumeral rhythm, the force couples that produce it and how faulty scapular mechanics contribute to subacromial pain.
  • Distinguish rotator cuff tendinopathy, full thickness tears, instability and adhesive capsulitis by history, capsular pattern and special tests.
  • Apply the precautions and phase progression after rotator cuff repair, Bankart repair, anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty.
  • Differentiate lateral and medial epicondylalgia, ulnar collateral ligament injury and the nerve entrapments around the elbow.
  • Recognize carpal tunnel syndrome, de Quervain tenosynovitis, common wrist fractures and the hand deformities, and choose an appropriate orthosis.
  • Use the flexor tendon zones to predict prognosis and protect a tendon repair.
  • Localize lesions of the brachial plexus and the radial, median and ulnar nerves from motor, sensory and deformity findings.
  • Apply the Seddon classification and the expected rate of axonal regrowth to plan testing and prognosis.

Section 1The shoulder complex

Joints and the scapulohumeral rhythm

The shoulder complex is four articulations working as one unit: the glenohumeral joint, the sternoclavicular joint, the acromioclavicular joint and the functional scapulothoracic articulation. The glenohumeral joint is a ball and socket with a shallow glenoid that covers only about a quarter to a third of the humeral head; the labrum deepens it, and the capsule, glenohumeral ligaments and rotator cuff supply the rest of its stability. That trade of bony stability for mobility is the reason the shoulder dislocates more than any other large joint and the reason rotator cuff function matters so much.

Full elevation of the arm (about 180 degrees) is shared between the glenohumeral joint and the scapula. The classic teaching ratio is 2:1: about 120 degrees of glenohumeral motion and 60 degrees of scapular upward rotation. The ratio is not constant through the range; in the first 30 degrees or so of abduction (the setting phase) the scapula moves little and variably, and most scapular contribution comes later. The clavicle elevates about 30 to 40 degrees at the sternoclavicular joint and rotates posteriorly about its long axis, which allows the scapula to finish upward rotation. If the clavicle cannot rotate (for example after acromioclavicular fusion), elevation is limited to roughly 110 to 120 degrees.

Two arthrokinematic rules drive many questions. The humeral head is convex moving on a concave glenoid, so the head glides opposite to the direction the shaft moves: during abduction the head rolls up and glides inferiorly; during flexion and internal rotation it glides posteriorly; during extension and external rotation it glides anteriorly. To gain abduction you therefore mobilize the humerus inferiorly; to gain external rotation, the traditional rule says anterior glide, although several studies show posterior glides also improve external rotation in adhesive capsulitis. Full elevation also requires external rotation of the humerus so the greater tubercle clears the acromion.

Force couples and scapular dyskinesis

Scapular upward rotation is produced by a force couple of the upper trapezius, lower trapezius and serratus anterior. The serratus also holds the medial border against the thorax and posteriorly tilts the scapula. At the glenohumeral joint the deltoid pulls the humerus upward, and the rotator cuff (especially infraspinatus, teres minor and subscapularis) compresses and depresses the head so the deltoid produces rotation rather than superior translation. When the cuff is weak or torn, the deltoid shears the head toward the acromion and the subacromial space narrows.

Scapular dyskinesis is any altered position or motion of the scapula: prominence of the medial border, early or excessive shrugging, or poor control on lowering. True winging of the medial border at rest or during a wall push up suggests long thoracic nerve palsy (serratus anterior); lateral winging with a depressed, laterally displaced scapula suggests spinal accessory nerve injury (trapezius), often after posterior triangle surgery. Dyskinesis from weakness or tightness (tight pectoralis minor, weak lower trapezius and serratus) is far more common than nerve palsy and responds to targeted exercise.

ElementNormal contributionWhat goes wrong
Glenohumeral jointAbout 120 degrees of elevation, inferior glide of the head, external rotation in elevationCapsular tightness (posterior capsule causes anterosuperior translation), cuff weakness lets the head ride up
ScapulothoracicAbout 60 degrees of upward rotation, posterior tilt, external rotationWeak serratus and lower trapezius, tight pectoralis minor: anterior tilt and reduced upward rotation narrow the subacromial space
SternoclavicularClavicular elevation, protraction and posterior rotationLoss of posterior rotation blocks the last part of elevation
AcromioclavicularSmall rotations that fine tune scapular positionSprain or arthritis: pain at the top of the arc (about 160 to 180 degrees) and with horizontal adduction
Thoracic spineExtension at end range elevationThoracic kyphosis limits elevation and favors anterior tilt of the scapula
Scapulohumeral rhythm during 180 degrees of elevation Glenohumeral about 120 degrees Scapula about 60 Overall ratio 2:1 (two degrees of humeral motion for every one of scapular rotation) 0 30 60 90 120 150 180 deg setting phase painful arc 60 to 120 AC arc Painful arc 60 to 120: subacromial structures (supraspinatus, bursa) pass under the acromion. Arc 160 to 180: acromioclavicular joint compressed at end range. Setting phase (first 30 or so): scapula seeks a stable position, little upward rotation.
Figure 3.1 Elevation is shared about 2:1 between the glenohumeral joint and the scapula. Note where pain falls in the arc: a mid range arc points to the subacromial space, an end range arc to the acromioclavicular joint.

Subacromial pain and rotator cuff disease

The older term impingement described compression of the supraspinatus tendon and subacromial bursa between the humeral head and the coracoacromial arch. Current practice increasingly uses subacromial pain syndrome or rotator cuff related shoulder pain, because most of the problem is a tendinopathy driven by load and age rather than mechanical pinching. The exam may still use the Neer stages, so know them: stage I, edema and hemorrhage, typically under 25 years, reversible; stage II, fibrosis and tendinitis, about 25 to 40 years; stage III, bone spurs and tendon rupture, over 40 years.

External impingement is classified as primary (structural narrowing: hooked type III acromion, acromioclavicular osteophytes) or secondary (functional narrowing from instability, cuff weakness, scapular dyskinesis or posterior capsule tightness). Internal impingement is a different entity: in the throwing athlete in abduction and external rotation, the articular side of the posterior supraspinatus and infraspinatus is pinched between the greater tuberosity and the posterosuperior glenoid and labrum. Throwers often show glenohumeral internal rotation deficit (GIRD), a loss of internal rotation of 20 degrees or more compared with the other side (or a loss of total arc), linked to posterior capsule tightness; the sleeper stretch and cross body stretch are the usual treatments.

Typical findings of rotator cuff related pain: lateral shoulder or upper arm pain (deltoid region), worse with overhead reaching and lying on the side, a painful arc between about 60 and 120 degrees, pain and possible weakness on resisted abduction and external rotation, and full or near full passive motion. Passive motion that is well preserved separates cuff disease from adhesive capsulitis.

Full thickness tears increase with age; many are asymptomatic in people over 60. The supraspinatus is torn most often. A large tear produces weakness and the inability to hold the arm raised (positive drop arm test), external rotation lag sign and hornblower sign (teres minor). An acute tear in a younger person after trauma, or an acute traumatic tear with marked weakness in any age, warrants early surgical referral; degenerative tears in older adults are first managed with exercise, which many patients do as well with as with surgery.

Conservative management of cuff related pain emphasizes progressive loading of the cuff and scapular muscles: isometrics for pain relief early, then isotonic external rotation, scaption below shoulder height, rows, serratus punch and lower trapezius work, progressing to overhead and functional loading. Add posterior capsule stretching when internal rotation is limited, thoracic mobility and education on load management. Subacromial decompression surgery has not been shown to beat exercise for most patients.

Shoulder instability

Instability ranges from subtle subluxation to frank dislocation. A useful classic split is TUBS (traumatic, unidirectional, Bankart lesion, often requires surgery) versus AMBRI (atraumatic, multidirectional, bilateral, treated with rehabilitation, and inferior capsular shift if rehab fails). About 95 percent of dislocations are anterior, from a force on the abducted and externally rotated arm. Associated lesions: a Bankart lesion (avulsion of the anteroinferior labrum and inferior glenohumeral ligament, sometimes with a bony fragment) and a Hill Sachs lesion (impaction fracture of the posterolateral humeral head against the glenoid rim). The axillary nerve is the nerve most often injured with anterior dislocation and proximal humerus fracture: check deltoid strength and sensation over the lateral shoulder (the regimental badge area). Posterior dislocation is associated with seizures and electric shock; the arm is held in internal rotation and cannot be externally rotated.

Recurrence after a first anterior dislocation is very high in young athletes (often quoted as well over half under age 20 to 25) and much lower in older adults, in whom an associated cuff tear is more common. SLAP lesions (superior labrum anterior to posterior) cause deep pain and clicking in throwers.

Adhesive capsulitis

Adhesive capsulitis (frozen shoulder) is inflammation followed by fibrosis of the glenohumeral capsule, producing painful, progressive loss of both active and passive motion in a capsular pattern: external rotation lost most, then abduction, then internal rotation (some sources list flexion with internal rotation; external rotation is always first). It is most common in people aged 40 to 65, in women, and strongly associated with diabetes mellitus (and thyroid disease); diabetic cases tend to be more severe and prolonged. The course is often described in stages: freezing (painful, pain dominant, motion beginning to decrease), frozen (stiffness dominant, pain easing), and thawing (gradual return of motion), lasting a year or more in total.

Management follows tissue irritability. In the high irritability stage use pain relieving modalities, gentle low grade mobilization (grades I and II), pendulums and pain free active assisted range; an intra articular corticosteroid injection combined with mobility exercise gives faster short term improvement and is recommended by the clinical practice guideline. As irritability falls, progress to sustained end range stretching and grade III and IV mobilization.

Board tip. Equal loss of active and passive motion means a capsular or joint problem (adhesive capsulitis, osteoarthritis). Active motion much less than passive motion means a contractile or neurologic problem (cuff tear, nerve palsy). Pain with resisted testing and full passive range points to a tendinopathy.

Special tests of the shoulder

No single shoulder test is diagnostic. Clusters work better: for a full thickness supraspinatus tear, a painful arc plus a positive drop arm test plus weakness in external rotation raises the probability considerably; for subacromial pain, a combination of Hawkins Kennedy, painful arc and infraspinatus weakness performs well. Use apprehension and relocation together for anterior instability.

TestHow it is donePositive findingSuggests
NeerExaminer stabilizes scapula and passively flexes the internally rotated arm to end rangePain in the anterior or lateral shoulderSubacromial pain (sensitive, not specific)
Hawkins KennedyShoulder and elbow flexed to 90 degrees, examiner internally rotates the humerusPainSubacromial pain
Painful arcActive abduction through full rangePain between about 60 and 120 degreesSubacromial pain or cuff tendinopathy
Empty can (Jobe)Arms at 90 degrees in the scapular plane, thumbs down, resist downward pressureWeakness or painSupraspinatus tear or tendinopathy (full can is equally accurate and less painful)
Drop armArm passively abducted to 90 degrees, patient lowers it slowlyArm drops or cannot be lowered smoothlyFull thickness cuff tear
External rotation lag signArm passively placed in near full external rotation, patient asked to holdArm drifts into internal rotationInfraspinatus and supraspinatus tear
HornblowerArm abducted 90 degrees, patient resists external rotationCannot externally rotate in abductionTeres minor tear
Lift off (Gerber) and belly pressHand behind back lifted off, or hand pressed into belly with elbow forwardCannot lift off, or elbow drops backSubscapularis tear
ApprehensionSupine, shoulder abducted 90 degrees, examiner externally rotatesPatient apprehension (not just pain)Anterior instability
Relocation (Jobe)Same position with posterior force on the humeral headApprehension relieved, more external rotation allowedConfirms anterior instability
Sulcus signInferior traction on the relaxed arm at the sideGap below the acromion (over 2 cm is marked)Inferior or multidirectional laxity
Load and shiftSeated, head centered then translated anterior and posteriorExcess translationInstability grading
O'Brien active compressionArm flexed 90, adducted 10, thumb down, resist; repeat palm upPain deep in the shoulder with thumb down, relieved palm upSLAP lesion (pain on top suggests AC joint)
Crank and biceps load IIAxial load or resisted elbow flexion in elevated, rotated positionsPain or clickLabral tear
SpeedResist shoulder flexion with elbow extended and forearm supinatedPain in the bicipital grooveBiceps tendinopathy or SLAP
YergasonElbow at 90 degrees, resist supination and external rotationPain or tendon snapping out of grooveBiceps tendinopathy, transverse humeral ligament tear
Cross body adductionArm at 90 degrees passively adducted across the chestPain at the AC jointAC joint pathology
Case. A 52 year old woman with type 2 diabetes reports four months of gradually worsening shoulder pain and stiffness with no injury. She cannot fasten her bra or reach the top shelf. Active and passive external rotation are both about 20 degrees, abduction 80 degrees, internal rotation moderately limited; resisted tests are strong and only mildly painful. Pain wakes her at night and is reproduced by any end range movement.
Reasoning: Equal active and passive loss in a capsular pattern (external rotation worst) in a middle aged woman with diabetes is adhesive capsulitis, not a cuff tear (that would show active less than passive and weakness). Night pain and pain before end feel mean high irritability, so the best initial plan is pain control, gentle grade I and II mobilizations and pain free range of motion, with education about the long course and referral for an intra articular injection to combine with therapy. Aggressive grade IV stretching now would flare her. The safety point: night pain alone is common in frozen shoulder, but check for red flags (weight loss, history of cancer, fever) that would suggest a tumor or infection.
Key point

The shoulder trades stability for motion, so its health depends on the cuff centering the humeral head and the scapula rotating upward under it. Sort shoulder pain by comparing active, passive and resisted motion: full passive with painful resisted tests and an arc is cuff tendinopathy; active far below passive with weakness is a tear or a nerve; equal active and passive loss in a capsular pattern is adhesive capsulitis or arthritis; apprehension in abduction and external rotation is instability.

Section 2Shoulder surgery and rehabilitation

Principles that apply to every shoulder protocol

Postoperative shoulder rehabilitation is governed by three questions: what tissue was repaired or replaced, what motion or load stresses that tissue, and how long that tissue needs before it tolerates the stress. Tendon to bone healing after rotator cuff repair takes roughly 12 weeks to reach useful strength and continues to mature for months; labral and capsular repairs need about 6 weeks of protection; a subscapularis tenotomy or peel during arthroplasty must be protected from stretch and active load for about 6 weeks. When a stem gives a protocol, follow it; when it does not, apply the tissue logic.

Progression between phases should be criterion based as well as time based. Typical criteria: pain controlled at rest and with the current exercises, passive range targets reached, no signs of a failed repair (sudden loss of active motion, a new pop with weakness), adequate strength (often expressed as a percentage of the uninvolved side) and normal scapular control before overhead or plyometric loading.

Rotator cuff repair

The repaired supraspinatus is under tension when the arm is adducted and is stressed most by active elevation and by passive motion beyond what the surgeon allows. Retear rates rise with age, tear size, fatty infiltration of the muscle, smoking and diabetes, and most retears happen in the first 3 to 6 months. Larger repairs and poorer tissue are progressed more slowly.

Phase (typical timing)GoalsAllowedAvoid
I. Protection (0 to about 6 weeks)Protect repair, control pain, prevent stiffnessSling with abduction pillow, pendulums, passive range within limits (often flexion and scaption to 90 to 120, external rotation to about 30 to 45 in the scapular plane), elbow, wrist and hand active motion, scapular settingActive shoulder elevation, lifting, reaching behind back, supporting body weight on the arm, sudden movements
II. Active motion (about 6 to 12 weeks)Restore full passive range, begin active motionWean sling, active assisted then active range in gravity reduced then upright positions, submaximal isometricsResisted strengthening of the repaired muscle, lifting over light objects
III. Strengthening (about 12 to 20 weeks or later)Restore strength, endurance and scapular controlProgressive bands and weights for cuff and scapular muscles, closed chain work, functional trainingHeavy overhead lifting, sudden loads
IV. Return to activity (about 4 to 6 months and beyond)Sport, work and heavy liftingPlyometrics, interval throwing, work simulation once strength criteria are metReturn before criteria are met
Rotator cuff repair: phases follow tendon to bone healing 06 wk12 wk16 wk20 wk6 mo + Protection Active Strengthening Return to activity slingpassive ROMno active lift wean slingAAROM toAROM progressive resistancecuff and scapularendurance plyometrics, sportinterval programsheavy lifting Most retears occur in the first 3 to 6 months. Large or massive tears, poor tissue, smoking, diabetes: progress more slowly. Advance on criteria (pain, range, strength, scapular control), not on the calendar alone.
Figure 3.2 A typical rotator cuff repair progression. Active elevation waits until about 6 weeks and resisted loading of the repaired tendon until about 12 weeks because tendon to bone healing is slow. Always follow the surgeon's protocol when one is given.
Board tip. After rotator cuff repair, the commonest wrong answer is "begin resisted abduction" or "active elevation" in the first 6 weeks. Passive range within limits, pendulums and distal joint exercise are the safe early choices.

Stabilization procedures

An arthroscopic Bankart repair reattaches the anteroinferior labrum and capsule to the glenoid rim. The tissue at risk is stretched by external rotation combined with abduction and by extension. Typical restrictions: sling for about 4 to 6 weeks; external rotation limited (often to about 30 degrees at the side in the first weeks, progressing gradually); no combined abduction and external rotation (the apprehension position) for about 6 weeks or longer; no extension behind the body. Isometrics and scapular work begin early; strengthening progresses from about 6 to 12 weeks; contact and overhead sport usually waits 4 to 6 months. A Latarjet procedure (transfer of the coracoid with the conjoined tendon to the anterior glenoid) is used for glenoid bone loss and recurrent instability; it protects the subscapularis and the bone block. Posterior stabilization reverses the logic: avoid internal rotation, horizontal adduction and flexion with internal rotation (posterior capsule stress).

A SLAP repair protects the biceps anchor: avoid resisted elbow flexion and forearm supination and avoid loaded biceps activity for about 6 weeks; limit external rotation in abduction early, because the peel back mechanism stresses the superior labrum. A biceps tenodesis also avoids resisted elbow flexion and supination for about 6 weeks.

Total shoulder arthroplasty

An anatomic total shoulder arthroplasty replaces the humeral head and resurfaces the glenoid. It requires a functioning rotator cuff and is used for glenohumeral osteoarthritis with an intact cuff. The deltopectoral approach detaches the subscapularis (tenotomy, peel or lesser tuberosity osteotomy), so the main early precautions protect that repair: limit passive external rotation (often to about 30 degrees, per surgeon) for about 6 weeks, no active internal rotation or resisted internal rotation for about 6 weeks, no lifting heavier than a cup of coffee, no supporting body weight with the hand (such as pushing up from a chair). The operated arm is typically supported so the elbow sits slightly forward of the trunk when lying supine, avoiding extension. Subscapularis failure produces weakness in internal rotation, a positive lift off or belly press and anterior instability.

A hemiarthroplasty replaces only the humeral head (for some fractures or when the glenoid cannot be resurfaced). After fracture fixation or hemiarthroplasty, tuberosity healing is the main concern, so active motion often waits until the tuberosities have united.

Reverse total shoulder arthroplasty

A reverse total shoulder arthroplasty (rTSA) puts a ball (the glenosphere) on the glenoid and a socket on the humerus. This moves the center of rotation medially and inferiorly, lengthening the deltoid lever arm and tensioning the deltoid so that it can elevate the arm without a rotator cuff. It is indicated for cuff tear arthropathy, massive irreparable cuff tears with pseudoparalysis, complex proximal humerus fractures in older adults and failed previous arthroplasty. Because rehabilitation depends on the deltoid, the emphasis is on deltoid and scapular strengthening; strengthening the absent cuff is not the goal, and full external and internal rotation are often not achievable.

The key risk is dislocation, which typically occurs with the arm in extension, adduction and internal rotation together, the position used to reach behind the back to tuck in a shirt or perform toileting hygiene, or to push up from a chair with the arm behind the body. Classic early precautions (about 12 weeks): no combined shoulder extension, adduction and internal rotation; no reaching behind the back; no extension past neutral (keep the elbow in front of the trunk, using a pillow under the elbow in supine); no supporting body weight with the operated arm; no lifting more than a light object. The acromion takes much more deltoid load after rTSA, so new acute pain over the acromion with loss of elevation suggests an acromial stress fracture.

FeatureAnatomic total shoulderReverse total shoulder
Rotator cuff neededYes, must be intactNo, deltoid substitutes
Typical indicationGlenohumeral osteoarthritis with intact cuffCuff tear arthropathy, massive irreparable tear, complex fracture in older adult
Center of rotationAnatomicMedialized and inferiorized
Main early precautionProtect subscapularis: limit passive external rotation, no active internal rotation for about 6 weeksAvoid extension plus adduction plus internal rotation (hand behind back), no weight bearing through the arm, about 12 weeks
Strengthening focusCuff and scapular muscles, then deltoidDeltoid and periscapular muscles
Expected outcomeNear functional range, good strengthElevation about 120 degrees or more, limited rotation, pain relief
Distinctive complicationSubscapularis failure, glenoid looseningDislocation, acromial or scapular spine stress fracture, scapular notching
Case. A 76 year old man is 3 weeks after a reverse total shoulder arthroplasty for cuff tear arthropathy. In the home he asks the therapist how to manage toileting and getting up from his recliner.
Reasoning: The dislocation position after rTSA is extension, adduction and internal rotation, exactly the motion of reaching behind for perineal hygiene and of pushing up with the arm behind the body. The best answer teaches him to perform hygiene with the other hand (or from the front using adaptive equipment) and to rise from the chair by scooting forward and pushing through the uninvolved arm. Choices that add rotator cuff strengthening, active internal rotation behind the back or pushing through both arms are wrong. Safety point: a sudden clunk with loss of motion means possible dislocation; keep the arm supported and notify the surgeon promptly.
Key point

Know which tissue each operation puts at risk and which motion stretches it: active elevation for a cuff repair, external rotation with abduction for an anterior stabilization, external rotation and active internal rotation for the subscapularis after anatomic arthroplasty, and extension with adduction and internal rotation for a reverse arthroplasty. Progress by tissue healing time and by criteria, and treat a sudden loss of active motion as possible failure.

Section 3The elbow and forearm

Lateral and medial epicondylalgia

Lateral epicondylalgia (tennis elbow) is a degenerative tendinopathy of the common extensor origin, chiefly the extensor carpi radialis brevis. Histology shows disorganized collagen and new vessels rather than inflammatory cells, which is why the terms tendinopathy or epicondylalgia are preferred to epicondylitis. It peaks between 35 and 55 years and is linked to repetitive gripping and wrist extension, in manual work more than in tennis. Findings: pain at or just distal to the lateral epicondyle, pain with resisted wrist extension and resisted middle finger extension, pain with passive wrist flexion with the elbow extended, and reduced pain free grip strength (the most useful outcome measure). Cozen test (resisted wrist extension with a fist) and Mill test (passive stretch into wrist flexion, pronation and elbow extension) reproduce pain.

Management: load modification, progressive tendon loading (isometrics for pain, then eccentric and concentric wrist extensor strengthening), a counterforce brace placed distal to the painful area, manual therapy including mobilization with movement of the elbow, and attention to cervical and thoracic contributions. Corticosteroid injection gives good short term relief but worse outcomes and more recurrence at one year than physical therapy or waiting, a classic exam point.

Medial epicondylalgia (golfer's elbow) affects the common flexor and pronator origin (pronator teres and flexor carpi radialis). Pain is reproduced by resisted wrist flexion and pronation and by passive wrist extension with elbow extension. It is often accompanied by ulnar neuropathy at the elbow, so always check ulnar nerve sensation and intrinsic strength.

Ulnar collateral ligament injury

The ulnar collateral ligament (UCL), especially its anterior bundle, is the primary restraint to valgus stress between about 20 and 120 degrees of elbow flexion. During the late cocking and early acceleration phases of throwing, huge valgus torque stretches the UCL, compresses the lateral radiocapitellar joint and shears the posteromedial olecranon (the valgus extension overload pattern). Overhead throwers present with medial elbow pain during throwing, loss of velocity and sometimes ulnar paresthesia. Tests: valgus stress test at about 20 to 30 degrees of flexion, milking maneuver and the moving valgus stress test (pain between about 70 and 120 degrees of flexion as the elbow is extended under valgus load). Partial tears are rehabilitated; complete tears in throwers who wish to return are often reconstructed with a tendon graft (commonly palmaris longus). After UCL reconstruction, valgus stress is avoided for months, a hinged brace is used early, and an interval throwing program usually begins around 4 months, with return to competitive pitching often taking 12 months or more. In young throwers the same forces cause medial epicondyle apophysitis (Little League elbow); pitch count limits and rest are the main prevention.

Fractures and dislocations around the elbow

The elbow stiffens quickly, so early protected motion matters, and its neurovascular structures are vulnerable. Know these patterns:

  • Supracondylar humerus fracture: the most common elbow fracture in children, from a fall on an outstretched hand with the elbow hyperextended. Risks: brachial artery injury, anterior interosseous nerve palsy (most common nerve injury; cannot make the OK sign), and Volkmann ischemic contracture from compartment syndrome of the forearm flexors. Pain with passive finger extension, increasing pain out of proportion and tense forearm swelling are emergencies.
  • Radial head fracture: the most common elbow fracture in adults, from a fall on an outstretched hand. Nondisplaced fractures are treated with brief sling use and early active motion within days. Look for associated injuries: the Essex Lopresti lesion (radial head fracture with interosseous membrane disruption and distal radioulnar joint injury).
  • Olecranon fracture: from a direct fall on the elbow; displaced fractures need fixation because the triceps pulls the fragment proximally. Avoid resisted elbow extension until healed.
  • Elbow dislocation: usually posterior, the second most commonly dislocated major joint in adults. The terrible triad is posterior dislocation with radial head and coronoid fractures. Stable reductions are moved early in a hinged brace; loss of extension is the commonest long term problem.
  • Monteggia (proximal ulna fracture with radial head dislocation; posterior interosseous nerve at risk) and Galeazzi (distal radius shaft fracture with distal radioulnar joint dislocation) fracture dislocations.

Heterotopic ossification and myositis ossificans of the brachialis are risks after elbow trauma, especially if the elbow is forcefully stretched. Avoid aggressive passive stretching after elbow trauma; use active motion, gentle low load prolonged stretch and static progressive orthoses instead.

Nerve entrapments around the elbow

Three nerves cross the elbow, and each has typical entrapment sites. Recognizing the motor and sensory pattern localizes the lesion.

SyndromeSiteKey findingsDistinguishing point
Cubital tunnel syndromeUlnar nerve behind the medial epicondyle, under the Osborne ligament and between the two heads of flexor carpi ulnarisNumbness of ring and little fingers, weak interossei and grip, positive elbow flexion test and Tinel at the cubital tunnel, Froment signSensory loss includes the dorsal ulnar hand (dorsal cutaneous branch leaves proximal to the wrist), unlike Guyon canal compression
Pronator syndromeMedian nerve between the two heads of pronator teres, under the lacertus fibrosus or flexor digitorum superficialis archAching volar forearm, numbness in thumb to radial ring finger, pain with resisted pronationPalmar cutaneous branch involved (thenar eminence numb), no night symptoms typical of carpal tunnel
Anterior interosseous syndromeMotor branch of median nerve in the proximal forearmWeak flexor pollicis longus, index flexor digitorum profundus and pronator quadratus; cannot make an OK sign (pinch looks flat)Purely motor, no sensory loss
Radial tunnel syndromeRadial nerve or posterior interosseous nerve at the arcade of Frohse (supinator)Lateral forearm aching 3 to 5 cm distal to the epicondyle, pain with resisted supination and resisted middle finger extensionMimics lateral epicondylalgia but tenderness is distal, over the supinator, and strength is normal
Posterior interosseous nerve syndromeSame site, true motor palsyWeak finger and thumb extension (finger drop), wrist extends with radial deviationWrist extension preserved because ECRL is innervated above the lesion; no sensory loss
Right elbow, anterior view: where nerves are trapped LATERAL MEDIAL Median nerve Ulnar nerve in cubitaltunnel, behind epicondyle Median through pronatorteres (pronator syndrome) Radial nerve dividesat lateral epicondyle Posterior interosseousenters supinator Superficial radialbranch (sensory) Dashed: ulnar nerve passes posterior to the medial epicondyle
Figure 3.3 Entrapment sites around the right elbow. The radial nerve splits into a sensory superficial branch and the motor posterior interosseous nerve, which can be trapped in the supinator; the median nerve passes between the heads of pronator teres; the ulnar nerve runs behind the medial epicondyle.
Board tip. Lateral elbow pain with tenderness over the epicondyle and painful resisted wrist extension is epicondylalgia; tenderness about four fingerbreadths distal, over the supinator, with pain on resisted supination suggests radial tunnel syndrome. Neither causes sensory loss.
Case. A 7 year old fell from monkey bars onto an outstretched hand and had a displaced supracondylar fracture pinned yesterday. In the hospital he cries with pain that is not relieved by medication, his forearm is tense, and passive extension of his fingers causes severe pain.
Reasoning: Pain out of proportion and pain with passive stretch of the forearm flexors after a supracondylar fracture are early signs of acute compartment syndrome; pulselessness and pallor are late signs and should not be awaited. The best action is to stop the session, keep the arm at heart level (not elevated above it), loosen anything constrictive if allowed and notify the physician immediately. Choosing gentle range of motion, ice and elevation, or documenting and reassessing tomorrow, is wrong. Untreated, the result is Volkmann ischemic contracture.
Key point

Elbow problems sort by side and by tissue: lateral and medial epicondylalgia are load related tendinopathies treated with progressive loading; the UCL fails under the valgus load of throwing; elbow fractures threaten the brachial artery and forearm compartments and stiffen fast; and the radial, median and ulnar nerves each have predictable trap points identified by motor and sensory patterns.

Section 4The wrist and hand

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is compression of the median nerve beneath the transverse carpal ligament, the most common entrapment neuropathy. Risk factors include female sex, pregnancy, diabetes, hypothyroidism, rheumatoid arthritis, obesity and repetitive forceful wrist flexion with vibration. Symptoms: numbness and tingling in the thumb, index, middle and radial half of the ring finger, worse at night and relieved by shaking the hand (the flick sign); clumsiness; in advanced cases thenar atrophy and weakness of abductor pollicis brevis and opponens pollicis. The palmar cutaneous branch leaves the median nerve proximal to the tunnel, so sensation over the thenar eminence is spared in CTS (thenar numbness suggests a more proximal lesion).

Tests include Phalen (sustained wrist flexion for up to 60 seconds reproduces symptoms), Tinel at the carpal tunnel, and the carpal compression test (Durkan), which is among the more sensitive. Nerve conduction studies show prolonged distal latency of the median nerve. Conservative care, recommended by the clinical practice guideline for mild to moderate cases: a neutral wrist orthosis worn at night, education to avoid sustained end range wrist positions, nerve and tendon gliding, and possibly corticosteroid injection. Thenar atrophy or persistent sensory loss warrants surgical referral for carpal tunnel release, after which scar management, gentle motion and gradual grip strengthening follow; pillar pain at the base of the palm is common for weeks.

De Quervain tenosynovitis and other tendinopathies

De Quervain tenosynovitis is thickening of the tendon sheath of the first dorsal compartment, containing the abductor pollicis longus and extensor pollicis brevis, at the radial styloid. It is common in new parents lifting infants, in middle aged women and with repetitive thumb use. Finkelstein test (examiner deviates the wrist ulnarly while the thumb is held flexed) and the more specific Eichhoff variant (patient grasps the thumb in a fist before ulnar deviation) reproduce pain over the radial styloid; the WHAT test (wrist hyperflexion and abduction of the thumb) is also described. Treatment: a thumb spica orthosis that leaves the interphalangeal joint free, activity modification, and corticosteroid injection, which is often effective. Distinguish it from intersection syndrome (pain and crepitus about 4 to 6 cm proximal to the wrist where the first compartment crosses the second, often in rowers) and from first carpometacarpal osteoarthritis (positive grind test at the thumb base).

Trigger finger is a flexor tendon catching at the A1 pulley, common in diabetes.

Wrist fractures and instability

InjuryMechanism and featuresKey concern
Colles fractureFall on outstretched hand with wrist extended; distal radius fragment displaced dorsally (dinner fork deformity); common in older women with osteoporosisMedian nerve symptoms, complex regional pain syndrome, stiffness; keep fingers, elbow and shoulder moving during immobilization
Smith fractureFall on flexed wrist; fragment displaced volarly (reverse Colles)Same complications, volar instability
Scaphoid fractureFall on outstretched hand in a young adult; tenderness in the anatomical snuffbox; initial x ray may be normalBlood supply enters distally, so proximal pole fractures risk avascular necrosis and nonunion; suspected fractures are immobilized in a thumb spica and reimaged
Scapholunate ligament tearFall on extended wrist; dorsal wrist pain, positive Watson (scaphoid shift) test, widened gap on x rayUntreated leads to scapholunate advanced collapse (SLAC wrist)
Triangular fibrocartilage complex (TFCC) tearFall or twisting; ulnar sided wrist pain with ulnar deviation and rotation, clickingDistal radioulnar joint instability
Boxer fracturePunching; fracture of the fifth metacarpal neckCheck rotational malalignment (fingers should point to the scaphoid in a fist)
Bennett and Rolando fracturesIntra articular fractures of the thumb metacarpal baseUsually need fixation; thumb carpometacarpal arthritis later
Gamekeeper (skier) thumbForced thumb abduction; ulnar collateral ligament of thumb MCP tornStener lesion (adductor aponeurosis trapped between ligament ends) requires surgery

After a distal radius fracture, the cast or orthosis is typically worn about 6 weeks. During that time, active motion of the fingers, elbow and shoulder prevents stiffness and swelling. After immobilization, active and active assisted wrist and forearm motion progress to strengthening. Monitor for complex regional pain syndrome: burning pain out of proportion, swelling, color and temperature change, and hypersensitivity. Early recognition, desensitization, graded motor imagery and active use are key.

Tendon injuries and flexor zones

The flexor tendon zones guide prognosis and protocols. Zone II, between the A1 pulley at the distal palmar crease and the insertion of flexor digitorum superficialis at the middle phalanx, contains both flexor tendons inside a tight fibro osseous sheath, so adhesions form easily. It was historically called no man's land. Zone I lies distal to the FDS insertion (FDP only; a jersey finger is an avulsion of FDP, most often of the ring finger, when a grabbing finger is forcibly extended). Zone III is the palm, zone IV the carpal tunnel and zone V the wrist and forearm.

Flexor tendon zones, right hand, palmar view Zone I Zone IItwo tendonsin sheath Zone III (palm) Zone IV (tunnel) Zone V (wrist) Thumb on the radial side (right hand, palm up) Thumb zones T I to T V Zone II: FDS insertion to A1 pulley, historic "no man's land"
Figure 3.4 Flexor tendon zones. Zone II, where both flexor tendons share a narrow sheath from the A1 pulley to the FDS insertion, has the highest risk of adhesions and needs early protected motion after repair.

After flexor tendon repair, the hand is placed in a dorsal blocking orthosis with the wrist in slight flexion (or neutral), MCP joints flexed about 50 to 70 degrees and interphalangeal joints extended against the orthosis. The aim is to permit tendon gliding without tension on the repair. Classic early protocols: passive flexion with active extension within the orthosis (Duran style passive motion; Kleinert style rubber band traction) or early active motion (place and hold or controlled active flexion), now favored for strong multistrand repairs. Avoid active gripping, passive extension of the wrist and fingers together and resisted flexion for about 6 to 8 weeks; light resistance usually begins around 8 weeks and full strengthening around 12 weeks. A repaired tendon is weakest around days 5 to 21, when rupture risk peaks.

Extensor injuries: a mallet finger is disruption of the terminal extensor tendon at the distal phalanx (zone I) and is treated with continuous DIP extension splinting for about 6 to 8 weeks with the PIP free; any flexion of the DIP during that time restarts the clock. A rupture of the central slip (zone III) allows the lateral bands to slip volarly and leads to a boutonniere deformity; it is splinted with the PIP in extension and the DIP free to flex actively.

Deformities

DeformityPostureTypical cause
BoutonnierePIP flexion, DIP hyperextensionCentral slip rupture, rheumatoid arthritis
Swan neckPIP hyperextension, DIP flexion (MCP often flexed)Rheumatoid arthritis, volar plate laxity, untreated mallet finger
Ulnar driftUlnar deviation of fingers at MCP joints with volar subluxationRheumatoid arthritis
Mallet fingerDIP flexed, cannot actively extendTerminal extensor tendon rupture
Dupuytren contractureProgressive MCP and PIP flexion, usually ring and little fingers, palpable cordsPalmar fascia fibrosis; northern European ancestry, men, diabetes
Claw hand (intrinsic minus)MCP hyperextension, IP flexionUlnar (with or without median) nerve palsy
Ape handThumb in the plane of the palm, thenar wastingMedian nerve palsy
Heberden and Bouchard nodesBony enlargement of DIP (Heberden) and PIP (Bouchard)Osteoarthritis

Splinting principles

Orthoses immobilize (rest inflamed or repaired tissue), mobilize (apply low load prolonged stress to lengthen tissue, as with dynamic or static progressive designs) or restrict motion. The safe position or intrinsic plus position for immobilizing the hand is wrist in about 20 to 30 degrees of extension, MCP joints in 70 to 90 degrees of flexion and IP joints in full extension, which keeps the MCP collateral ligaments and the IP volar plates at length so the hand does not stiffen. A resting hand orthosis in a functional position is used for rheumatoid arthritis flares. Check every orthosis for pressure points over bony prominences, especially in insensate skin, and teach a wearing schedule and skin checks.

Board tip. Position for a neutral carpal tunnel night orthosis: wrist neutral (0 degrees). Position for a mallet finger: DIP in extension or slight hyperextension, PIP free. Position for de Quervain: thumb spica including the wrist, IP free. Position for safe immobilization: wrist extended, MCPs flexed, IPs extended.
Case. A 35 year old carpenter had a zone II flexor tendon repair of his index finger 10 days ago. At the clinic he says it feels fine and asks to try making a tight fist to see how much he can grip.
Reasoning: Days 5 to 21 are the window of greatest rupture risk because the repair softens before collagen remodeling strengthens it. Active gripping and resisted flexion are contraindicated for about 6 to 8 weeks. The best answer continues the prescribed protected motion program (passive flexion with active extension inside the dorsal blocking orthosis, or place and hold if the surgeon ordered early active motion) and educates him to wear the orthosis at all times. Choices such as grip strengthening, passive finger extension with the wrist extended, or removing the orthosis for work are wrong. Safety point: a sudden loss of active flexion suggests rupture and needs the surgeon.
Key point

Hand problems are recognized by location and posture: median symptoms at night with a positive Phalen test suggest carpal tunnel syndrome, pain at the radial styloid with ulnar deviation suggests de Quervain, snuffbox tenderness is a scaphoid fracture until proven otherwise, and characteristic finger postures name the tendon or nerve at fault. Protect repairs by zone and healing time, and splint in positions that keep ligaments at length.

Section 5Peripheral nerve injuries of the upper limb

The brachial plexus

The brachial plexus forms from the ventral rami of C5 to T1 and is organized as roots, trunks, divisions, cords and terminal branches (a common memory aid is "Read That Darn Cadaver Book"). C5 and C6 join as the upper trunk, C7 continues as the middle trunk, and C8 and T1 form the lower trunk. Each trunk splits into anterior and posterior divisions. The three posterior divisions form the posterior cord (axillary and radial nerves), the anterior divisions of the upper and middle trunks form the lateral cord (musculocutaneous nerve and the lateral root of the median nerve), and the anterior division of the lower trunk forms the medial cord (ulnar nerve and the medial root of the median nerve). Branches from the roots include the dorsal scapular (C5, rhomboids) and long thoracic (C5 to C7, serratus anterior); from the upper trunk the suprascapular nerve (supraspinatus and infraspinatus).

RootsTrunksDivisionsCordsBranches C5C6C7C8T1 UpperMiddleLower LateralPosteriorMedial Musculocutaneous Axillary Radial Median Ulnar anterior (solid) posterior (dashed) Erb palsy (upper trunk, C5 and C6): waiter's tip, arm adducted, internally rotated, elbow extended, pronated. Klumpke palsy (lower trunk, C8 and T1): claw hand, intrinsic weakness, possible Horner syndrome.
Figure 3.5 A simplified brachial plexus. All posterior divisions form the posterior cord (axillary and radial); the median nerve takes roots from both the lateral and medial cords. Upper trunk lesions affect the shoulder and elbow, lower trunk lesions the hand.

Erb palsy (upper trunk, C5 and C6) results from forced separation of the head and shoulder (birth with shoulder dystocia, motorcycle falls). The deltoid, cuff, biceps and brachialis are weak, producing the waiter's tip posture. Klumpke palsy (lower trunk, C8 and T1) results from traction on the abducted arm (grabbing a branch while falling, breech birth). It weakens the intrinsic hand muscles and long finger flexors and may include Horner syndrome (ptosis, miosis, anhidrosis) if T1 sympathetic fibers are injured, which also suggests a root avulsion with a poor prognosis. Thoracic outlet syndrome most commonly compresses the lower trunk, giving ulnar side symptoms; provocative tests (Adson, Roos elevated arm stress test, Wright hyperabduction) have poor specificity.

Radial, median and ulnar nerve lesions

Nerve and levelMotor lossSensory lossClassic sign
Axillary (surgical neck fracture, anterior dislocation)Deltoid and teres minor: weak abduction and external rotationLateral shoulder (regimental badge)Flattened deltoid contour
MusculocutaneousBiceps, brachialis, coracobrachialis: weak elbow flexion and supinationLateral forearmAbsent biceps reflex
Radial at the axilla (crutch palsy)Triceps plus all wrist and finger extensorsPosterior arm, forearm and dorsal radial handWrist drop with weak elbow extension
Radial at the spiral groove (midshaft humerus fracture, Saturday night palsy)Wrist and finger extensors, brachioradialis; triceps sparedDorsal first web spaceWrist drop
Posterior interosseousFinger and thumb extensors, ECU; ECRL sparedNoneFinger drop, radial deviation on wrist extension
Median at or above the elbowForearm pronators, FCR, FDS, lateral FDP, FPL, thenar muscles, lateral two lumbricalsPalmar thumb, index, middle and radial ring finger, including thenar eminenceBenediction (hand of benediction) on attempted fist: index and middle stay extended
Median at the wrist (carpal tunnel, laceration)Thenar muscles (APB, opponens, superficial FPB), lateral lumbricalsSame digits, thenar eminence sparedApe hand, loss of opposition
Ulnar at the elbowFCU, medial FDP, hypothenar, interossei, medial lumbricals, adductor pollicisLittle finger and ulnar ring finger, palmar and dorsal handClaw less marked (ulnar paradox), Froment sign, Wartenberg sign
Ulnar at the wrist (Guyon canal, cyclists)Intrinsics, FDP to ring and little intactPalmar ulnar digits; dorsal hand sparedClaw hand more marked (ring and little fingers)

Froment sign: when pinching paper between thumb and index finger, the thumb IP joint flexes because flexor pollicis longus (median) substitutes for a weak adductor pollicis (ulnar). Wartenberg sign: the little finger rests abducted from weak third palmar interosseous. The ulnar paradox: a more proximal ulnar lesion produces less clawing because FDP to the ring and little fingers is also paralyzed, so the IP joints are not pulled into flexion. The same logic applies to median lesions; a high median lesion causes the benediction posture on attempting a fist, while a low median lesion leaves finger flexion intact.

Seddon classification, recovery and testing

Seddon (Sunderland)What is damagedElectrodiagnosisPrognosis
Neurapraxia (grade 1)Local myelin injury, axon intact, conduction blockConduction block across the lesion, no denervation potentialsFull recovery in days to about 12 weeks, no Tinel progression
Axonotmesis (grades 2 to 4)Axon disrupted, connective tissue sheaths (endoneurium at least partly) intactWallerian degeneration; fibrillations and positive sharp waves after about 2 to 3 weeksRegrowth at about 1 mm per day (about 1 inch per month); good to fair recovery depending on grade
Neurotmesis (grade 5)Complete transection of nerve and sheathsDenervation, no voluntary unitsNo recovery without surgical repair; outcome often incomplete

After axonal injury the distal segment undergoes Wallerian degeneration. Regeneration proceeds at roughly 1 mm per day, so a lesion 30 cm above a muscle needs about 10 months to reach it; motor end plates degenerate if reinnervation takes much beyond 12 to 18 months, so proximal lesions recover less. An advancing Tinel sign along the nerve tracks regrowth. Needle EMG should be delayed about 3 weeks after injury, because fibrillation potentials and positive sharp waves take that long to appear. Sensory recovery typically returns in sequence: pain and temperature, then touch, then moving two point discrimination, then static two point discrimination. Test with Semmes Weinstein monofilaments (the 4.31 filament marks the threshold of normal light touch on the hand in common teaching, and inability to feel 6.65 means loss of protective sensation) and two point discrimination (normal fingertip static value about 6 mm or less).

Rehabilitation during recovery: protect anesthetic skin with visual checks and education (burns and pressure injury are the main hazards), maintain passive range and prevent contracture with orthoses (a wrist cock up orthosis or dynamic extension orthosis for radial palsy, a thumb web spacer for median palsy, an anticlaw MCP blocking orthosis for ulnar palsy), avoid overstretching denervated muscle, begin active assisted and then resisted exercise as muscle reinnervates, and use desensitization and sensory reeducation.

Board tip. Wrist drop with intact triceps localizes the radial nerve to the spiral groove; wrist drop plus triceps weakness puts the lesion in the axilla; finger drop with intact wrist extension and no sensory loss is the posterior interosseous nerve.
Case. A 28 year old man sustained a midshaft humerus fracture 2 weeks ago. He cannot extend his wrist or fingers and has numbness on the dorsum of the first web space; elbow extension is strong. He asks whether he will recover and wants an EMG today.
Reasoning: The radial nerve wraps the spiral groove of the midshaft humerus, so wrist drop with spared triceps fits a lesion there; most of these are neurapraxia or axonotmesis and recover. Denervation potentials take about 3 weeks to appear, so EMG is usually done after that time. The distance from the midshaft to the wrist extensors is roughly 10 to 15 cm, so reinnervation at about 1 mm per day could take several months. The best intervention is a wrist cock up orthosis (or a dynamic extension orthosis) to keep the wrist and fingers functional and to prevent overstretching of the extensors, passive range of motion and education. Strengthening the paralyzed extensors now is wrong, and the absence of an advancing Tinel by several months warrants re referral.
Key point

Localize upper limb nerve lesions by combining motor loss, sensory map and the characteristic posture, remembering that more proximal lesions add more muscles and that branches leaving early (dorsal ulnar sensory, palmar median sensory, triceps from the radial) help pinpoint the level. Seddon grade and the 1 mm per day regrowth rate drive prognosis, and meanwhile the job is to protect insensate skin, prevent contracture and splint for function.

The chapter in one breath

  • Elevation is shared about 2:1 between the glenohumeral joint and scapula; the serratus anterior and trapezius rotate the scapula upward while the rotator cuff holds the humeral head down.
  • Full passive range with a painful arc and painful resisted tests means cuff tendinopathy; active much less than passive means a tear or nerve palsy.
  • Adhesive capsulitis loses external rotation most, links to diabetes, and is treated according to irritability.
  • Anterior dislocation risks the axillary nerve, Bankart and Hill Sachs lesions, and recurrence in the young.
  • After rotator cuff repair no active elevation for about 6 weeks and no resisted loading until about 12; after reverse total shoulder avoid extension, adduction and internal rotation together.
  • Lateral epicondylalgia is an ECRB tendinopathy managed with loading; injections help short term only.
  • Supracondylar fractures threaten the brachial artery and forearm compartments; pain with passive finger extension is an emergency.
  • Carpal tunnel syndrome spares the thenar skin and is splinted in neutral at night; de Quervain involves APL and EPB.
  • Zone II flexor repairs are protected in a dorsal blocking orthosis, with rupture risk highest at days 5 to 21.
  • Wrist drop (radial), ape hand and benediction (median) and claw hand (ulnar) localize nerve lesions; axonotmesis regrows about 1 mm per day.

Words worth knowing

TermWhat it means
Scapulohumeral rhythmThe coordinated 2:1 ratio of glenohumeral to scapular motion during arm elevation.
Scapular dyskinesisAltered scapular position or motion, often from muscle imbalance.
Painful arcPain during mid range active abduction (about 60 to 120 degrees) from subacromial structures.
GIRDGlenohumeral internal rotation deficit, a loss of internal rotation common in throwers.
Bankart lesionAvulsion of the anteroinferior labrum and capsule after anterior dislocation.
Hill Sachs lesionImpaction defect of the posterolateral humeral head from an anterior dislocation.
SLAP lesionTear of the superior labrum extending anterior to posterior, near the biceps anchor.
Capsular patternThe joint specific order of motion loss caused by capsular restriction.
Adhesive capsulitisInflammation and fibrosis of the shoulder capsule causing painful loss of active and passive motion.
Reverse total shoulder arthroplastyReplacement with a ball on the glenoid and socket on the humerus so the deltoid can elevate without a cuff.
EpicondylalgiaPain from degenerative tendinopathy at the lateral or medial epicondyle.
Volkmann ischemic contractureFibrotic flexion contracture of the forearm after untreated compartment syndrome.
Anatomical snuffboxHollow between EPL and the APL and EPB tendons; tenderness suggests scaphoid fracture.
Dorsal blocking orthosisSplint that stops wrist and finger extension to protect a flexor tendon repair.
Intrinsic plus positionWrist extended, MCPs flexed, IPs extended; the safe position for hand immobilization.
Boutonniere deformityPIP flexion with DIP hyperextension from central slip disruption.
Froment signThumb IP flexion during key pinch, revealing weak adductor pollicis in ulnar palsy.
Ulnar paradoxProximal ulnar lesions cause less clawing than distal ones because FDP is also weak.
Wallerian degenerationBreakdown of the axon and myelin distal to an axonal injury.
NeurapraxiaConduction block without axonal loss; recovers fully.
AxonotmesisAxon disruption with intact sheaths; regrows about 1 mm per day.
NeurotmesisComplete nerve transection requiring surgical repair.

Check yourself

Which arthrokinematic glide should be used to improve shoulder abduction?
Answer. Inferior glide of the humeral head. The convex head glides opposite to the direction of shaft movement, so elevation needs inferior glide.
A 60 year old cannot hold his arm at 90 degrees of abduction after a fall; passive range is full. Which test is most likely positive?
Answer. The drop arm test, indicating a full thickness rotator cuff tear. Active far below passive motion points to a contractile or nerve problem rather than a capsular one.
What is the first motion lost in adhesive capsulitis?
Answer. External rotation, followed by abduction and internal rotation, the glenohumeral capsular pattern.
Which activity is most dangerous 4 weeks after a reverse total shoulder arthroplasty?
Answer. Reaching behind the back (extension, adduction and internal rotation together), such as tucking in a shirt or toileting, which risks dislocation.
Five weeks after rotator cuff repair, a patient asks to start lifting light dumbbells overhead. What is the best response?
Answer. Not yet. Resisted loading of the repaired tendon usually waits until about 12 weeks; at this point passive and progressing active assisted motion are appropriate.
A thrower has medial elbow pain reproduced between about 70 and 120 degrees as the elbow is extended under valgus load. What structure is injured?
Answer. The anterior bundle of the ulnar collateral ligament; this is a positive moving valgus stress test.
Numbness of the thumb, index and middle fingers that includes the thenar eminence suggests compression where?
Answer. Proximal to the carpal tunnel, such as pronator syndrome, because the palmar cutaneous branch to the thenar skin leaves before the tunnel.
How is a mallet finger splinted?
Answer. DIP held continuously in extension for about 6 to 8 weeks with the PIP free; any DIP flexion during that period restarts the timeline.
A cyclist has clawing of the ring and little fingers and palmar ulnar numbness but normal sensation on the dorsal ulnar hand. Where is the lesion?
Answer. The ulnar nerve in Guyon canal at the wrist. The dorsal cutaneous branch leaves proximal to the wrist, so dorsal sensation is spared.
An axonotmesis occurs 20 cm proximal to the first muscle it supplies. About how long until reinnervation could begin?
Answer. About 200 days, roughly 6 to 7 months, using a regrowth rate of about 1 mm per day.
Chapter 4 · Musculoskeletal

Musculoskeletal: The Lower Extremity and Gait

Most of what a physical therapist does for the lower extremity comes down to one question: can this patient bear weight and walk safely, and if not, why not? The NPTE tests that question through hip and knee arthroplasty precautions, ligament and meniscus injuries, ankle sprains, the gait cycle and its deviations, and weight bearing orders after fracture. This chapter ties the tissue, the protocol and the gait pattern together so you can reason from findings to the safest correct answer.

By the end of this chapter you can

  • Recognize hip osteoarthritis, femoroacetabular impingement, labral tears and hip fractures, and apply the total hip precautions that match the surgical approach.
  • Choose and interpret the special tests for ACL, PCL, collateral ligament and meniscus injuries.
  • Manage patellofemoral pain and progress rehabilitation after ACL reconstruction and total knee arthroplasty using time and criteria.
  • Apply the Ottawa ankle and foot rules and distinguish lateral, medial and high ankle sprains, Achilles disorders and plantar heel pain.
  • Describe foot posture and the windlass mechanism and relate pronation and supination to the gait cycle.
  • Name the phases of the gait cycle, the normal joint angles and muscle activity in each, and the normal spatiotemporal values.
  • Identify common gait deviations, including Trendelenburg, steppage, vaulting and circumduction, and their causes.
  • Apply fracture healing timelines and the five weight bearing orders, and adapt care for osteoporosis, rheumatoid arthritis and lower limb amputation.

Section 1The hip

Hip osteoarthritis

The hip is a deep ball and socket joint whose stability comes mainly from bone, the labrum and strong capsular ligaments (iliofemoral, pubofemoral and ischiofemoral, all tightening in extension). Osteoarthritis of the hip is a disease of the whole joint: cartilage loss, subchondral sclerosis, osteophytes and capsular thickening. The classic presentation is groin or anterior thigh pain (sometimes referred to the knee), morning stiffness lasting less than an hour, pain with weight bearing and a capsular pattern of loss: internal rotation and flexion most, then abduction, with extension also limited. The hip clinical practice guideline lists features that support the diagnosis in adults over 50: moderate anterior or lateral hip pain with weight bearing, morning stiffness under an hour, and hip internal rotation and flexion each limited by more than 15 degrees compared with the other side.

Evidence based treatment includes patient education and weight management, manual therapy (mobilization and manipulation) for short term pain relief and motion, flexibility and strengthening (especially hip abductors, extensors and quadriceps), functional and balance training and an assistive device when needed. A cane is held in the hand opposite the painful hip: it moves with the involved leg and reduces the abductor force needed on the stance side, lowering joint reaction force. Carrying a load in the hand on the same side as the painful hip also reduces abductor demand, whereas carrying it on the opposite side increases it.

Femoroacetabular impingement and labral tears

Femoroacetabular impingement (FAI) is abnormal contact between the femoral head neck junction and the acetabular rim. A cam lesion is an aspherical bump at the femoral head neck junction, more common in young athletic men; it is jammed into the acetabulum in flexion and internal rotation, shearing the cartilage and labrum. A pincer lesion is acetabular overcoverage (retroversion or a deep socket), more common in middle aged women, where the rim crushes the labrum. Mixed forms are common. Patients report groin pain with prolonged sitting, deep squatting, pivoting and getting in and out of a car. The FADIR test (flexion, adduction, internal rotation) is very sensitive, so a negative test helps rule out intra articular pathology, but it is not specific.

A labral tear causes groin pain with mechanical symptoms (clicking, catching, locking), often with a C sign (the patient cups the lateral hip with thumb and fingers). Most occur in the anterosuperior labrum. Initial treatment is activity modification, avoiding end range flexion and rotation under load, core and hip strengthening and movement retraining. After arthroscopic labral repair or osteoplasty, typical precautions are protected weight bearing (often flat foot or partial weight bearing for 2 to 4 weeks), limits on flexion (often to about 90 degrees) and on external rotation and extension early (to protect the capsule), and avoidance of active straight leg raising and loaded hip flexion, which irritate the iliopsoas.

Lateral hip pain and other conditions

Greater trochanteric pain syndrome (gluteal tendinopathy, with or without trochanteric bursitis) causes lateral hip pain worse lying on the side, climbing stairs and standing on one leg. Single leg stance held for 30 seconds reproducing lateral hip pain is a useful test. Avoid compressive positions (crossing legs, hip adduction stretches such as the iliotibial band stretch) and progress isometric and then isotonic abductor loading. Remember hip conditions in children and adolescents: Legg Calve Perthes disease (avascular necrosis of the femoral head, boys about 4 to 8 years, painless limp), slipped capital femoral epiphysis (obese adolescents, often boys about 10 to 16, knee or groin pain, obligatory external rotation with hip flexion; a non weight bearing emergency referral) and developmental dysplasia (Ortolani and Barlow tests in infants).

Hip fractures

Hip fractures in older adults usually follow a fall from standing height in a person with osteoporosis. The leg is classically shortened and externally rotated. Location determines treatment because of the blood supply to the femoral head, which comes mainly from the medial circumflex femoral artery through retinacular vessels along the neck:

  • Femoral neck (intracapsular) fractures can disrupt this supply, leading to avascular necrosis and nonunion. Displaced neck fractures in older adults are usually treated with hemiarthroplasty or total hip arthroplasty; nondisplaced ones with screws.
  • Intertrochanteric and subtrochanteric (extracapsular) fractures have good blood supply and are fixed with a sliding hip screw or intramedullary nail.

Modern fixation and arthroplasty generally allow weight bearing as tolerated immediately, and early mobilization (within 24 to 48 hours) reduces complications such as pneumonia, pressure injury, deep vein thrombosis and delirium. Mortality within a year is high, and many patients do not return to prior function, so balance training, strengthening and fall prevention are core goals. If a hemiarthroplasty was done through a posterior approach, posterior hip precautions apply.

Total hip arthroplasty and precautions by approach

The precautions after total hip arthroplasty (THA) follow the capsule and muscles that were cut, because those positions are the ones that let the femoral head lever out of the socket. Many surgeons now relax or drop precautions, especially with the anterior approach, so the surgeon's orders always come first; on the exam, apply the classic set for the stated approach.

ApproachTissue disruptedDislocation directionClassic precautions (often about 6 to 12 weeks)
Posterior (posterolateral)Short external rotators, posterior capsulePosteriorNo hip flexion past 90 degrees, no adduction past midline (no crossing legs), no internal rotation; raised toilet seat, pillow between knees, avoid low chairs
Anterior (direct anterior)Anterior capsule, intermuscular interval (tensor fasciae latae and sartorius)AnteriorNo hip extension past neutral, no external rotation (especially combined with extension, as in stepping back and turning outward), no bridging or prone lying with extension early per surgeon; lateral femoral cutaneous nerve numbness is common
Anterolateral (lateral)Partial detachment of gluteus medius and minimusAnterior (less common)Avoid extension and external rotation; avoid active or resisted abduction early to protect the repaired abductors; Trendelenburg gait may persist
Total hip precautions follow the approach Posterior approach Anterior approach head escapes posteriorly head escapes anteriorly keep hip angle at 90 or more no extension past neutral Avoid: flexion past 90 adduction past midline internal rotation Avoid: extension external rotation bridging early Danger: low chair, crossing legs, bending to put on shoes, pivoting inward on the operated leg Danger: lunging back, pivoting outward on the operated leg
Figure 4.1 The direction of dislocation matches the side of the capsule that was opened. After a posterior approach the risky positions combine flexion, adduction and internal rotation; after an anterior approach they combine extension and external rotation.

Early rehabilitation after THA: ankle pumps, quadriceps and gluteal sets, heel slides within precautions, bed mobility and transfers using adaptive equipment (reacher, sock aid, long handled shoe horn), gait training with a walker progressing to a cane, and stair training (up with the good, down with the bad: the uninvolved leg leads going up, the involved leg and assistive device lead going down). Most cemented and modern cementless implants allow weight bearing as tolerated. Watch for DVT (calf pain, swelling, warmth; the Wells criteria guide referral), dislocation (sudden pain, a shortened and rotated limb, inability to bear weight), infection and leg length discrepancy.

Board tip. Hip capsular pattern: internal rotation and flexion most limited. A patient after posterior THA sitting in a low recliner or bending to tie shoes is at risk; after anterior THA, a lunge or a step back with the leg turned out is the danger.
Case. An 80 year old woman is 1 day after a posterior approach total hip arthroplasty for a displaced femoral neck fracture. The order reads weight bearing as tolerated. The therapist is teaching her to sit down on a standard height toilet and to put on her socks.
Reasoning: A low toilet requires flexing the hip beyond 90 degrees, and reaching to the foot adds flexion and often internal rotation, the exact posterior dislocation positions. The best answer is a raised toilet seat (or commode over the toilet), backing up until she feels it, sliding the operated leg forward as she sits, and a sock aid and reacher for dressing. Teaching her to cross the operated leg over the other knee to reach her foot or to bend forward fully is wrong. Safety point: sudden severe pain with a shortened, internally rotated leg after a posterior approach suggests dislocation; stop and notify the surgeon.
Key point

Hip problems separate by location and age: groin pain with loss of internal rotation in an older adult is osteoarthritis, groin pain with sitting and pivoting in a young athlete suggests FAI or a labral tear, and lateral pain with side lying suggests gluteal tendinopathy. Fracture location decides blood supply and surgery, and precautions after arthroplasty mirror the approach: posterior means no flexion past 90, adduction or internal rotation; anterior means no extension with external rotation.

Section 2The knee

Ligament injuries

The anterior cruciate ligament (ACL) resists anterior translation of the tibia on the femur and rotational loads. Most tears are noncontact: deceleration, cutting or landing with the knee near extension, valgus collapse and tibial rotation. Patients report a pop, rapid swelling (hemarthrosis within hours) and giving way. Women have a higher risk, linked to landing mechanics, neuromuscular control and other factors; injury prevention programs that train landing, cutting and hamstring strength reduce ACL injuries. The unhappy triad classically combines ACL, MCL and medial meniscus tears, although lateral meniscus tears are actually more common with acute ACL injury.

The posterior cruciate ligament (PCL) resists posterior tibial translation; it is torn by a fall on a flexed knee with the foot plantarflexed or a dashboard injury. Isolated PCL tears are usually managed nonoperatively with quadriceps emphasis, since the quadriceps pulls the tibia anteriorly; avoid isolated resisted hamstring work early because it pulls the tibia posteriorly. The medial collateral ligament (MCL) resists valgus stress and is injured by a blow to the lateral knee; most isolated MCL tears heal well with a hinged brace and early motion. The lateral collateral ligament resists varus and is often injured with the posterolateral corner, which may need surgery.

TestHow it is donePositive findingSuggests
LachmanKnee in 20 to 30 degrees flexion, stabilize femur, translate tibia anteriorlyIncreased translation, soft or absent end feelACL tear (most sensitive ACL test)
Anterior drawerKnee at 90 degrees, foot stabilized, pull tibia forwardIncreased translationACL tear (less sensitive acutely due to guarding)
Pivot shiftValgus and internal rotation as the knee moves from extension to flexionClunk as the subluxed lateral tibial plateau reduces near 30 to 40 degreesACL tear (most specific)
Posterior drawerKnee at 90 degrees, push tibia posteriorlyIncreased posterior translationPCL tear (most accurate PCL test)
Posterior sag (Godfrey)Supine, hips and knees at 90 degreesTibia sags posteriorlyPCL tear
Valgus stressValgus force at 0 and at 30 degrees of flexionGapping at 30 only: MCL; gapping at 0: MCL plus cruciate or capsuleMCL injury
Varus stressVarus force at 0 and 30 degreesLateral gappingLCL or posterolateral corner
Dial testProne, compare external rotation at 30 and 90 degreesOver 10 degrees more at 30 only: posterolateral corner; at both: PCL plus cornerPosterolateral corner injury
McMurrayFlex fully, rotate tibia and extendPainful click along the joint lineMeniscus tear
ThessalySingle leg stance in 20 degrees flexion, rotate trunk and kneeJoint line pain or catchingMeniscus tear
Joint line tendernessPalpate medial and lateral joint linePainMeniscus tear (sensitive, not specific)
Apley compression and distractionProne, knee at 90, compress and rotate, then distract and rotatePain with compression (meniscus), with distraction (ligament)Meniscus versus ligament
OberSide lying, top hip extended, lower the leg toward the tableLeg stays abductedIliotibial band or TFL tightness

Meniscus injuries

The menisci deepen the tibial plateau, spread load and assist stability. The medial meniscus is attached to the MCL and joint capsule, less mobile, and injured more often; the lateral meniscus is more mobile. Only the outer third (the red zone) has a good blood supply, so peripheral tears can be repaired while inner (white zone) tears are usually trimmed. Patients report twisting on a loaded, flexed knee, delayed swelling (over 24 hours), joint line pain and mechanical symptoms (locking, catching). A truly locked knee that cannot extend suggests a displaced bucket handle tear and needs prompt surgical referral. Degenerative tears in middle aged and older adults respond to exercise as well as to arthroscopic partial meniscectomy in most trials. After partial meniscectomy, weight bearing as tolerated and rapid progression are usual. After meniscus repair, protect the repair: limited weight bearing or a brace locked in extension for weight bearing (often about 4 to 6 weeks), limited flexion (often to 90 degrees), and no deep squatting or loaded flexion beyond 90 for about 3 to 4 months.

Patellofemoral pain

Patellofemoral pain is diffuse anterior knee pain around or behind the patella, worse with squatting, stairs (especially descending), running and prolonged sitting (the movie sign). It is common in adolescents and young adults, especially women. Contributing factors include weak hip abductors and external rotators (allowing dynamic knee valgus and femoral internal rotation under the patella), quadriceps weakness, reduced flexibility and excessive load. The Q angle (the angle between a line from the ASIS to the center of the patella and a line from the center of the patella to the tibial tubercle) averages about 13 degrees in men and 18 degrees in women; a larger angle increases lateral pull. The clinical practice guideline supports combined hip and knee strengthening as the core intervention, plus patellar taping and foot orthoses for short term relief, and education on load management. Squat and step exercises are often started in a pain free arc (open chain knee extension is gentler on the patellofemoral joint from 90 to 45 degrees and closed chain exercise from 0 to 45 degrees).

Related conditions: patellar tendinopathy (jumper's knee, pain at the inferior pole with jumping, treated with progressive isometric and heavy slow resistance or eccentric decline squats), Osgood Schlatter disease (tibial tubercle apophysitis in adolescents), iliotibial band syndrome (lateral knee pain in runners, often near 30 degrees of flexion), and patellar dislocation (usually lateral, in young women, often with a medial patellofemoral ligament tear).

ACL reconstruction rehabilitation

Common grafts are bone patellar tendon bone (strong bony fixation, more anterior knee pain and kneeling pain), hamstring tendon (less anterior knee pain, avoid aggressive hamstring loading for about 6 to 8 weeks) and quadriceps tendon. Grafts go through ligamentization: they are weakest about 6 to 12 weeks after surgery as the graft revascularizes, so although the patient feels well, the graft is vulnerable. Accelerated protocols are standard: immediate weight bearing as tolerated (if no meniscus repair), early full extension (loss of extension is the most troublesome complication; a cyclops lesion or arthrofibrosis may be the cause), quadriceps activation with neuromuscular electrical stimulation, and closed chain exercise early.

Open chain knee extension stresses the ACL graft most between about 0 and 45 degrees (the quadriceps pulls the tibia forward near extension), so it is commonly restricted early to 90 to 45 degrees; closed chain exercise in roughly 0 to 60 degrees produces low graft strain because of hamstring cocontraction and compression. Running usually begins around 3 months once there is no effusion, full motion and adequate strength. Return to sport is generally considered no earlier than about 9 months, when a battery of criteria is met: quadriceps and hamstring limb symmetry index of 90 percent or more, hop test symmetry of 90 percent or more (single, triple, crossover and timed hops), full motion, no effusion and psychological readiness. Returning before 9 months and with poor strength symmetry substantially increases reinjury risk.

ACL reconstruction: time plus criteria 01 mo2 mo3 mo5 mo7 mo9 mo + Earlyfull extension Strengthclosed chain Running and agilityfrom about 3 months Returnto sport graft weakest 6 to 12 wk Return to sport criteria (usual teaching) Quadriceps and hamstring strength at least 90 percent of the other side Hop tests (single, triple, crossover, timed) at least 90 percent symmetry Full motion, no effusion, psychological readiness, and at least about 9 months
Figure 4.2 ACL reconstruction rehabilitation. Restore full extension first, respect the period of graft weakness even though the knee feels good, and return to sport only when time and strength and hop symmetry criteria are both met.

Total knee arthroplasty

Total knee arthroplasty (TKA) relieves pain in advanced knee osteoarthritis. Goals after surgery: early mobilization (often the day of surgery), weight bearing as tolerated, quadriceps activation, control of swelling, and range of motion targets of full extension and at least about 90 degrees of flexion early (about 105 to 115 for stairs and rising from low chairs, about 110 for many daily tasks). Extension loss is functionally worst, so avoid a pillow under the knee; place a towel roll under the ankle instead. Quadriceps strength is markedly reduced after TKA, and early progressive strengthening plus neuromuscular electrical stimulation improves quadriceps strength and function (supported by the guideline). Continuous passive motion adds little and is not recommended routinely. Watch for DVT, infection, wound problems and arthrofibrosis; a patient who has not reached about 90 degrees by 6 to 12 weeks may be referred for manipulation under anesthesia.

Board tip. Lachman is the most sensitive ACL test, pivot shift the most specific; posterior drawer is the best PCL test. After ACL reconstruction the first priority is full extension and quadriceps activation; after a PCL injury, emphasize the quadriceps and delay isolated hamstring resistance.
Case. A 17 year old soccer player is 10 weeks after a bone patellar tendon bone ACL reconstruction. She has full motion, no effusion and wants to start cutting drills because her knee feels normal. Her quadriceps limb symmetry index is 72 percent.
Reasoning: The graft is still near its weakest point during ligamentization, and her strength is far below the 90 percent target, so cutting and pivoting are not appropriate yet. The best choice is progressive quadriceps strengthening (closed chain and open chain in a protected arc), neuromuscular and landing training, and a straight line running progression around 3 months if criteria are met. Starting sport specific cutting now or clearing her for return because motion is full is wrong. Safety point: early return and strength asymmetry strongly predict a second ACL injury, in either knee.
Key point

Knee injuries are recognized by mechanism and tests: a noncontact pivot with a pop and rapid swelling is an ACL tear (Lachman), a dashboard blow is the PCL (posterior drawer), a twist with delayed swelling and locking is the meniscus. Patellofemoral pain responds to combined hip and knee strengthening. After ACL reconstruction and TKA, restore extension and quadriceps first, and use objective criteria rather than time alone to progress.

Section 3The ankle and foot

Ankle sprains and the Ottawa rules

The lateral ankle sprain is the most common sports injury. The mechanism is inversion and plantarflexion, and the ligaments fail in sequence: the anterior talofibular ligament (ATFL, weakest and most often torn, taut in plantarflexion), then the calcaneofibular ligament (CFL), and rarely the posterior talofibular ligament. Grade I is a stretch without laxity, grade II a partial tear with some laxity, grade III a complete tear with gross laxity and marked swelling. The anterior drawer test (ATFL) and the talar tilt (inversion) test (CFL) assess laxity. Management: protection and optimal loading early, a semirigid or lace up brace for moderate to severe sprains (better than a cast), early weight bearing, range of motion, then progressive strengthening (evertors and dorsiflexors), and balance and proprioceptive training, which reduces recurrence. Up to a third or more develop chronic ankle instability.

A high ankle sprain injures the distal tibiofibular syndesmosis (anterior inferior tibiofibular ligament) by forced external rotation and dorsiflexion. It causes pain above the ankle, a positive squeeze test (compressing tibia and fibula at midcalf produces distal pain) and external rotation (Kleiger) test, and takes roughly twice as long to recover as a lateral sprain. A medial (deltoid) sprain from eversion is uncommon and often accompanies a fibular fracture.

The Ottawa ankle rules decide when x rays are needed after acute ankle trauma, with sensitivity near 100 percent for fracture. An ankle series is needed if there is pain in the malleolar zone plus any of: bone tenderness along the distal 6 cm of the posterior edge or tip of the lateral malleolus, bone tenderness along the distal 6 cm of the posterior edge or tip of the medial malleolus, or inability to bear weight both immediately and in the emergency department (four steps). A foot series is needed if there is pain in the midfoot zone plus bone tenderness at the base of the fifth metatarsal or the navicular, or inability to bear weight for four steps.

Ottawa ankle and foot rules: where to press (right foot) Medial view (toes point left) Lateral view (toes point right) Posterior edge and tip,medial malleolus(distal 6 cm) Navicular Posterior edge and tip,lateral malleolus(distal 6 cm) Base of 5th metatarsal Plus: unable to bear weight for four steps, both right after injury and when examined
Figure 4.3 The four Ottawa bone tenderness sites on a right foot. Tenderness at either malleolus or inability to bear weight calls for ankle films; tenderness at the base of the fifth metatarsal or the navicular calls for foot films. The lateral malleolus sits lower than the medial.

Achilles disorders

Achilles tendinopathy is either midportion (2 to 6 cm above the insertion, the area of poorest blood supply) or insertional. Risk factors include increased training load, older age, obesity, fluoroquinolone antibiotics and reduced calf strength. Morning stiffness and pain that warms up with activity are typical. The guideline supports progressive tendon loading: the eccentric heel drop program (Alfredson) or heavy slow resistance for midportion tendinopathy. For insertional tendinopathy, avoid dropping the heel below the step (dorsiflexion compresses the tendon against the calcaneus), so eccentrics are performed to floor level only. Heel lifts can reduce symptoms short term.

Achilles rupture occurs with sudden push off or landing, usually in middle aged recreational athletes ("I felt like I was kicked"). Findings: a palpable gap, weak plantarflexion (other plantarflexors still work, so active plantarflexion can be present), and a positive Thompson test (squeezing the calf produces no plantarflexion). Both operative and nonoperative care, when paired with early functional rehabilitation in a boot with heel wedges, produce similar rerupture rates. Protect from dorsiflexion past neutral for about 8 to 12 weeks and from forceful stretching for months.

Plantar heel pain

Plantar fasciitis (plantar heel pain) causes pain at the medial calcaneal tubercle that is worst with the first steps in the morning or after rest and eases with walking, then returns after prolonged standing. Risk factors include limited ankle dorsiflexion, high body mass index and prolonged standing. The windlass test (passive great toe extension in standing reproduces pain) is specific. Guideline supported interventions: manual therapy, plantar fascia specific and calf stretching, taping, prefabricated or custom foot orthoses for short term relief, night splints holding the ankle in dorsiflexion for patients with morning pain, education and strengthening. Distinguish tarsal tunnel syndrome (tibial nerve under the flexor retinaculum, burning and numbness in the sole, positive Tinel behind the medial malleolus) and a calcaneal stress fracture (positive squeeze test of the calcaneus, often in runners).

Foot fractures

FractureFeaturesKey point
Ankle (bimalleolar, trimalleolar)Rotational injuries; unstable patterns need fixationOften non weight bearing about 6 weeks after fixation, then progressive loading
Fifth metatarsal avulsion (pseudo Jones)Peroneus brevis pulls off the tuberosity during inversionHeals well in a walking boot or hard shoe
Jones fractureMetaphyseal diaphyseal junction of fifth metatarsalWatershed blood supply, high nonunion risk; non weight bearing or fixation in athletes
Metatarsal stress fractureSecond metatarsal most often (march fracture), runners and military recruitsConsider relative energy deficiency and bone health in athletes
Navicular stress fractureVague dorsal midfoot pain in jumpers and sprintersHigh risk; non weight bearing cast often needed
Calcaneal fractureFall from height landing on heelsCheck the lumbar spine (associated compression fracture)
Lisfranc injuryTarsometatarsal joint injury, plantar ecchymosisOften missed; unstable injuries need fixation

Foot posture and mechanics

The subtalar joint produces the triplanar motions of pronation (in open chain: eversion, abduction and dorsiflexion) and supination (inversion, adduction and plantarflexion). In closed chain the calcaneus everts while the talus adducts and plantarflexes, and the tibia rotates internally with pronation. During gait the foot pronates from initial contact through loading response to absorb shock and adapt to the ground, as the transverse tarsal joint axes become parallel and the midfoot unlocks. It then supinates from midstance through terminal stance, and the axes converge so the foot becomes a rigid lever for push off. The windlass mechanism assists: extension of the toes at heel off tightens the plantar fascia, raising the arch and inverting the calcaneus.

A pes planus (flat, overpronated) foot is flexible if the arch reappears when non weight bearing or on toe rise, and rigid if not (consider tarsal coalition). Excess pronation is associated with medial tibial stress syndrome, posterior tibial tendon dysfunction, patellofemoral pain and plantar heel pain. Posterior tibial tendon dysfunction is the commonest cause of acquired flatfoot in adults; signs include the too many toes sign from behind and inability to perform a single leg heel raise. A pes cavus (high arched, supinated) foot is rigid and poor at shock absorption, linked to lateral ankle sprains, stress fractures and neurologic disease (Charcot Marie Tooth). Other forefoot terms: hallux valgus (bunion, lateral deviation of the great toe), hallux rigidus (first MTP arthritis limiting extension, which needs about 60 degrees or more for normal push off), Morton neuroma (third web space interdigital neuroma) and claw and hammer toes.

Board tip. ATFL is tested by the anterior drawer in plantarflexion, CFL by talar tilt. A high ankle sprain hurts with external rotation and the squeeze test and heals slowly. Morning first step heel pain is plantar fasciitis; morning stiffness 2 to 6 cm above the heel is midportion Achilles tendinopathy.
Case. A 24 year old basketball player inverted his ankle 1 hour ago. He walked off the court with help and limps four steps in the clinic. He has swelling and tenderness over the ATFL just anterior to the lateral malleolus, but no bone tenderness on the posterior edge or tip of either malleolus, the base of the fifth metatarsal or the navicular.
Reasoning: He can bear weight four steps and has no Ottawa bone tenderness, so radiographs are not indicated and fracture is very unlikely. The best management is protection with a semirigid brace or lace up support, early weight bearing as tolerated, edema control and range of motion, then strengthening and balance training. Ordering films, casting or strict non weight bearing are wrong choices. Safety point: reassess if the squeeze or external rotation test is positive (syndesmosis) or if he cannot bear weight later; the rules apply to adults and need to be re applied when findings change.
Key point

Ankle and foot problems follow the mechanism and the location of pain: inversion injures the ATFL, external rotation the syndesmosis, sudden push off ruptures the Achilles. The Ottawa rules decide imaging. Tendon disorders respond to progressive loading, plantar heel pain to stretching, orthoses and night splints, and the foot changes from a mobile adapter (pronation) to a rigid lever (supination) during each step.

Section 4Normal and pathological gait

Phases and terminology

One gait cycle (a stride) runs from initial contact of one foot to the next initial contact of the same foot. It is divided into stance (about 60 percent) and swing (about 40 percent). A step is from initial contact of one foot to initial contact of the other, so one stride contains two steps. Double limb support occurs twice per cycle, each about 10 percent at normal speed (roughly 20 percent in all); as walking speed increases, double support shrinks, and running has no double support but a flight phase instead. Older adults and people with impaired balance walk with longer double support.

Two vocabularies appear on the exam. The Rancho Los Amigos terms are preferred: initial contact, loading response, midstance, terminal stance, preswing, initial swing, midswing and terminal swing. The traditional terms are heel strike, foot flat, midstance, heel off, toe off, acceleration, midswing and deceleration. They do not line up perfectly; for example traditional heel off begins terminal stance, and traditional toe off ends preswing.

The gait cycle of the right limb (Rancho Los Amigos terms) Stance about 60 percent Swing about 40 percent LR0 to 10 Midstance10 to 30 Terminal stance30 to 50 PSw50 to 60 Initial60 to 73 Midswing73 to 87 Terminal87 to 100 010305060100 Initial contact at 0 (heel strike) Toe off at about 60 Double limb support (red): about 0 to 10 and 50 to 60 percent Left limb is in its preswing while the right limb is in loading response, and vice versa. LR, loading response; PSw, preswing. Faster walking shortens double support.
Figure 4.4 The eight Rancho phases. Stance occupies about 60 percent of the cycle and includes two short periods of double limb support (red); single limb support spans midstance and terminal stance.

Spatiotemporal values

MeasureTypical adult valueClinical note
CadenceAbout 100 to 120 steps per minute (about 110)Increases with speed; women slightly higher
Gait speedAbout 1.2 to 1.4 m/s at comfortable paceAbout 1.2 m/s commonly cited to cross a street safely; under 0.4 m/s household walker, 0.4 to 0.8 limited community, over 0.8 community walker (stroke categories); under about 1.0 m/s in older adults flags risk of falls and poor outcomes
Step lengthAbout 70 cm (stride about 1.4 m)Compare sides for asymmetry
Step width (base of support)About 5 to 10 cmWide base in ataxia, sensory loss, fear of falling
Center of mass displacementAbout 5 cm vertically and 5 cm side to sideLowest at double support, highest at midstance
Pelvic rotation and dropAbout 4 degrees forward rotation each side; about 5 degrees contralateral pelvic drop in stanceExcess drop is Trendelenburg

Joint angles and muscle activity

Muscles in stance mostly work eccentrically to absorb and control motion; propulsion comes from the plantarflexors in terminal stance and the hip flexors in preswing and initial swing. Knowing which muscle is active in which phase lets you predict the deviation produced by its weakness.

PhaseHipKneeAnkleKey muscle activity
Initial contactAbout 30 degrees flexionNear full extension (0 to 5 flexion)NeutralTibialis anterior holds the ankle; hamstrings and gluteus maximus active
Loading responseAbout 30 flexion, starting to extendFlexes to about 15 to 20Plantarflexes about 5 to 10Quadriceps eccentric (controls knee flexion), tibialis anterior eccentric (lowers forefoot), gluteus maximus and medius
MidstanceExtends to neutralExtends to about 5 flexionDorsiflexes to about 5 to 10Soleus and gastrocnemius eccentric (control tibial advance), gluteus medius stabilizes pelvis
Terminal stanceAbout 10 to 20 apparent hyperextensionNear full extensionAbout 10 dorsiflexion, heel risesPlantarflexors at peak; tibialis posterior and peroneals
PreswingMoves toward neutralFlexes to about 35 to 40Plantarflexes about 15 to 20Hip flexors (adductor longus, rectus femoris, iliopsoas) begin
Initial swingFlexes to about 15 to 20Flexes to about 60 (maximum)About 5 to 10 plantarflexion, moving upIliopsoas, short head of biceps femoris, tibialis anterior
MidswingAbout 25 to 30 flexionExtends to about 25NeutralTibialis anterior keeps toes clear
Terminal swingAbout 30 flexionNear full extensionNeutralHamstrings eccentric (decelerate the shank), quadriceps and tibialis anterior prepare for contact

Range needed for normal walking, commonly taught: about 30 degrees hip flexion and 10 degrees apparent hyperextension, about 60 degrees knee flexion, about 10 degrees ankle dorsiflexion and 20 degrees plantarflexion, and about 60 degrees or more first MTP extension. Stairs need more knee flexion (about 90 to 105) and rising from a standard chair about 90 to 105 degrees of knee and hip flexion.

Common gait deviations and their causes

DeviationWhat you seeUsual causes
Trendelenburg gaitPelvis drops on the swing side during stance on the weak side; compensated form leans the trunk over the stance limbWeak gluteus medius on the stance side, superior gluteal nerve injury, hip OA (lean reduces joint load)
Gluteus maximus gaitBackward trunk lean at initial contactWeak hip extensors (inferior gluteal nerve)
Quadriceps weaknessForward trunk lean or hand pushing on thigh, knee kept extended or hyperextended in loading responseFemoral nerve palsy, L3 to L4 radiculopathy, after TKA
Genu recurvatumKnee snaps back in stanceQuadriceps weakness, plantarflexion contracture, plantarflexor spasticity
Foot slapForefoot slaps after initial contactMild dorsiflexor weakness (eccentric control lost)
Steppage gaitExcess hip and knee flexion in swing to clear a dropped foot, toe first contactFoot drop: common fibular nerve palsy, L4 to L5 radiculopathy, peripheral neuropathy
CircumductionSwing limb moves in an arc to the sideFunctionally long limb: knee extension contracture or brace locked in extension, plantarflexion contracture, weak hip flexors or dorsiflexors, hemiplegia
Hip hikingPelvis elevates on the swing sideSame as circumduction, or weak hamstrings so knee cannot flex
VaultingRises on the toes of the stance limb so the other limb can clearLong swing limb (locked knee, prosthesis too long, poor knee flexion)
Antalgic gaitShortened stance on the painful limb, shorter step of the opposite limbPain anywhere in the limb
Hip flexion contractureForward trunk lean or increased lumbar lordosis, short step of the opposite limb, no terminal stance extensionHip OA, prolonged sitting, transfemoral amputation positioning
Weak plantarflexorsNo heel rise, excess dorsiflexion and knee flexion in stance, short opposite stepTibial nerve palsy, S1 radiculopathy, Achilles rupture
ScissoringSwing limb crosses the midlineHip adductor spasticity (cerebral palsy)
Ataxic gaitWide base, irregular, staggeringCerebellar lesion or proprioceptive loss (worse with eyes closed if sensory)
Parkinsonian gaitShuffling, reduced arm swing, festination, freezingParkinson disease
Board tip. In Trendelenburg gait the weak gluteus medius is on the stance side; the pelvis drops on the opposite (swing) side. A cane in the hand opposite the weak hip reduces the abductor demand. Foot slap means mild dorsiflexor weakness at loading response; steppage means no active dorsiflexion during swing.
Case. A 58 year old man presents after a fibular head fracture 3 weeks ago. During swing on the left he lifts his left knee high and his left toes touch the ground first at contact. He has numbness on the dorsum of the foot.
Reasoning: Excessive hip and knee flexion in swing with toe first contact is a steppage gait from foot drop. The common fibular nerve wraps the fibular neck and is easily injured there; the deep branch supplies tibialis anterior and the toe extensors, and sensation over the dorsum of the foot and first web space fits. The best intervention is a posterior leaf spring or other ankle foot orthosis, plus education to protect the insensate skin. Circumduction training, hip flexor strengthening alone or a heel lift are wrong. Safety point: after a fibular head fracture, also check for compartment syndrome early on.
Key point

Learn the gait cycle by phase: what each joint is doing and which muscle controls it. Weakness shows up in the phase where that muscle is supposed to work (quadriceps and dorsiflexors at loading response, gluteus medius in single limb stance, plantarflexors in terminal stance, dorsiflexors in swing), and a functionally long limb in swing produces circumduction, hip hiking or vaulting.

Section 5Fractures, weight bearing and orthopedic special populations

Fracture healing

Bone heals by two routes. Secondary (indirect) healing with callus occurs when there is some motion at the fracture, as with casting, intramedullary nails or external fixation. Primary (direct) healing without visible callus occurs with rigid compression plating, where osteons cross the fracture directly. Secondary healing passes through overlapping stages.

Secondary bone healing: overlapping stages Inflammatory Soft callus Hard callus Remodeling 01 wk3 wk6 to 8 wk12 wkmonths to years hematoma, inflammation, days 1 to 7 fibrocartilage bridge, about 2 to 3 weeks Dashed line: clinical union in many adult fractures. Children heal faster, older adults slower. woven bonereplaces cartilage
Figure 4.5 Fracture healing overlaps in stages. Clinical union, when the fracture is stable and painless, commonly arrives around 6 to 8 weeks in adults, but radiographic remodeling continues for months to years, so loading is progressed step by step.

Factors that delay healing: smoking, diabetes, poor nutrition, older age, NSAIDs in some studies, corticosteroids, infection, poor blood supply (scaphoid, femoral neck, talus, fifth metatarsal Jones zone, distal tibia), excessive motion and open fractures. A delayed union is slower than expected; a nonunion has stopped healing (often after about 6 to 9 months). Malunion heals in a poor position. Watch after any fracture for compartment syndrome (pain out of proportion and with passive stretch), fat embolism (after long bone fractures, typically 24 to 72 hours: confusion, dyspnea, petechiae), DVT and pulmonary embolism, and complex regional pain syndrome. Exercise prescription during immobilization keeps the joints above and below moving and maintains strength in the rest of the body.

Weight bearing status

OrderMeaningSuitable gait pattern and device
Non weight bearing (NWB)No weight on the limb; foot does not touch the floorThree point gait with walker or axillary crutches; requires good upper body strength and balance
Toe touch or touch down (TTWB, TDWB)Foot touches for balance only, essentially no weightWalker or crutches, three point pattern
Partial (PWB)A stated percentage or amount, for example 50 percent of body weightWalker or crutches, three point gait; teach with a bathroom scale
Weight bearing as tolerated (WBAT)Any amount the patient can tolerateWalker, crutches or cane as needed, wean as able
Full (FWB)No restrictionDevice only for balance or pain

Weight bearing orders come from the surgeon and depend on fixation stability more than on the fracture alone. Most hip fractures and arthroplasties allow weight bearing as tolerated; intra articular fractures (tibial plateau, pilon, calcaneus), unstable ankle fractures and many osteotomies require non weight bearing or touch down weight bearing for about 6 to 12 weeks. Patients poorly judge partial weight bearing, so teach it with a scale and recheck. If a patient cannot maintain a NWB restriction safely, a wheelchair may be the safer mobility choice. For gait patterns: three point gait (device and involved limb together) for a restricted limb; two point and four point gaits (reciprocal, with each crutch moving with the opposite limb) for bilateral weakness; swing to and swing through for bilateral lower extremity paralysis. On stairs with crutches, go up with the good limb first and down with the crutches and involved limb first.

Osteoporosis

Osteoporosis is low bone mass with microarchitectural deterioration. The World Health Organization defines it by DXA T score (comparison with young adult peak bone mass): normal T score at or above negative 1.0; osteopenia (low bone mass) between negative 1.0 and negative 2.5; osteoporosis at or below negative 2.5; severe osteoporosis at or below negative 2.5 with a fragility fracture. Z scores compare with age matched peers and are used in children and premenopausal adults. Common fragility fractures: vertebral compression (often thoracic, causing kyphosis and height loss), distal radius (Colles) and hip.

Exercise for bone health combines progressive resistance training, impact or weight bearing activity as tolerated, balance training and posture work (back extensor strengthening reduces vertebral fracture risk). For people with osteoporosis, avoid loaded spinal flexion (sit ups, toe touches, deep forward bending with rotation, some yoga poses) and sudden twisting, which raise vertebral compression fracture risk. Teach hip hinge lifting, home fall prevention and adequate calcium and vitamin D. Pain with mild trauma or a sudden onset of thoracic pain in an older adult with osteoporosis suggests a compression fracture and needs medical evaluation.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory arthritis of the synovium. Contrast it with osteoarthritis:

FeatureRheumatoid arthritisOsteoarthritis
PathologyAutoimmune synovitis, pannus erodes cartilage and boneDegenerative whole joint disease, cartilage loss, osteophytes
JointsSymmetric small joints: MCP, PIP, wrist, MTP; cervical spine (C1 to C2)Asymmetric weight bearing joints, DIP, PIP, thumb base, hip, knee, spine
Morning stiffnessMore than about an hourUnder about 30 minutes
Systemic signsFatigue, fever, weight loss, nodules, anemia, lung and eye diseaseNone
LabsRheumatoid factor, anti CCP, raised ESR and CRPNormal
Hand deformitiesUlnar drift, swan neck, boutonniereHeberden and Bouchard nodes

During an acute flare (warm, swollen, painful joints), use rest, splinting in a functional position, gentle active or active assisted range of motion (one or two repetitions to maintain motion), isometrics and joint protection; avoid vigorous stretching and resisted exercise through inflamed joints. Between flares, use aerobic exercise, low load strengthening, joint protection and energy conservation. Long term corticosteroid use causes osteoporosis and skin fragility. Atlantoaxial instability from transverse ligament laxity is a serious risk: avoid cervical manipulation and end range upper cervical flexion, and report symptoms such as occipital headache, dizziness, bilateral paresthesia or gait change as possible cord compression.

Amputation level overview

Lower limb amputations in adults are mostly due to vascular disease and diabetes; trauma and tumor are the main causes in younger people. Energy cost of walking rises as the level becomes more proximal, and bilateral and transfemoral amputees often need more help.

LevelKey points
Partial foot (toe, transmetatarsal, Chopart)Low energy cost; Chopart tends to an equinus contracture
Syme (ankle disarticulation)End bearing heel pad, limited prosthetic clearance
TranstibialEnergy cost roughly 20 to 40 percent above normal; avoid knee flexion contracture (no pillow under the knee, no prolonged sitting with knee bent)
Knee disarticulationEnd bearing, long lever, knee center lower than the other side
TransfemoralEnergy cost roughly 60 to 100 percent above normal; avoid hip flexion, abduction and external rotation contracture (no pillow between the thighs or under the residual limb, prone lying daily)
Hip disarticulation and hemipelvectomyHighest energy cost; many patients use a wheelchair

Preprosthetic care: residual limb shaping with figure of eight elastic wrapping (tighter distally, diagonal turns, no circular turns that form a tourniquet) or a shrinker, positioning to prevent contractures, strengthening (especially hip extensors and abductors), desensitization, skin inspection of both limbs (the remaining foot is at high risk in diabetes), cardiovascular training and transfer and wheelchair training. Phantom limb sensation is nearly universal and harmless; phantom pain responds to mirror therapy, graded motor imagery and desensitization. A rigid removable dressing protects transtibial limbs and limits edema.

Board tip. Osteoporosis is a T score of negative 2.5 or lower; avoid loaded spinal flexion. Transfemoral amputees develop hip flexion and abduction contractures; transtibial amputees develop knee flexion contractures. Partial weight bearing is taught with a scale.
Case. A 66 year old woman with osteoporosis (T score negative 3.0) and a healed wrist fracture is referred for exercise. She asks for abdominal crunches and toe touch stretches to flatten her stomach and loosen her back.
Reasoning: Repeated or loaded spinal flexion raises compressive force on the anterior vertebral bodies and increases the risk of vertebral compression fracture in osteoporosis. The best program combines progressive resistance training, weight bearing or impact activity as tolerated, balance training and spinal extensor strengthening, with neutral spine core work and hip hinge mechanics. Crunches, toe touches and sit ups with rotation are wrong choices. Safety point: sudden mid back pain after minor strain or a cough in this patient should be evaluated as a possible compression fracture.
Key point

Bone heals in overlapping stages, with clinical union around 6 to 8 weeks in many adult fractures and remodeling for months; weight bearing follows the surgeon's view of fixation stability, and the gait pattern and device follow the order. Osteoporosis calls for loading without loaded flexion, RA for joint protection during flares and caution in the upper cervical spine, and amputation care for contracture prevention, limb shaping and protection of the other foot.

The chapter in one breath

  • Hip osteoarthritis limits internal rotation and flexion first; a cane goes in the opposite hand.
  • Cam FAI affects young men, pincer FAI middle aged women; labral tears click and catch.
  • Femoral neck fractures threaten the blood supply to the head; most hip fracture repairs allow weight bearing as tolerated and early mobilization.
  • Posterior THA: no flexion past 90, adduction past midline or internal rotation; anterior THA: no extension or external rotation.
  • Lachman is the most sensitive ACL test, pivot shift the most specific, posterior drawer the best PCL test; McMurray and Thessaly test the meniscus.
  • Patellofemoral pain responds to combined hip and knee strengthening; after ACL reconstruction, restore extension first and return to sport at about 9 months with 90 percent symmetry.
  • After TKA, prioritize full extension, quadriceps strength (with NMES) and at least 90 degrees of flexion.
  • The Ottawa rules use malleolar, fifth metatarsal and navicular tenderness and four step weight bearing to decide on x rays.
  • Achilles tendinopathy and plantar heel pain respond to progressive loading and stretching; the Thompson test detects Achilles rupture.
  • Stance is about 60 percent of the gait cycle; weakness shows up in the phase where a muscle normally works (gluteus medius, Trendelenburg; dorsiflexors, steppage).
  • Bone reaches clinical union around 6 to 8 weeks; osteoporosis is a T score of negative 2.5 or lower and loaded flexion is avoided.
  • Transfemoral amputees risk hip flexion and abduction contractures, transtibial amputees knee flexion contractures.

Words worth knowing

TermWhat it means
Capsular pattern of the hipLoss of internal rotation and flexion first, then abduction, from capsular restriction.
Femoroacetabular impingementAbnormal contact between the femoral head neck junction and acetabular rim, as cam or pincer types.
FADIR testFlexion, adduction and internal rotation of the hip to provoke intra articular pain.
Avascular necrosisBone death from loss of blood supply, a risk after femoral neck and scaphoid fractures.
HemiarthroplastyReplacement of only the femoral head, often for displaced femoral neck fractures.
Lachman testAnterior tibial translation at 20 to 30 degrees flexion to test the ACL.
Pivot shiftA clunk of the lateral tibial plateau reducing during flexion, specific for ACL tear.
Posterolateral cornerLCL, popliteus and related structures that resist varus and external rotation.
Red zoneThe vascular outer third of the meniscus, where tears can heal after repair.
Q angleAngle between the quadriceps line of pull and the patellar tendon, larger in women.
LigamentizationRemodeling of an ACL graft into ligament-like tissue, weakest at about 6 to 12 weeks.
Limb symmetry indexInvolved limb performance as a percentage of the uninvolved limb.
SyndesmosisFibrous joint between distal tibia and fibula, injured in a high ankle sprain.
Ottawa ankle rulesDecision rule using bone tenderness and weight bearing to decide on ankle or foot x rays.
Thompson testCalf squeeze that produces no plantarflexion when the Achilles is ruptured.
Windlass mechanismToe extension tightening the plantar fascia to raise the arch and stiffen the foot.
Jones fractureFracture at the metaphyseal diaphyseal junction of the fifth metatarsal with poor healing.
Double limb supportPeriods when both feet are on the ground, about 10 percent twice per cycle.
Trendelenburg gaitContralateral pelvic drop in stance from weak gluteus medius on the stance side.
Steppage gaitExcess hip and knee flexion in swing to clear a dropped foot.
VaultingRising onto the toes of the stance limb to clear a long swing limb.
NonunionA fracture that has stopped healing without bony union.
Three point gaitDevice and involved limb advance together, then the uninvolved limb.
T scoreBone density compared with young adult peak, in standard deviations.
PannusInflamed synovial tissue in rheumatoid arthritis that erodes cartilage and bone.
Phantom limb painPainful sensation perceived in the amputated part.

Check yourself

Which motions should a patient avoid after a posterior approach total hip arthroplasty?
Answer. Hip flexion beyond 90 degrees, adduction past midline and internal rotation, the positions that lever the head out posteriorly.
A 13 year old obese boy has a limp and knee pain; his hip externally rotates when flexed. What is the best action?
Answer. Make him non weight bearing and refer urgently for slipped capital femoral epiphysis. Knee pain in an adolescent can be referred from the hip.
Which test is most sensitive for an acute ACL tear?
Answer. The Lachman test at 20 to 30 degrees of knee flexion. The pivot shift is the most specific.
After an isolated PCL tear, which muscle group should be emphasized?
Answer. The quadriceps, which pull the tibia anteriorly and offset the posterior sag; isolated resisted hamstring work is delayed.
Two weeks after TKA a patient sleeps with a pillow under the knee. What should you teach?
Answer. Remove it and place a towel roll under the ankle to promote full extension; knee flexion contracture is the most limiting complication.
Which findings would require an ankle x ray under the Ottawa rules?
Answer. Malleolar zone pain with bone tenderness at the posterior edge or tip of either malleolus (distal 6 cm), or inability to bear weight four steps immediately and when examined.
During single limb stance on the right, the left side of the pelvis drops. Which muscle is weak?
Answer. The right gluteus medius, on the stance side.
In which phase is maximum knee flexion (about 60 degrees) reached during walking?
Answer. Initial swing, which allows the foot to clear the ground.
A patient ordered toe touch weight bearing on the left asks which gait pattern to use with a walker. What is correct?
Answer. A three point gait: the walker and the left limb advance together with the toe touching only for balance, then the right limb steps through.
How should a patient with a new transfemoral amputation be positioned to prevent contracture?
Answer. Lying prone daily with the hip extended and adducted; avoid pillows under or between the thighs and prolonged sitting, which favor hip flexion and abduction contracture.
Chapter 5 · Neuromuscular

Neuromuscular Foundations: Neuroanatomy, Examination and Motor Control

Every neurologic question on the licensing exam is really a localization problem followed by a management problem: where is the lesion, what will the patient be able to do, and what is the safest, most effective intervention? This chapter builds the foundation for the neuromuscular half of the exam: the anatomy that predicts deficits, the examination that confirms them, the motor learning science that shapes treatment, the balance tests with their cutoffs, and the interventions with the strongest evidence.

By the end of this chapter you can

  • Match the cortical areas, cerebellum, basal ganglia and brainstem to their functions and predict the deficit from a lesion in each.
  • Trace the corticospinal tract, dorsal column medial lemniscus and spinothalamic tract, state where each crosses, and use that to predict ipsilateral or contralateral signs.
  • Screen all twelve cranial nerves and name the arterial territory most likely involved from a cluster of findings.
  • Perform and grade a neurologic examination: sensation, deep tendon reflexes, the Modified Ashworth Scale, coordination tests and upper versus lower motor neuron signs.
  • Apply the stages of motor learning, practice schedules, feedback types and the principles of experience dependent neuroplasticity to a treatment plan.
  • Explain the systems model of balance, the ankle, hip and stepping strategies, and the six conditions of the Sensory Organization Test.
  • Recall the usual exam cutoffs for the Berg Balance Scale, Timed Up and Go, Dynamic Gait Index, Functional Gait Assessment, functional reach and gait speed.
  • Choose among task specific training, constraint induced movement therapy, body weight supported treadmill training and functional electrical stimulation, including eligibility, dosage and contraindications.

Section 1Neuroanatomy that the exam tests

The exam asks you to read a vignette, recognize the pattern of deficits and connect it to a structure and a blood supply. For each system, ask what it normally does and what a patient looks like when it fails.

The cerebral cortex

Each hemisphere has four lobes on its lateral surface (frontal, parietal, temporal and occipital) plus the limbic lobe and insula, which lie deep or medial. The central sulcus separates the frontal lobe (motor planning and execution) from the parietal lobe (sensation and spatial processing). The lateral (Sylvian) fissure separates the frontal and parietal lobes above from the temporal lobe below.

The primary motor cortex (precentral gyrus, Brodmann area 4) contains the cell bodies of many upper motor neurons. Its body map, the motor homunculus, places the leg and foot on the medial surface of the hemisphere inside the longitudinal fissure, and the trunk, arm, hand and face progressively more lateral, with the face just above the lateral fissure. That layout explains why anterior cerebral artery strokes cause leg greater than arm weakness and middle cerebral artery strokes cause face and arm greater than leg weakness.

The premotor cortex and supplementary motor area plan and sequence movement and set up anticipatory postural adjustments; lesions cause apraxia and poor initiation. The prefrontal cortex governs executive function, so frontal damage brings impulsivity, perseveration and poor insight, which matter more for safety than strength. The dominant hemisphere (left in almost all right handed and most left handed people) holds the language areas. The nondominant (usually right) inferior parietal lobule governs spatial attention, so damage there produces unilateral neglect and anosognosia. The limbic system links emotion, motivation and memory, which is why lability and memory loss are common after brain injury. Figure 5.1 maps the main areas.

FrontalParietalTemporalOccip. Premotor and SMA (6) Primary motor (4) Primary somatosensory (3,1,2) Broca area (44, 45) Primary auditory (41, 42) Wernicke (22) Primary visual (17) Cerebellum Brainstem AnteriorPosterior CS
Figure 5.1 Functional areas of the left (dominant) hemisphere, lateral view, front to the left. CS marks the central sulcus between the red motor strip and the blue sensory strip. Broca and Wernicke areas sit on either side of the lateral fissure; the visual cortex is mostly on the medial surface at the occipital pole.

The long tracts and where they cross

Three tracts answer most lateralization questions. The rule is simple: find where the tract crosses, and the side of the deficit flips at that level.

  • Lateral corticospinal tract (voluntary movement). Upper motor neurons leave the motor cortex, pass through the corona radiata and the posterior limb of the internal capsule, descend through the cerebral peduncle and the basis pontis, and form the medullary pyramids. About 85 to 90 percent of fibers cross at the pyramidal decussation in the caudal medulla and descend in the lateral funiculus to synapse on anterior horn cells. The uncrossed remainder forms the anterior corticospinal tract, which mainly controls axial and proximal muscles. A lesion above the decussation gives contralateral weakness; a lesion in the cord gives ipsilateral weakness below the level.
  • Dorsal column medial lemniscus (DCML: discriminative touch, vibration, proprioception, two point discrimination). First order neurons enter the cord and ascend ipsilaterally in the fasciculus gracilis (lower body, medial) and fasciculus cuneatus (upper body above about T6, lateral). They synapse in the nucleus gracilis and cuneatus of the medulla; second order fibers cross as the internal arcuate fibers and ascend as the medial lemniscus to the ventral posterolateral (VPL) nucleus of the thalamus, then to the postcentral gyrus. Cord lesions cause ipsilateral loss; lesions above the medulla cause contralateral loss.
  • Spinothalamic tract (anterolateral system: pain, temperature, crude touch). First order fibers synapse in the dorsal horn; second order fibers cross in the anterior white commissure within one or two segments and ascend in the anterolateral cord to the VPL thalamus. A cord lesion therefore causes contralateral pain and temperature loss beginning one to two segments below the lesion.

The spinocerebellar tracts carry unconscious proprioception to the ipsilateral cerebellum. The reticulospinal and vestibulospinal tracts control posture and tone; loss of cortical inhibition over them contributes to spasticity and antigravity posturing after brain injury.

Fasciculus gracilis (leg)DCML, crosses in medulla Fasciculus cuneatus (arm)DCML, crosses in medulla Lateral corticospinalcrossed at pyramids Dorsal spinocerebellaruncrossed, to cerebellum Spinothalamiccrosses within 1 to 2 segments Anterior corticospinalmostly uncrossed, axial Dorsal horn (sensory) Ventral horn (LMN cell bodies) Posterior (dorsal) Anterior (ventral)
Figure 5.2 Major tracts in a cervical cord cross section (tracts drawn on one side only). Ascending sensory tracts are blue, green and gold; descending motor tracts are red. The crossing level of each tract predicts whether a cord lesion produces ipsilateral or contralateral signs.
Board tip. In a spinal cord hemisection, the deficits split by tract: weakness and loss of vibration and proprioception on the same side as the lesion, and loss of pain and temperature on the opposite side starting a level or two lower. If a vignette describes this split, the answer is Brown-Sequard syndrome, and the tract crossing levels are the reason.

Cerebellum

The cerebellum compares intended with actual movement and corrects errors in timing, force and direction; it does not cause weakness. Midline lesions (vermis, flocculonodular lobe) cause truncal ataxia, wide based gait and nystagmus; lateral hemisphere lesions cause limb dysmetria, intention tremor and dysdiadochokinesia. Because the cerebellar output crosses once and the corticospinal tract crosses again, cerebellar lesions produce signs on the same side as the lesion. Other features are hypotonia, a positive rebound phenomenon, scanning or ataxic dysarthria, and a gait that does not improve much with vision (contrast with sensory ataxia).

Basal ganglia

The basal ganglia (caudate and putamen, which form the striatum; globus pallidus; subthalamic nucleus; substantia nigra) select desired movements and suppress unwanted ones through a loop with the cortex and thalamus. In the simplified model, the direct pathway facilitates movement and the indirect pathway inhibits it. Dopamine from the substantia nigra pars compacta excites the direct pathway (D1 receptors) and inhibits the indirect pathway (D2 receptors), so its net effect is to promote movement. Loss of dopamine in Parkinson disease produces a hypokinetic disorder: bradykinesia, rigidity, resting tremor and postural instability. Degeneration of the caudate in Huntington disease and a lesion of the subthalamic nucleus (contralateral hemiballismus) produce hyperkinetic disorders. External cues help because automatic, internally cued movement is impaired.

Brainstem and cranial nerves

The brainstem (midbrain, pons, medulla) contains the cranial nerve nuclei, all of the long tracts, the reticular activating system for arousal, and centers for breathing, heart rate and blood pressure. A brainstem lesion is suggested by crossed findings: an ipsilateral cranial nerve deficit with contralateral weakness or sensory loss in the body, often with vertigo, diplopia, dysarthria, dysphagia or ataxia. Cranial nerves III and IV are in the midbrain; V, VI, VII and VIII in the pons; IX, X, XI (in part) and XII in the medulla.

NerveMain functionBedside screenFinding with lesion
I OlfactorySmellIdentify a familiar odor, each nostrilAnosmia, common after frontal head injury
II OpticVisionAcuity, visual fields by confrontation, pupillary light reflex (afferent)Field cut; pattern localizes the lesion
III OculomotorMost eye movements, eyelid elevation, pupil constrictionTrack an H pattern; pupil responseEye down and out, ptosis, dilated pupil
IV TrochlearSuperior oblique (depresses the adducted eye)Look down and inVertical diplopia worse going downstairs; head tilt away
V TrigeminalFacial sensation; muscles of masticationLight touch on three divisions; clench jaw; corneal reflex (afferent)Facial numbness; jaw deviates toward the weak side
VI AbducensLateral rectusLook laterallyEye turned in; horizontal diplopia
VII FacialFacial expression, taste anterior two thirdsRaise brows, close eyes tight, smileLMN: whole half of face; UMN: lower face only, forehead spared
VIII VestibulocochlearHearing and balanceFinger rub, head impulse test, observe nystagmusHearing loss, vertigo, nystagmus
IX GlossopharyngealPharynx sensation, taste posterior thirdGag reflex (afferent)Reduced gag, dysphagia
X VagusPalate, pharynx, larynx; parasympatheticSay "ah," watch the uvula; voice qualityUvula deviates away from the lesion; hoarseness, dysphagia
XI AccessorySternocleidomastoid and upper trapeziusResisted shrug and head turnWeak shrug; shoulder droops; scapular winging (lateral)
XII HypoglossalTongue movementProtrude tongueTongue deviates toward the lesion side

Blood supply

The brain is supplied by two paired systems that join at the base in the circle of Willis. The anterior circulation comes from the internal carotid arteries, which give the anterior cerebral artery (medial frontal and parietal lobes: leg and foot area, bladder control, frontal executive areas) and the middle cerebral artery (lateral convexity: face and arm motor and sensory areas, language areas in the dominant hemisphere, spatial attention in the nondominant hemisphere, and through lenticulostriate branches the internal capsule and basal ganglia). The posterior circulation comes from the vertebral arteries, which join as the basilar artery to supply the brainstem and cerebellum and end as the two posterior cerebral arteries (occipital lobe, inferior temporal lobe, thalamus). Communicating arteries allow collateral flow. Chapter 6 matches each artery to its stroke syndrome.

Case. A 66 year old man is referred to outpatient therapy for "dizziness and clumsiness." He reports two days of vertigo. On examination his right arm overshoots on finger to nose, rapid alternating movements are slow and irregular on the right, he has a hoarse voice and difficulty swallowing, his face has decreased pain sensation on the right, and his left arm and leg have decreased pain and temperature sensation. Strength is 5/5 throughout.
Reasoning: First localize. Ipsilateral face and contralateral body sensory loss is a crossed pattern, which places the lesion in the brainstem; hoarseness and dysphagia point to the medulla (nucleus ambiguus, CN IX and X); right sided ataxia without weakness fits the right inferior cerebellar peduncle. This is a right lateral medullary (Wallenberg) syndrome from the vertebral or posterior inferior cerebellar artery. The tempting choices are a peripheral vestibular disorder (but peripheral disorders do not cause sensory loss or dysphagia) and a cerebellar hemisphere stroke alone (which would not explain the crossed sensory loss). The best action is not to start vestibular rehabilitation but to stop and refer urgently for emergency medical evaluation, because a new posterior circulation stroke can progress. New onset vertigo with any of the "D" signs (diplopia, dysarthria, dysphagia, dysmetria, drop attacks) or crossed sensory signs is a red flag.
Key point

Localize before you treat. The homunculus explains why the ACA hits the leg and the MCA hits the face and arm; the crossing levels of the corticospinal, dorsal column and spinothalamic tracts explain which side is affected; cerebellar signs are ipsilateral and never cause weakness; basal ganglia lesions disturb the amount and automaticity of movement; and crossed cranial nerve and body signs point to the brainstem and the posterior circulation, which is a medical emergency when new.

Section 2The neurologic examination

The neurologic examination localizes the problem, separates upper from lower motor neuron involvement, sets a baseline and catches findings that need referral. Begin with a systems review: arousal, orientation, ability to follow commands, communication, vital signs and red flags. A patient who cannot follow commands cannot give valid sensory or strength results.

Sensory examination

Sensation is tested in three groups. Superficial (exteroceptive) sensation includes pain (sharp versus dull with a safety pin or broken tongue depressor), temperature (warm and cold test tubes), light touch (cotton ball or fingertip) and pressure. Deep (proprioceptive) sensation includes proprioception (static joint position sense), kinesthesia (awareness of movement) and vibration (128 Hz tuning fork over a bony prominence). Combined cortical sensation includes stereognosis (identifying an object by touch), graphesthesia (recognizing numbers traced on the skin), two point discrimination, tactile localization, barognosis (weight) and recognition of texture, and bilateral simultaneous stimulation (extinction, a sign of neglect).

Technique rules: demonstrate with vision, then occlude vision; apply stimuli randomly and at irregular intervals; compare sides; and test superficial before deep and cortical sensation, because cortical tests mean little if primary sensation is absent. Pain and temperature test the anterolateral system; vibration and proprioception test the dorsal columns. In diabetes, inability to feel the 5.07 (10 gram) monofilament means loss of protective sensation. Patterns localize: dermatomal (root), named nerve field, stocking and glove (polyneuropathy), a trunk sensory level (cord), or one whole side including the face (contralateral thalamus, capsule or cortex).

Reflexes

Deep tendon reflexes (muscle stretch reflexes) test a monosynaptic arc: muscle spindle, Ia afferent, the spinal segment, the alpha motor neuron and the muscle. Descending pathways normally damp the arc. A lower motor neuron or sensory lesion breaks the arc and reduces the reflex; an upper motor neuron lesion removes inhibition and exaggerates it. Use reinforcement (Jendrassik maneuver) before calling a reflex absent.

GradeResponseMeaning
0No response, even with reinforcementLMN lesion, root or nerve lesion, or spinal shock
1+Diminished, low normalMay be normal; abnormal if asymmetric
2+Average, normalNormal
3+Brisker than averageMay be normal; suspect UMN if asymmetric or with other signs
4+Very brisk, hyperactive, often with clonusUMN lesion
ReflexMain root levelPathologic reflexPositive sign and meaning
BicepsC5 (C6)BabinskiGreat toe extension and toe fanning on stroking the lateral sole: corticospinal lesion (normal in infants)
BrachioradialisC6HoffmannThumb and index flexion on flicking the middle fingernail: UMN lesion at or above the cervical cord
TricepsC7ClonusRhythmic beats on a quick sustained stretch (ankle is classic); more than three to five beats is abnormal
PatellarL4 (L3)ChaddockToe extension on stroking the lateral malleolus: same meaning as Babinski
Medial hamstringL5OppenheimToe extension on stroking down the medial tibia
AchillesS1Superficial abdominalsAbsent in UMN lesions above the segment (and in some normal people)

Tone and spasticity

Tone is the resistance of a relaxed muscle to passive stretch. Spasticity is a velocity dependent increase in resistance to passive stretch caused by hyperexcitable stretch reflexes after an upper motor neuron lesion; it may show a clasp knife response (high resistance that suddenly gives way). It favors upper extremity flexors and lower extremity extensors. Rigidity is increased resistance that is not velocity dependent and is present in both agonist and antagonist; lead pipe rigidity is uniform through the range and cogwheel rigidity is ratchety (tremor superimposed on rigidity), typical of Parkinson disease. Hypotonia or flaccidity follows lower motor neuron or cerebellar lesions and the early shock phase of stroke and spinal cord injury. Decorticate (arms flexed, legs extended) and decerebrate (all four extremities extended) posturing are described in Chapter 6.

Spasticity is graded with the Modified Ashworth Scale (MAS), testing with the patient relaxed and supine and moving the limb through the range in about one second. The Modified Tardieu Scale compares the catch angle at fast stretch (R1) with slow passive range (R2); a large gap suggests a reflex component, a small gap suggests contracture.

MAS gradeDescription
0No increase in tone
1Slight increase: a catch and release, or minimal resistance at the end of the range
1+Slight increase: a catch followed by minimal resistance through less than half of the remaining range
2More marked increase through most of the range, but the part is easily moved
3Considerable increase; passive movement is difficult
4The part is rigid in flexion or extension

Coordination

Coordination tests separate cerebellar, sensory and basal ganglia problems. Nonequilibrium tests are done sitting or lying: finger to nose, finger to therapist's finger, heel to shin, rapid alternating movements such as pronation and supination (inability is dysdiadochokinesia), finger tapping and foot tapping, drawing a circle, and the rebound test (the limb overshoots when resistance is suddenly released). Observe for dysmetria (overshoot or undershoot), intention tremor (increasing as the target nears, cerebellar), resting tremor (decreasing with movement, basal ganglia) and decomposition of movement. Test with eyes open and then closed: a sensory ataxia worsens dramatically without vision, whereas cerebellar ataxia changes little. Equilibrium tests are done standing and walking: the Romberg test (feet together, eyes open then closed; positive if balance is maintained with eyes open but lost with eyes closed, indicating a proprioceptive or vestibular problem, not cerebellar), the sharpened (tandem) Romberg, single limb stance, tandem walking and walking with sudden stops and turns.

Motor cortex Internal capsule Brainstem, pyramids Anterior horn cell Muscle nerve Upper motor neuron lesion Spasticity, velocity dependent (clasp knife) Hyperreflexia, clonus, Babinski and Hoffmann Weakness in patterns (synergies), not single muscles Little or slow disuse atrophy, no fasciculations Contralateral if above decussation Examples: stroke, TBI, MS, SCI, ALS (UMN part) Lower motor neuron lesion Flaccidity, hyporeflexia or areflexia Early marked atrophy, fasciculations, fibrillations on EMG Weakness in a root, nerve or myotome distribution Examples: radiculopathy, neuropathy, Guillain Barre, polio
Figure 5.3 The upper motor neuron runs from the cortex to the anterior horn cell; the lower motor neuron runs from the anterior horn cell to the muscle. The side of the lesion on this chain predicts the cluster of signs. ALS damages both and shows a mixed picture.

Upper versus lower motor neuron signs

A stroke and a peroneal nerve palsy can both cause foot drop, but the stroke patient has a brisk ankle jerk, clonus and plantarflexor spasticity, while the palsy patient has a flaccid foot, anterior compartment atrophy and a nerve pattern of sensory loss. A spinal cord injury gives LMN signs at the injured level and UMN signs below it once spinal shock resolves. ALS mixes both in the same limb.

Cranial nerve screening and other components

Cranial nerve screening (table in Section 1) focuses on findings that change management: visual field loss, nystagmus and eye movement problems, facial weakness pattern, and dysphagia signs such as a wet voice or coughing with swallowing, which call for speech language pathology referral and aspiration precautions. The full examination also covers cognition, communication, perception, motor function, balance and gait.

Board tip. Manual muscle testing assumes isolated control. In a patient with strong flexor synergy after stroke, a "4/5 biceps" is misleading because the force comes from a mass pattern; the exam expects you to describe motor control (for example, Brunnstrom stage or Fugl-Meyer score) instead of reporting MMT grades. Likewise, the Romberg tests sensory inputs, not the cerebellum.
Case. A 52 year old woman reports six months of progressive hand weakness and frequent tripping. Examination shows atrophy and visible fasciculations of the intrinsic hand muscles bilaterally, 4+ patellar reflexes with three beats of ankle clonus, a positive Hoffmann sign, and normal sensation in all modalities.
Reasoning: Classify each sign. Atrophy and fasciculations are lower motor neuron signs; hyperreflexia, clonus and Hoffmann are upper motor neuron signs; sensation is spared. Mixed UMN and LMN signs with normal sensation is the classic presentation of amyotrophic lateral sclerosis. A cervical myelopathy can also mix signs (LMN at the level, UMN below) and must be excluded, but it usually produces some sensory change, so the best answer is that the findings are most consistent with motor neuron disease and require physician referral for diagnosis. A peripheral neuropathy is wrong because it causes hyporeflexia and sensory loss. Safety point: progressive neurologic findings that do not fit a musculoskeletal pattern need referral before a plan of care continues.
Key point

Test in a logical order (cognition and safety first, superficial before cortical sensation, reflexes and tone before function), compare sides, and interpret findings as patterns. Velocity dependent resistance is spasticity, velocity independent resistance is rigidity, and both differ from contracture. Upper motor neuron lesions give spasticity, hyperreflexia and pathologic reflexes; lower motor neuron lesions give flaccidity, hyporeflexia, atrophy and fasciculations; mixed signs suggest ALS or a cord lesion at and below the level.

Section 3Motor control and motor learning

Motor control is the ability to regulate the mechanisms essential to movement: posture, stability and the coordination of muscles across joints. Motor learning is a set of internal processes, associated with practice or experience, that produce a relatively permanent change in the capability for skilled movement. The difference matters on the exam. Performance is what you see during practice, and it can be inflated by guidance and frequent feedback or depressed by fatigue. Learning is inferred from retention (performance after a rest period without practice) and transfer (performance of a related task or in a new setting). Conditions that depress in-session performance often produce better learning.

Theories of motor control

Older reflex and hierarchical theories (cortex in charge, reflexes released when higher control is lost) underlie the neurofacilitation approaches. The current systems and dynamic systems theories hold that movement emerges from the interaction of the individual, the task and the environment, and that changing a control parameter such as speed can shift the pattern (walking becomes running). So train functional tasks in meaningful environments and manipulate task constraints, rather than expecting normalized tone alone to restore function. Open loop control runs a preprogrammed command without feedback (fast, ballistic movements); closed loop control uses ongoing sensory feedback to correct movement (slow, accurate tasks and early learning).

Stages of motor learning

Stage (Fitts and Posner)Learner characteristicsTherapist strategies
CognitiveFiguring out what to do; many errors, variable and inefficient performance; high attention demand; relies on visionClear demonstration and simple verbal instruction; frequent feedback, including knowledge of performance; blocked practice; guided movement; closed, quiet environment; break complex tasks into parts if needed
AssociativeRefining how to do it; fewer, more consistent errors; begins to detect own errors; increasing reliance on proprioceptionReduce and fade feedback; promote self assessment before giving feedback; shift toward random and variable practice; gradually add environmental challenge
AutonomousPerformance is automatic and consistent; little attention needed; can do a secondary task at the same timeMinimal, occasional feedback; random practice in varied, open environments; dual task training; community and real world settings

Gentile's two stage model starts with getting the idea of the movement, then moves to fixation (refining one consistent pattern for closed skills in a stable environment) or diversification (building adaptable patterns for open skills in a changing environment). Progressing from closed to open tasks, and from body stability to transport with manipulation, is a principled way to advance a program.

Practice schedules

VariableOptionsBest use
Order of tasksBlocked (repeat one task many times, AAA BBB CCC) versus random (mixed order, ABC BCA CAB)Blocked for initial acquisition and for patients with cognitive impairment; random for retention and transfer once the movement is understood (contextual interference effect)
Rest distributionMassed (practice time greater than rest) versus distributed (rest equal to or greater than practice)Distributed for patients with low endurance, poor motivation, fatigue (MS) or risk of injury; massed is efficient when fatigue is not a concern, as in constraint induced therapy
VariabilityConstant (same version every trial) versus variable (different heights, speeds, surfaces)Variable practice builds a generalized motor program and improves transfer to new situations
Task divisionWhole versus part practiceWhole for continuous skills such as walking; part for discrete, serial tasks with separable steps such as a wheelchair transfer (practice locking brakes, scooting, pivoting, then combine)
Physical versus mentalMental practice (cognitive rehearsal or motor imagery)Adds to physical practice; useful when fatigue, pain or safety limits repetitions
GuidanceManual or verbal guidance versus discovery learning with errors allowedGuidance early for safety and to convey the idea; withdraw it, because heavy guidance makes the learner dependent and reduces retention

The contextual interference effect explains why random practice beats blocked practice for learning. Switching tasks forces the learner to reconstruct the action plan on each trial and to compare tasks, which is effortful and lowers performance during the session but strengthens memory for each skill. Blocked practice lets the learner repeat the same plan from working memory, which looks good in the session and fades by the next visit.

Performance (higher is better) Acquisition (practice sessions) Retention test (after a delay, no practice) Blocked practice Random practice better learning drops off
Figure 5.4 The contextual interference effect. Blocked practice (red) looks better during the session; random practice (teal) retains better after a delay. Learning is judged on the retention and transfer tests, not on in-session performance.

Feedback

Intrinsic feedback comes from the learner's own senses (proprioception, vision, vestibular input). Extrinsic (augmented) feedback comes from an outside source: the therapist, a mirror, a video or a biofeedback device. Extrinsic feedback is described along several dimensions.

  • Knowledge of results (KR) is information about the outcome of the movement ("you walked 30 meters," "the cup reached the shelf"). Knowledge of performance (KP) is information about the movement pattern itself ("you kept your knee straight at heel strike"). KP is especially useful when a patient reaches the goal using an abnormal pattern; KR is enough when the outcome tells the learner what went wrong.
  • Concurrent feedback (during the movement) aids performance but breeds dependence; terminal feedback comes after. A short delay while the learner estimates their own error improves retention.
  • Frequency. Feedback after every trial helps early acquisition but weakens retention (the guidance hypothesis). Better learning follows faded feedback (high frequency early, decreasing later), bandwidth feedback (given only when error exceeds a set range), summary feedback (after a set of trials, summarizing all) and average feedback (the mean of a set of trials).
  • Focus of attention. An external focus on the effect of the movement ("push the floor away") generally produces better learning than an internal focus on body parts ("straighten your knee").
Board tip. When a question asks which feedback schedule best promotes long term retention, choose the reduced option: faded, bandwidth or summary feedback, KR rather than continuous concurrent KP, and random rather than blocked practice. When it asks what to do on day one with a confused patient learning a new transfer, choose the supportive option: demonstration, guidance, blocked practice and frequent feedback.

Principles of experience dependent neuroplasticity

Recovery after a lesion combines spontaneous recovery (resolving edema, reperfusion of the penumbra, reversal of diaschisis) and experience dependent plasticity (synaptogenesis, sprouting, unmasking of latent pathways, cortical map reorganization). Regaining the original pattern is restitution; reaching the goal another way is compensation. A widely cited synthesis lists ten principles.

PrincipleMeaning for treatment
Use it or lose itFunctions not driven will degrade; avoid prolonged nonuse of the affected limb
Use it and improve itTraining that drives a function enhances it
SpecificityThe nature of the training determines the plasticity; practice the skill you want
Repetition mattersLasting change needs many repetitions, often hundreds per session, far above typical clinical doses
Intensity mattersSufficient intensity (effort, heart rate, challenge) is needed to induce change
Time mattersDifferent forms of plasticity occur at different times after injury; there may be windows of heightened responsiveness, while very early, very intense use can sometimes worsen a lesion in animal models
Salience mattersTraining must be meaningful and rewarding to the patient
Age mattersPlasticity occurs more readily in younger brains, but older adults still respond
TransferencePlasticity from one training experience can enhance related behaviors
InterferencePlasticity in one direction can block other learning, for example a learned compensatory pattern that interferes with recovery of the normal one

Learned nonuse is a classic illustration of interference and of use it or lose it: after a stroke, early failed attempts to use the affected arm are punished, successful use of the other arm is rewarded, and the patient stops trying the affected arm even after motor capacity returns.

Case. A 74 year old man two weeks after a left MCA stroke has mild expressive aphasia and moderate right hemiparesis. He is learning to transfer from wheelchair to bed. He forgets to lock the brakes and pushes up from the armrest only after several cues. His daughter asks how to help him practice at home.
Reasoning: He is in the cognitive stage of learning a serial task, and aphasia limits verbal instruction. Best choices: demonstrate and use short, consistent cues or gestures; use part practice for the trouble steps (brakes, scoot forward, feet back) then combine them into the whole transfer; use blocked practice and frequent feedback at first; and keep the environment consistent. Teach the daughter the same sequence of cues. Random practice with summary feedback is the right goal later, but it is the wrong choice now because errors in a transfer are a fall risk. Safety point: practice with a gait belt and a locked chair until he reliably initiates brake locking himself.
Key point

Learning is shown by retention and transfer, not by performance in the session. Match the practice and feedback to the stage: early learners need demonstration, guidance, blocked practice and frequent feedback; later learners need random and variable practice, faded or summary feedback and real world challenge. Plasticity is driven by specific, repetitive, intense and meaningful practice, and nonuse or poor compensatory habits work against recovery.

Section 4Balance and fall risk

Balance (postural control) is the ability to keep the body's center of mass over its base of support. It has a static component (holding a posture), a dynamic component (controlling the center of mass during movement), a reactive component (recovering from an unexpected perturbation) and an anticipatory component (preparing the body before a voluntary movement, such as activating the trunk before reaching).

The systems model of balance

Balance emerges from interacting systems, any of which can be the limiting factor: sensory input (somatosensory input dominates on a firm surface in good light; vision reports head position relative to the surroundings; vestibular input reports head position relative to gravity and resolves conflicts when the other two are inaccurate), central integration that reweights inputs, motor output (ankle and hip strength, ankle dorsiflexion range, timing of responses), cognition (attention and dual tasking) and biomechanics (base of support and limits of stability).

Postural strategies

StrategyWhen it is usedMuscle activationNotes
AnkleSmall, slow perturbations on a firm, broad surfaceDistal to proximal (for a backward sway: tibialis anterior, quadriceps, abdominals)Needs intact ankle range, strength and foot sensation; body moves as an inverted pendulum about the ankle
HipLarger or faster perturbations, or a narrow or compliant surface (beam, foam)Proximal to distal (hip and trunk muscles first)Moves the center of mass by flexing or extending at the hips; overused in older adults with weak ankles
SteppingPerturbation pushes the center of mass beyond the base of supportRapid step or reach to create a new baseSlow or absent steps predict falls; train protective stepping in all directions

Sensory organization testing

The Sensory Organization Test (SOT), performed on computerized dynamic posturography, measures sway under six conditions that systematically remove or distort visual and somatosensory input. Sway referencing means the platform or visual surround tilts in step with the patient's sway, so the input is present but inaccurate. The modified Clinical Test of Sensory Interaction in Balance (mCTSIB) is the clinical version: the patient stands for 30 seconds on a firm surface with eyes open, firm with eyes closed, foam with eyes open, and foam with eyes closed. Standing on foam degrades somatosensory input; closing the eyes removes vision.

Eyes openEyes closedSway referencedvision Fixedsupport Swayreferencedsupport 123 456 VisionSomatosensoryVestibular SomatosensoryVestibular SomatosensoryVestibular VisionVestibular Vestibular only Vestibular only Each cell lists the inputs that remain accurate.
Figure 5.5 The six conditions of the Sensory Organization Test. Patients who rely on vision fall in conditions 2, 3, 5 and 6; patients who rely on somatosensation fall in 4, 5 and 6; patients with vestibular loss fall in 5 and 6. The clinical mCTSIB approximates conditions 1, 2, 4 and 5 using foam.

Standardized balance and fall risk tests

Choose a test that matches the patient's level and the question being asked. Cutoffs vary by study; these are the values usually taught for community dwelling older adults.

TestWhat it involvesScoringUsual fall risk cutoff
Berg Balance Scale14 static and dynamic tasks (sit to stand, standing unsupported, reaching, turning 360 degrees, stool stepping, tandem and single leg stance)0 to 4 each, maximum 56Below 45 indicates increased fall risk; ceiling effect in higher level patients
Timed Up and GoRise from a chair, walk 3 meters, turn, return, sitSeconds13.5 seconds or more (community older adults); 12 seconds or more is a common screening threshold; adding a cognitive or manual task (TUG cognitive) detects dual task deficits
Dynamic Gait Index8 gait tasks: speed changes, head turns, pivot, obstacles, stairs0 to 3 each, maximum 2419 or less
Functional Gait Assessment10 items, a revision of the DGI adding narrow base, eyes closed and backward walkingMaximum 3022 or less
Functional reachMaximal forward reach in standing without steppingInches or centimetersLess than 6 inches suggests high risk (about four times); 6 to 10 inches moderate (about twice)
Tinetti POMABalance and gait subscalesMaximum 2818 or less high risk; 19 to 23 moderate risk
Five Times Sit to StandFive chair rises as fast as possible, arms crossedSecondsMore than about 12 to 15 seconds, depending on the study
Four Square Step TestStep forward, sideways and backward over canes in a cross patternSecondsMore than 15 seconds in older adults
Activities specific Balance Confidence (ABC)Self rated confidence in 16 activities0 to 100 percentBelow 67 percent suggests fall risk
Mini-BESTest14 items covering anticipatory, reactive, sensory and dynamic gaitMaximum 28Cutoffs vary by diagnosis; strong for Parkinson disease

Gait speed as a vital sign

Comfortable gait speed, usually measured with the 10 Meter Walk Test over the middle 6 meters to exclude acceleration and deceleration, is fast, reliable and predictive of falls, hospitalization, discharge destination and survival. Classic categories from stroke research: below 0.4 m/s suggests a household ambulator, 0.4 to 0.8 m/s a limited community ambulator, and above 0.8 m/s a community ambulator. A speed below about 1.0 m/s in older adults flags increased risk of adverse outcomes, and crossing a street safely at a timed signal typically requires about 1.2 m/s or more. A change of about 0.1 m/s is commonly cited as a meaningful change.

Householdambulator Limited communityambulator Community ambulator 00.20.40.60.81.01.21.4 Comfortable gait speed (m/s), 10 Meter Walk Test Below 1.0: higher risk of falls and poor outcomes (older adults) About 1.2 or more: street crossing
Figure 5.6 Gait speed categories commonly used on the exam. The 0.4 and 0.8 m/s thresholds come from stroke studies of household and community walking; about 0.1 m/s is a meaningful change for most populations.

Fall risk factors and prevention

Falls are multifactorial. Intrinsic risk factors include a history of falls (the strongest single predictor), lower extremity weakness, gait and balance impairment, visual impairment, peripheral neuropathy, cognitive impairment, depression, orthostatic hypotension, urinary urgency and incontinence, foot problems, and fear of falling. Medications are a major modifiable factor: psychoactive drugs (sedatives, hypnotics, antidepressants, antipsychotics), antihypertensives, opioids, and polypharmacy (often defined as four or more medications). Extrinsic factors include poor lighting, loose rugs, clutter, lack of grab bars, unsafe footwear and stairs without rails.

Prevention follows a screen, assess, intervene sequence: ask about falls in the past year, unsteadiness and fear of falling; assess gait, strength, balance, orthostatic blood pressure, vision, feet and home hazards, and request a medication review by the prescriber. The most effective single intervention is progressive, challenging balance exercise, about three hours per week over months, usually with strengthening (structured home programs and tai chi both reduce falls). Add home modification, footwear, vision correction, management of orthostatic hypotension and vitamin D for those who are deficient. Walking alone, without balance challenge, does not reliably prevent falls.

Board tip. Know which test fits the question. A frail patient who cannot walk without an assistive device: Berg (static and transitional tasks). A high functioning patient or one with vestibular complaints: DGI or FGA (head turns and dynamic gait). A quick screen in a busy clinic: TUG. Fear of falling: ABC scale. Fall risk "in Parkinson disease": the Mini-BESTest. A sensory question: mCTSIB or SOT.
Case. An 81 year old woman with type 2 diabetes is seen in home health after a fall in the bathroom at night. Berg score is 41/56, TUG is 16 seconds, she cannot feel the 10 gram monofilament on either foot, and she falls toward the floor when asked to stand with feet together and eyes closed. Her blood pressure falls from 138/76 supine to 112/68 after three minutes standing. She takes a sleeping pill.
Reasoning: Several risk factors interact: loss of protective sensation means she relies on vision, which explains the positive Romberg and the nighttime fall in the dark; she meets the definition of orthostatic hypotension (a drop of 20 mmHg or more systolic or 10 mmHg or more diastolic within three minutes); and a hypnotic adds sedation. Berg below 45 and TUG above 13.5 seconds confirm high risk. The best plan is multifactorial: progressive balance and strength training emphasizing visual and vestibular use, night lights and grab bars, slow positional changes, and communication with her physician about the orthostatic drop and the sedative. The tempting single answer "prescribe a walker" is incomplete and does not address the causes. Safety point: report the orthostatic hypotension and the medication concern to the prescriber; do not adjust medications yourself.
Key point

Balance depends on sensory input (somatosensory, visual, vestibular), central integration, motor output and cognition, so a fall has more than one cause. Use the SOT or mCTSIB to identify which sense the patient depends on, standardized tests with known cutoffs (Berg below 45, TUG 13.5 seconds or more, DGI 19 or less, FGA 22 or less) to quantify risk, and gait speed as a functional vital sign. Prevention is multifactorial, with progressive, challenging balance exercise as its core.

Section 5Neurologic outcome measures and interventions

Patients improve the tasks they practice, with enough repetitions, at enough intensity, in a meaningful context. The exam expects you to match outcome measures to questions and to know who is eligible for the highest evidence interventions and how they are dosed.

Choosing outcome measures

Classify measures by the ICF: body function (Fugl-Meyer, Modified Ashworth), activity (10 Meter Walk Test, Berg, ARAT, FIM) and participation (community mobility). Include at least one activity measure, because functional goals are written at that level. The minimal detectable change exceeds measurement error; the minimal clinically important difference is the smallest change patients perceive as meaningful.

MeasureWhat it measuresScoring and key facts
Fugl-Meyer AssessmentMotor recovery after stroke, based on the recovery sequence (reflexes, synergies, out of synergy, isolated movement)Motor total 100 (upper extremity 66, lower extremity 34); also sensation, balance, joint range and pain sections
Action Research Arm TestUpper extremity activity: grasp, grip, pinch, gross movement19 items, maximum 57
Box and Block TestGross manual dexterityBlocks moved in 60 seconds, each hand
Nine Hole Peg TestFine dexteritySeconds to place and remove 9 pegs; common in MS
10 Meter Walk TestGait speedComfortable and fast speeds; see Section 4
Six Minute Walk TestWalking enduranceDistance; stop for chest pain, severe dyspnea, pallor, leg cramps or staggering
Functional Independence MeasureBurden of care across 18 items (13 motor, 5 cognitive)Each item 1 (total assist) to 7 (complete independence); total 18 to 126
NIH Stroke ScaleAcute stroke severity0 to 42; higher is worse

Task specific training

Task specific (task oriented) training means practicing whole, functional tasks (or meaningful parts of them) in a realistic context, with many repetitions, progressive difficulty and feedback. Examples include repeated sit to stand from different seat heights, reaching for objects of different sizes at different distances, and stepping practice over and around obstacles. It exploits specificity. Strengthening still helps when weakness limits the task, and progressive resistance training after stroke does not worsen spasticity.

Walking recovery: intensity and stepping practice

The clinical practice guideline on improving locomotor function in chronic (more than six months) stroke, spinal cord injury and brain injury recommends moderate to high intensity walking training as the core intervention: large amounts of stepping practice at about 60 to 80 percent of heart rate reserve or 70 to 85 percent of age predicted maximum heart rate, or a rating of perceived exertion of roughly 15 to 17 on the 6 to 20 scale. Train on a treadmill or overground with variable tasks (speeds, slopes, surfaces, obstacles). Balance training without walking, seated exercise and robotic gait training should not replace stepping practice when walking is the goal. Beta blockers blunt heart rate, so use perceived exertion in those patients.

Body weight supported treadmill training (BWSTT) unloads part of body weight with a harness so patients who cannot yet walk independently can step safely and repetitively. Start with no more than about 30 to 40 percent support, reduce it as loading improves, and progress speed toward normal. A large trial in subacute stroke found BWSTT no better than an equal dose of progressive home exercise: the active ingredient is the amount and intensity of stepping, not the device.

Constraint induced movement therapy

Constraint induced movement therapy (CIMT) reverses learned nonuse by restraining the less affected upper extremity and intensively training the more affected one. The traditional protocol has three components: restraint of the less affected hand in a mitt for about 90 percent of waking hours; intensive training of the more affected arm for about six hours per day for two weeks using shaping (tasks progressed in small steps, with immediate feedback on improvement) and repetitive task practice; and a transfer package of behavioral strategies (daily activity log, home practice, problem solving) to carry use into daily life. Modified CIMT (mCIMT) uses shorter daily training (for example, a few hours) over more weeks with restraint for part of the day and is more practical in most settings.

Eligibility is essential: the classic minimum motor criteria are at least 20 degrees of active wrist extension and 10 degrees of active extension at the thumb and at least two fingers (metacarpophalangeal and interphalangeal joints). Patients also need safe balance while wearing the mitt and enough cognition to participate. Very high dose CIMT in the first days after stroke has not shown added benefit.

Patient goal? Walking Use of the affected arm Moderate to high intensity stepping(70 to 85% HRmax, RPE 15 to 17),treadmill or overground, BWS if needed Active wrist ext 20°and finger ext 10°? Yes: CIMTor modified CIMT No: task practicewith NMES or FES,mirror therapy,assisted repetitions Foot drop: AFO or peroneal FEStimed to swing phase
Figure 5.7 A simplified decision path for choosing high evidence interventions. Every branch shares the same active ingredients: task specific practice, many repetitions and adequate intensity. Screen vital signs and safety before every progression.

Electrical stimulation in neurologic rehabilitation

Neuromuscular electrical stimulation (NMES) produces muscle contraction by depolarizing the motor nerve. When the contraction is timed to accomplish a functional task (dorsiflexion during swing, grasp and release, cycling) it is called functional electrical stimulation (FES). Common uses are listed below.

  • Foot drop (stroke, MS, incomplete SCI): a peroneal nerve stimulator triggered by a heel switch or tilt sensor fires the dorsiflexors during swing; outcomes are similar to an AFO, but it needs an intact peripheral nerve.
  • Shoulder subluxation after stroke: stimulate the supraspinatus and posterior deltoid, ideally early in the flaccid stage.
  • Hand recovery: wrist and finger extensor stimulation with task practice; EMG triggered stimulation adds a volitional component.
  • FES cycling after SCI: preserves muscle and fitness; watch for autonomic dysreflexia at T6 and above.
ParameterTypical setting for motor NMES and FESReason
WaveformBiphasic pulsed current (symmetric or asymmetric)Comfort and no net charge buildup under electrodes
FrequencyAbout 30 to 50 pulses per second (often 35 for functional use)Produces a fused (tetanic) contraction; higher frequencies fatigue faster
Pulse durationAbout 200 to 350 microseconds for large muscles, shorter for small musclesRecruits motor fibers comfortably
AmplitudeTo a visible, functional contraction (for strengthening, as high as tolerated)Force depends on the number of motor units recruited
On:off timeStart about 1:3 to 1:5; progress toward 1:1 as tolerance improvesLimits fatigue in weak, deconditioned muscle
RampAbout 1 to 2 seconds or more; longer if spasticity in the antagonistComfort, and avoids triggering a stretch reflex in the antagonist

Contraindications to electrical stimulation include a demand type cardiac pacemaker or implanted defibrillator (avoid stimulation near it and generally avoid stimulation in these patients unless cleared), placement over the carotid sinus or anterior neck, over a known or suspected deep vein thrombosis or thrombophlebitis, over the trunk or pelvis during pregnancy, over an area of active or suspected malignancy, and over the eyes. Precautions include impaired sensation, inability to communicate discomfort, cardiac disease, seizure disorder, open wounds or damaged skin, and patients at risk of autonomic dysreflexia. Check the skin before and after each session.

Other options include mirror therapy (a visual illusion of the affected limb moving normally), mental practice, robotic and virtual reality devices that add repetitions, and bilateral arm training for patients who do not meet CIMT criteria. Older facilitation approaches such as NDT and PNF have not proven superior to task specific training.

Board tip. If a CIMT candidate question gives you range of motion, check the numbers: active wrist extension at least 20 degrees and finger extension at least 10 degrees. A patient with a flaccid hand is not a candidate. If a walking question asks for the most effective intervention in chronic stroke, choose high intensity, variable stepping practice over balance board training, seated exercise or a robotic device.
Case. A 58 year old woman eight months after a right MCA stroke walks with a cane at 0.52 m/s and wants to walk to her neighborhood store. She has foot drop on the left with a dorsiflexion catch on the Modified Tardieu, her resting heart rate is 72, she is not taking beta blockers, and her blood pressure is controlled. Her left hand has 30 degrees of active wrist extension and 15 degrees of finger extension.
Reasoning: Her speed places her in limited community ambulation (0.4 to 0.8 m/s); the goal requires community ambulation above 0.8 m/s. The best primary intervention for walking is moderate to high intensity stepping practice on the treadmill and overground (about 70 to 85 percent of age predicted maximal heart rate, roughly 113 to 138 beats per minute for a 58 year old) with variable tasks, plus a peroneal FES device or AFO for foot drop. Her hand meets the motor criteria, so modified CIMT is an appropriate addition for the arm. Wrong choices: low intensity balance exercises alone, or waiting for spasticity to be "normalized" before walking. Safety point: monitor blood pressure and symptoms during high intensity work and stop for chest pain, dizziness, severe dyspnea or a hypertensive response.
Key point

Choose outcome measures at the activity level for goals and know their scales (Fugl-Meyer 100 motor, ARAT 57, FIM 18 to 126). The highest value interventions share the same ingredients: task specific practice, many repetitions and adequate intensity. For walking, that means moderate to high intensity stepping practice; for the arm, CIMT when the patient has at least 20 degrees of active wrist extension and 10 degrees of finger extension; and FES timed to function for foot drop, subluxation and paralyzed muscles, with its contraindications respected.

The chapter in one breath

  • The homunculus puts the leg medially (ACA) and the face and arm laterally (MCA); Broca and Wernicke areas are in the dominant hemisphere, and neglect follows nondominant parietal lesions.
  • The corticospinal tract crosses at the pyramids, the dorsal columns cross in the medulla and the spinothalamic tract crosses within one or two segments; these levels predict which side is affected.
  • Cerebellar lesions cause ipsilateral ataxia, dysmetria and intention tremor without weakness; basal ganglia lesions cause hypokinetic or hyperkinetic disorders.
  • Crossed findings (ipsilateral cranial nerve, contralateral body) localize to the brainstem and the posterior circulation; new ones need emergency referral.
  • Spasticity is velocity dependent and graded with the Modified Ashworth Scale; rigidity is not velocity dependent.
  • UMN signs: spasticity, hyperreflexia, clonus, Babinski; LMN signs: flaccidity, hyporeflexia, atrophy, fasciculations.
  • Learning is measured by retention and transfer; random practice and reduced feedback improve learning even though they lower in-session performance.
  • Match strategies to the cognitive, associative and autonomous stages, and apply the principles of experience dependent plasticity: specificity, repetition, intensity and salience.
  • Balance uses somatosensory, visual and vestibular input; SOT conditions 5 and 6 leave only vestibular input.
  • Usual fall risk cutoffs: Berg below 45, TUG 13.5 seconds or more, DGI 19 or less, FGA 22 or less, ABC below 67 percent; gait speed below 0.4, 0.4 to 0.8 and above 0.8 m/s for household, limited and community walking.
  • For walking, use moderate to high intensity stepping practice; for the arm, CIMT needs 20 degrees of wrist and 10 degrees of finger extension; FES works only with an intact peripheral nerve.

Words worth knowing

TermWhat it means
AnosognosiaUnawareness or denial of one's own deficit, typically after a nondominant parietal lesion; a major safety concern.
ApraxiaInability to perform a learned, purposeful movement despite intact strength, sensation, coordination and comprehension.
Blocked practiceRepeating one task many times before moving to the next; good for early acquisition, weaker for retention.
ClonusRhythmic, involuntary oscillating contractions in response to a quick sustained stretch; an upper motor neuron sign.
Constraint induced movement therapyRestraint of the less affected arm plus intensive shaping practice of the more affected arm to overcome learned nonuse.
Contextual interferenceThe learning benefit of practicing several tasks in a mixed order, which disrupts performance but improves retention.
Crossed findingsCranial nerve signs on one side with body signs on the other; localizes to the brainstem.
DysdiadochokinesiaImpaired ability to perform rapid alternating movements; a cerebellar sign.
DysmetriaInability to judge the distance or range of a movement, causing overshoot or undershoot of a target.
Functional electrical stimulationElectrical stimulation timed to produce a functional movement, such as dorsiflexion during the swing phase of gait.
Intention tremorTremor that appears or worsens as a limb approaches a target; a cerebellar sign.
Knowledge of performanceFeedback about the quality or pattern of the movement itself.
Knowledge of resultsFeedback about the outcome of the movement relative to the goal.
Modified Ashworth ScaleA six level ordinal scale (0, 1, 1+, 2, 3, 4) that grades resistance to passive stretch in spasticity.
NeuroplasticityThe capacity of the nervous system to change its structure and function in response to experience or injury.
Random practicePracticing several tasks in a varied order; improves retention and transfer.
RigidityIncreased resistance to passive movement that is not velocity dependent and affects agonists and antagonists equally.
Romberg testStanding with feet together, eyes open then closed; loss of balance only with the eyes closed points to a proprioceptive or vestibular deficit.
ShapingProgressing a task in small, achievable steps with immediate feedback on improvement; a core element of CIMT.
SpasticityVelocity dependent increase in resistance to passive stretch due to hyperexcitable stretch reflexes after an upper motor neuron lesion.

Check yourself

A patient has weakness and sensory loss of the left leg much greater than the left arm, plus urinary incontinence and slowed responses. Which artery is most likely involved?
Answer. The right anterior cerebral artery. The ACA supplies the medial hemisphere where the leg area of the homunculus lies, and the medial frontal lobe controls bladder inhibition and initiation. Signs are contralateral to the lesion.
After a right spinal cord hemisection at T8, which deficits are expected on each side below the lesion?
Answer. Right side: weakness (lateral corticospinal tract) and loss of vibration and proprioception (dorsal columns, which ascend ipsilaterally). Left side: loss of pain and temperature beginning one to two segments below the lesion (spinothalamic fibers have already crossed).
A patient protrudes the tongue and it deviates to the left. Where is the lesion if the problem is in the nerve itself?
Answer. The left hypoglossal nerve (CN XII). The intact right genioglossus pushes the tongue toward the weak side, so with a lower motor neuron lesion the tongue deviates toward the lesion.
During passive elbow extension, a therapist feels a catch followed by minimal resistance through less than half of the remaining range. What is the Modified Ashworth grade?
Answer. 1+. Grade 1 is a catch and release or minimal resistance only at end range; grade 2 is a marked increase through most of the range with the limb still easily moved.
A patient with right sided incoordination shows intention tremor on finger to nose and dysdiadochokinesia, with normal strength. Which side and structure are most likely involved?
Answer. The right cerebellar hemisphere. Cerebellar signs are ipsilateral to the lesion, and the cerebellum affects coordination, not strength.
A patient walks well on parallel bar practice with continuous verbal correction but performs poorly when tested the next day. What change to the feedback schedule would best improve retention?
Answer. Reduce and delay feedback: use faded, bandwidth or summary feedback and ask the patient to self assess first. Continuous concurrent feedback creates dependence (the guidance hypothesis) and depresses retention.
A patient keeps her balance in SOT conditions 1 to 4 but falls in conditions 5 and 6. What does this pattern suggest?
Answer. Vestibular dysfunction. Conditions 5 and 6 remove accurate vision and somatosensation, leaving only vestibular input.
A community dwelling 78 year old scores 47/56 on the Berg and 15 seconds on the TUG. How should these results be interpreted?
Answer. The Berg is above the usual cutoff of 45, but the TUG of 15 seconds exceeds 13.5 seconds, so fall risk is increased. The Berg has a ceiling effect in higher functioning people, which is why a dynamic test such as the TUG, DGI or FGA adds information.
Which minimum active motion criteria are traditionally required for constraint induced movement therapy?
Answer. At least 20 degrees of active wrist extension and 10 degrees of active extension of the thumb and at least two fingers, along with adequate balance and safety while wearing the mitt.
A patient has foot drop from a peroneal nerve laceration with denervation of the anterior compartment. Is a peroneal FES device appropriate?
Answer. No. FES depolarizes the motor nerve and requires an intact lower motor neuron. A denervated muscle does not respond to standard NMES parameters; an ankle foot orthosis is the better choice for foot clearance.
Chapter 6 · Neuromuscular

Neuromuscular: Stroke, Brain Injury and Spinal Cord Injury

Stroke, traumatic brain injury and spinal cord injury fill a large share of neurologic questions on the licensing exam, and they share one theme: the location of the lesion predicts the deficits, the prognosis and the dangers. This chapter teaches you to read a stroke syndrome from its artery, stage motor recovery, manage the agitated patient with brain injury, classify a spinal cord injury and predict function from its level, and recognize the medical emergencies, such as autonomic dysreflexia, that you must act on immediately.

By the end of this chapter you can

  • Match the deficits of MCA, ACA, PCA, vertebrobasilar and lacunar strokes to their arteries, including the aphasias, neglect and pusher syndrome.
  • Describe Brunnstrom stages and the upper and lower extremity flexion and extension synergies.
  • Apply positioning, hemiplegic shoulder care, gait training and acute care blood pressure precautions after stroke.
  • Use the Glasgow Coma Scale and Rancho Los Amigos levels to classify brain injury and plan behavior management.
  • Apply graded return to learn and return to sport after concussion and recognize red flags.
  • Classify a spinal cord injury with the key muscles, key sensory points and the ASIA Impairment Scale, and identify the incomplete cord syndromes.
  • Predict functional outcomes by level from C1 to S5, including tenodesis.
  • Recognize and manage autonomic dysreflexia, orthostatic hypotension, heterotopic ossification, pressure injury and spasticity.

Section 1Stroke syndromes by artery

A stroke (cerebrovascular accident) is the sudden onset of a focal neurologic deficit from interrupted blood flow lasting more than 24 hours or showing infarction on imaging. About 85 to 87 percent are ischemic (thrombotic, embolic often from atrial fibrillation, or small vessel lacunar disease). The rest are hemorrhagic: intracerebral hemorrhage, usually from chronic hypertension, and subarachnoid hemorrhage, usually from a ruptured aneurysm and announced by a sudden "worst headache of my life." A transient ischemic attack (TIA) is a temporary episode without infarction; it is a warning, and about one in ten patients has a stroke within the following weeks to months, so new or recurring symptoms require emergency referral. The public warning sign BE FAST covers balance loss, eye (vision) changes, face drooping, arm weakness, speech difficulty and time to call emergency services. Major modifiable risk factors are hypertension (the most important), atrial fibrillation, diabetes, smoking, hyperlipidemia, obesity and physical inactivity.

Arterial syndromes

Each artery supplies a predictable territory (Chapter 5), so each stroke produces a predictable cluster. Deficits from hemispheric strokes appear on the side of the body opposite the lesion. The hemisphere matters as much as the artery: a dominant (usually left) hemisphere lesion causes language deficits; a nondominant (usually right) lesion causes neglect and visuospatial problems.

ArteryMotor and sensoryOther key findings
Middle cerebral (most common)Contralateral hemiparesis and sensory loss, face and arm greater than legContralateral homonymous hemianopia; eyes deviate toward the lesion; dominant side: aphasia (Broca, Wernicke or global); nondominant side: neglect, anosognosia, visuospatial deficits, impulsivity
Anterior cerebralContralateral hemiparesis and sensory loss, leg greater than arm, face sparedUrinary incontinence; abulia (lack of initiative), slowed responses, perseveration; grasp reflex; apraxia; personality change
Posterior cerebralUsually little weakness; contralateral sensory loss if the thalamus is involvedContralateral homonymous hemianopia with macular sparing; visual agnosia, prosopagnosia; alexia without agraphia (dominant); memory loss; thalamic pain syndrome (severe burning pain on the contralateral body)
VertebrobasilarCrossed signs: ipsilateral cranial nerve deficit, contralateral body weakness or sensory loss; may be bilateralVertigo, nystagmus, diplopia, dysarthria, dysphagia, ataxia, drop attacks, decreased consciousness
Lateral medullary (Wallenberg; vertebral or PICA)Ipsilateral face and contralateral body loss of pain and temperature; no major weaknessIpsilateral Horner syndrome and limb ataxia, dysphagia, hoarseness, vertigo, nystagmus
Locked in syndrome (basilar, ventral pons)Quadriplegia, anarthriaConsciousness and vertical eye movements and blinking preserved; communicate by eye movement
Lacunar (small penetrating arteries)Pure motor (posterior limb internal capsule), pure sensory (thalamus), ataxic hemiparesis, dysarthria clumsy hand, sensorimotorNo cortical signs: no aphasia, neglect or field cut; generally good recovery
Anterior (frontal) Posterior (occipital) ACA: medial frontal, parietal Leg and foot, bladder, initiation MCA: lateral convexity Face and arm, language, attention Deep MCA branches Internal capsule, basal ganglia PCA: occipital, thalamus Vision, memory, thalamic sensation
Figure 6.1 Simplified arterial territories in a horizontal slice, anterior at the top. The ACA runs along the medial surface where the leg area lies; the MCA covers the lateral convexity, and its deep lenticulostriate branches supply the internal capsule (pure motor lacunar strokes); the PCA supplies the occipital lobe and thalamus.

Aphasia

Aphasia is an acquired disorder of language, distinct from dysarthria (a motor speech disorder of articulation with intact language). Classify aphasia with three questions: is speech fluent, is comprehension intact, and can the patient repeat?

TypeFluencyComprehensionRepetitionLesion and notes
Broca (expressive)Nonfluent, effortful, telegraphicRelatively intactImpairedDominant inferior frontal gyrus; patient aware and frustrated; often with right hemiparesis (arm and face)
Wernicke (receptive)Fluent but empty, paraphasias, jargonImpairedImpairedDominant posterior superior temporal gyrus; often unaware of errors; may have little weakness
GlobalNonfluentImpairedImpairedLarge dominant MCA stroke; usually dense hemiplegia
ConductionFluentIntactImpairedArcuate fasciculus
Transcortical motor or sensoryNonfluent or fluentIntact or impairedIntactWatershed areas around the language center; repetition spared
AnomicFluentIntactIntactWord finding difficulty only; common in recovery

Communication strategies: for Broca aphasia, ask yes or no questions, allow time, and offer gestures or picture boards. For Wernicke aphasia, use short, simple sentences with demonstration and gestures, and do not rely on the patient's verbal report of understanding.

Neglect and pusher syndrome

Unilateral spatial neglect is failure to attend to the side of space and body opposite the lesion, most often left neglect after a right parietal stroke. It differs from hemianopia: a patient with hemianopia alone knows the field is missing and turns the head to compensate, while a patient with neglect does not. Neglect is tested with line bisection, cancellation tasks and copying drawings, and it predicts poor function and falls. Treatment includes visual scanning training, anchoring cues on the neglected side, prism adaptation, mirror therapy and trunk rotation toward the neglected side. Early on, place the call light and key items on the intact side for safety while training attention toward the neglected side during therapy.

Pusher syndrome (contraversive pushing) is a disorder of perceived body verticality, usually from a lesion of the posterolateral thalamus. The patient perceives upright as tilted toward the less affected side, so they actively push with the less affected arm and leg toward the hemiparetic side and resist any attempt to correct the posture toward midline, which causes falls toward the weak side. It is more common with right hemisphere lesions and often coexists with neglect. Treatment uses vision, which is intact: show the patient vertical references (a door frame, the therapist's body, a mirror), have them reach toward objects on the less affected side so that weight shifts over the midline, and seat or stand them with the less affected side next to a wall so that pushing is futile. Avoid pulling the patient upright against their push; that increases resistance. The prognosis for resolution within months is good.

Board tip. Separate the look alikes. A left MCA stroke patient is often cautious, slow and aware of deficits, so give many demonstrations and avoid long verbal instructions. A right MCA stroke patient is often impulsive, overestimates ability and ignores the left side, so give verbal cues, slow the pace and supervise closely for safety. Pusher syndrome pushes toward the weak side; ordinary hemiplegic patients lean or fall toward the weak side without pushing.
Case. A 71 year old right handed woman on day three after a stroke sits with her trunk tilted to the left. When the therapist tries to bring her upright, she pushes forcefully with her right hand on the mat and extends her right leg, resisting. She does not look to the left, and when shaving her face in a picture task she draws only the right side. Her left arm and leg are weak.
Reasoning: Left weakness and left neglect indicate a right hemisphere stroke; active pushing with the nonparetic limbs toward the paretic side and resistance to correction is pusher syndrome. The best initial strategy uses visual feedback of vertical and functional reaching to the right so that she moves her weight toward midline herself. The tempting choice, manually pushing her trunk back to midline, triggers more pushing. Weight shifting toward the left is the wrong direction. Safety point: she will fall to the left; guard on the left, use a gait belt and lock the wheelchair, and place items on her right side outside therapy until neglect improves.
Key point

The artery predicts the pattern: MCA strokes hit the face and arm with aphasia (dominant) or neglect (nondominant); ACA strokes hit the leg with behavioral and bladder changes; PCA strokes cause visual field loss and thalamic pain; vertebrobasilar strokes cause crossed signs, vertigo and ataxia; lacunar strokes are pure motor or pure sensory without cortical signs. Classify aphasia by fluency, comprehension and repetition, and treat pusher syndrome with vision of vertical, not force.

Section 2Stroke recovery and rehabilitation

Most motor recovery after stroke occurs in the first three months, with the steepest gains in the first weeks, but meaningful improvement continues for many months and responds to training even years later. Recovery tends to proceed from proximal to distal and from mass patterns to isolated movement. Early return of some voluntary movement, particularly finger extension and shoulder abduction in the first days, predicts good upper extremity recovery; a flaccid arm with no movement at four weeks predicts poor recovery of hand function.

Brunnstrom stages and synergies

After an upper motor neuron lesion, voluntary movement often first returns within stereotyped mass patterns called synergies, in which the patient cannot move one joint without the others in the pattern. Brunnstrom described the sequence of recovery in stages; patients may stop at any stage.

StageToneMovement
1FlaccidityNo voluntary movement
2Spasticity beginsBasic synergy components appear, often as associated reactions
3Spasticity peaksVoluntary movement only within synergy
4Spasticity declinesSome movements out of synergy (for example, hand behind back, elbow flexed 90 degrees with forearm pronation and supination)
5Spasticity further declinesMore complex combinations out of synergy (shoulder abduction with elbow extended, shoulder flexion to 180 degrees)
6Spasticity disappearsIsolated joint movements with near normal coordination
7NormalNormal motor function (some versions combine this with stage 6)
SegmentUE flexion synergyUE extension synergyLE flexion synergyLE extension synergy
ProximalScapular retraction and elevation; shoulder abduction and external rotationScapular protraction; shoulder adduction and internal rotationHip flexion, abduction, external rotationHip extension, adduction, internal rotation
MiddleElbow flexion (strongest component)Elbow extensionKnee flexionKnee extension
DistalForearm supination; wrist and finger flexionForearm pronation (strongest with shoulder adduction); wrist extension, finger flexionAnkle dorsiflexion and inversion; toe extensionAnkle plantarflexion and inversion; toe flexion

The typical resting posture of the hemiplegic arm (shoulder adducted and internally rotated, elbow flexed, forearm pronated, wrist and fingers flexed) mixes the strongest components of both synergies; the leg is typically held in extension synergy (hip adduction, knee extension, plantarflexion and inversion), which supports standing but causes toe drag and circumduction in swing.

1234567 FlaccidSynergiesemerge Moves insynergy Some outof synergy Complexcombos Isolatedmovement Normal Spasticity peaks Bars: voluntary motor control Dashed line: spasticity
Figure 6.2 Brunnstrom stages of recovery. Voluntary control (bars) climbs in steps while spasticity (dashed line) rises to a peak at stage 3, when movement is possible only within synergy, and then declines as isolated movement returns.

Positioning and the hemiplegic shoulder

Positioning aims to prevent contracture, pressure injury and shoulder injury, and to give sensory input to the affected side. In supine, support the affected shoulder on a pillow with the scapula protracted and the arm slightly abducted and externally rotated, elbow extended, wrist neutral; keep the hip and knee in neutral with a small towel under the hip to limit external rotation. Side lying on the affected side is encouraged for sensory input and elongation of the trunk, with the shoulder protracted forward so the patient does not lie on the point of the shoulder. In sitting, support the affected arm on a lap tray or armrest trough. Turn every two hours in bed when the patient cannot reposition.

Hemiplegic shoulder pain affects many survivors and has several causes: inferior glenohumeral subluxation (in the flaccid stage the rotator cuff and deltoid no longer hold the humeral head, and gravity pulls it down; palpate a gap below the acromion), rotator cuff and biceps tendon injury, adhesive capsulitis, spasticity of the internal rotators and adductors, complex regional pain syndrome (shoulder hand syndrome with a painful, swollen, discolored hand), and impingement from raising the arm overhead without scapular upward rotation and humeral external rotation. Prevention is the best treatment:

  • Never pull on the affected arm during transfers or bed mobility; teach caregivers to move the patient through the trunk.
  • Support the arm in sitting (lap tray, arm trough) and when standing or walking; a sling may be used for standing and walking in the flaccid stage but should not be worn constantly because it holds the arm in adduction and internal rotation.
  • Perform range of motion with scapular mobilization and external rotation before elevation; avoid overhead pulleys, which cause impingement and pain.
  • Use NMES to the supraspinatus and posterior deltoid to reduce subluxation, and strapping (taping) to reduce pain.

Gait training after stroke

Common deviations reflect the stance and swing problems of the paretic leg. Treatment combines high intensity stepping practice (Chapter 5), strengthening, orthoses and, when needed, an assistive device.

DeviationUsual causesTypical management
Toe drag, foot slap or initial contact with the forefootWeak dorsiflexors; plantarflexor spasticity or contractureAFO or peroneal FES; dorsiflexor training; plantarflexor stretching
Knee hyperextension in stance (genu recurvatum)Weak quadriceps locking the knee; plantarflexor spasticity or contracture pushing the tibia back; poor proprioceptionAFO set in slight dorsiflexion; quadriceps training in small knee flexion ranges; plantarflexor tone management
Knee buckling in stanceWeak quadriceps or hip extensorsStrengthening; AFO with anterior stop or KAFO in severe cases
Circumduction or hip hiking in swingReduced hip and knee flexion and ankle dorsiflexion; extensor synergySwing phase training, dorsiflexion assist, treat the cause rather than the compensation
Trendelenburg or lateral trunk leanWeak hip abductorsHip abductor strengthening; cane in the opposite (less affected) hand
Short stance time on the paretic leg, short step with the nonparetic legWeakness, poor balance, fearWeight shift and stance training on the paretic leg; stepping practice

A hemi walker or quad cane gives more stability than a straight cane for patients with poor balance and one functional upper extremity; any cane is held in the hand opposite the weak leg.

Acute care precautions

In the acute phase, protect the brain's perfusion. For ischemic stroke treated with intravenous thrombolysis (alteplase or tenecteplase), blood pressure is kept below 180/105 mmHg for 24 hours afterward, and therapy is usually delayed or limited during that first day while bleeding risk is highest; watch for signs of hemorrhage (new headache, declining consciousness, worsening deficit) and bleeding from puncture sites. For ischemic stroke without thrombolysis, permissive hypertension up to about 220/120 mmHg is commonly allowed in the first 24 to 48 hours to maintain flow to the penumbra. In hemorrhagic stroke, blood pressure is lowered (a systolic target around 140 mmHg is common), so a rising pressure is a reason to stop. Facility protocols vary; follow the physician's specific parameters.

Mobilization should begin once the patient is medically stable, typically within the first days. A large trial found that very early, high dose mobilization within the first 24 hours produced worse outcomes than usual care, so current guidelines advise against high dose mobilization in the first day while supporting short, frequent sessions afterward. Monitor for orthostatic hypotension, cardiac arrhythmias (atrial fibrillation is common), dysphagia and aspiration (keep the head of bed elevated and follow the swallowing plan), deep vein thrombosis, and new or worsening neurologic signs, which require stopping and notifying the team immediately.

Board tip. Exam questions often test the hemiplegic shoulder: the best answer protects the joint (support the arm, avoid pulling, avoid overhead pulleys, use NMES to the supraspinatus and posterior deltoid) rather than pushing range. A cane goes in the hand opposite the weak leg, and a sling is for standing and walking in the flaccid stage, not all day.
Case. A 63 year old man is seen on day two after a left MCA ischemic stroke treated with thrombolysis 30 hours ago. He has a flaccid right arm with a one finger breadth gap below the acromion, and a right hemiparesis. His blood pressure is 176/98 at rest and rises to 188/104 when he sits on the edge of the bed. Nursing reports he coughs when drinking water.
Reasoning: He is past the first 24 hours after thrombolysis, but he still exceeds a commonly used ceiling of about 180/105 during activity; the best action is to return him to a supported position, recheck, and notify the physician for parameters rather than continue to standing. Coughing with thin liquids suggests aspiration risk: keep the head of bed elevated and confirm a swallow evaluation by speech language pathology. Protect the subluxed shoulder by supporting the arm on a pillow or lap tray and teaching staff not to pull on it. Wrong choices: aggressive overhead range of motion (impingement), or continuing the session at that pressure.
Key point

Recovery moves from flaccidity through synergies and peak spasticity to isolated movement (Brunnstrom stages). Know the components of each synergy and the typical posture they create. Protect the hemiplegic shoulder, train gait with stepping practice and orthoses that target the cause of each deviation, and respect blood pressure limits: below 180/105 after thrombolysis, permissive up to about 220/120 without it, and lower targets after hemorrhage.

Section 3Traumatic brain injury

Traumatic brain injury (TBI) results from an external force: falls (most common overall, especially in older adults and young children), motor vehicle crashes, assaults, sports and blast. Primary injury occurs at impact: contusions, often in a coup and contrecoup pattern at the frontal and temporal poles; hematomas; and diffuse axonal injury from shearing during acceleration and rotation, which causes prolonged coma with few focal signs. Secondary injury develops over hours to days from hypoxia, hypotension, cerebral edema, raised intracranial pressure, seizures and infection; much of acute medical care aims to prevent it.

An epidural hematoma (usually a torn middle meningeal artery with a temporal fracture) classically causes a brief loss of consciousness, a lucid interval, then rapid deterioration. A subdural hematoma (torn bridging veins) may be acute or chronic; chronic subdural hematoma in older adults and people on anticoagulants presents with gradual confusion, headache or new falls days to weeks after minor trauma, and is a reason to refer an older patient whose cognition declines after a fall.

Severity scales

Glasgow Coma ScaleScore: response
Eye opening (1 to 4)4 spontaneous; 3 to voice; 2 to pain; 1 none
Verbal (1 to 5)5 oriented; 4 confused; 3 inappropriate words; 2 incomprehensible sounds; 1 none
Motor (1 to 6)6 obeys commands; 5 localizes pain; 4 withdraws; 3 abnormal flexion (decorticate); 2 extension (decerebrate); 1 none

The total ranges from 3 to 15. Severity is classified as mild 13 to 15, moderate 9 to 12 and severe 3 to 8 (a score of 8 or less generally means coma and the need to protect the airway). Duration of loss of consciousness and of post traumatic amnesia (PTA, the period of confusion and inability to form new memories after injury) also grade severity; PTA longer than about a day suggests at least moderate injury and longer than a week severe injury, and PTA duration is one of the best predictors of long term outcome. Decorticate posturing (arms flexed, legs extended) reflects a lesion above the red nucleus in the midbrain; decerebrate posturing (all four limbs extended, arms pronated) reflects a brainstem lesion below the red nucleus and carries a worse prognosis.

Rancho Los Amigos levels of cognitive functioning

LevelBehaviorTherapy focus
I No responseNo response to stimuliPositioning, range of motion, skin and pulmonary care, sensory stimulation
II Generalized responseInconsistent, nonpurposeful reactions to stimuliSame, with structured stimulation of one modality at a time
III Localized responseSpecific but inconsistent responses; may follow simple commands, turn toward soundSimple commands, early sitting and functional tasks, family education
IV Confused, agitatedHeightened activity, aggression or bizarre behavior, cannot process information, short attentionSafety and calm: see behavior management below
V Confused, inappropriate, nonagitatedFollows simple commands; distractible; poor memory; may confabulateStructured, familiar tasks; repetition; external memory aids
VI Confused, appropriateGoal directed with cues; recalls tasks with repetition; improving self careFunctional retraining with decreasing cues
VII Automatic, appropriateRobot like, appropriate routine behavior; poor judgment and insight in new situationsCommunity skills, problem solving, safety awareness; supervision for new tasks
VIII Purposeful, appropriateRecalls and integrates past and recent events; needs standby assistance for adaptationReturn to work, school and driving evaluation
IX and X (revised scale)Purposeful, appropriate with standby assistance on request (IX) and modified independent (X)Long term goals and participation

Behavior management and medical precautions

The patient at Rancho level IV is confused and agitated because of the injury, not by choice. Management principles: keep the environment calm, quiet and low in stimulation (one person speaking, television off); use consistent staff and a consistent daily schedule; give short, simple instructions; offer limited choices; keep sessions short and change activities often; allow safe movement (an enclosed or floor level bed, supervised walking) rather than restraints, which increase agitation; do not argue with confabulation, but gently redirect; and stay calm and step back if the patient becomes aggressive. Overlearned, automatic tasks such as walking or folding towels are better than new learning at this stage.

In the acute phase, intracranial pressure (ICP) is normally about 5 to 15 mmHg, and sustained values above about 20 mmHg require treatment. Cerebral perfusion pressure (CPP) equals mean arterial pressure minus ICP, with a target of about 60 to 70 mmHg. Activities that raise ICP include the Valsalva maneuver, isometric exercise, coughing, neck flexion or rotation that obstructs venous drainage, hip flexion beyond 90 degrees, the head down position and noxious stimulation. Keep the head of the bed at about 30 degrees with the head in midline, and stop activity and notify the nurse if ICP rises and stays elevated. Other complications include seizures, heterotopic ossification (common in TBI as well as SCI), spasticity, dysphagia, and endocrine and sleep disturbances.

Concussion and return to play

A concussion is a mild traumatic brain injury caused by a direct or transmitted force to the head that produces a rapid onset of transient neurologic dysfunction, usually without structural injury on standard imaging. Loss of consciousness is not required. Symptoms include headache, dizziness, nausea, light and noise sensitivity, feeling slowed or "in a fog," poor concentration, irritability and sleep disturbance. Signs on the sideline include balance problems, confusion, blank stare and amnesia. Any athlete suspected of a concussion is removed from play and is not returned the same day.

Red flags requiring emergency transfer: worsening or severe headache, repeated vomiting, seizure, deteriorating consciousness, increasing confusion or agitation, weakness or numbness in the limbs, double vision, slurred speech, unequal pupils, and severe neck pain or tenderness (suspect cervical injury and immobilize). Second impact syndrome, rapid and often fatal brain swelling after a second blow before recovery from the first, is the main reason for conservative return.

Current consensus favors a short period of relative rest (about 24 to 48 hours), followed by gradual return of light activity that does not more than mildly worsen symptoms. Early subsymptom threshold aerobic exercise speeds recovery; exercise tolerance can be determined with a graded treadmill test and the training heart rate set below the level that provokes symptoms. Return to learn (school or work) proceeds first, with academic accommodations as needed. Most adults recover within about two weeks and most children within about four weeks; symptoms beyond that warrant a multidisciplinary evaluation, often including vestibular, oculomotor and cervical spine assessment.

123456 Symptomlimited activity Aerobicexercise, lightthen moderate Individualsport specificexercise Noncontacttraining drills,high intensity Full contactpracticeafter medicalclearance Return tosport At least 24 hours per step. If symptoms worsen more than mildly, drop back a step. Return to learn comes before full return to sport. Removed from play on the day of injury; no same day return.
Figure 6.3 Graded return to sport after concussion. Each step lasts at least 24 hours; the athlete progresses only while symptoms stay at most mildly increased, and needs medical clearance before contact.
Board tip. Know the GCS cutoffs (13 to 15 mild, 9 to 12 moderate, 8 or less severe), that motor score 3 is decorticate and 2 is decerebrate, and that the Rancho IV patient needs a calm, low stimulation environment, consistent staff, short tasks and no restraints if avoidable. For concussion, the trap answer is a same day return or complete rest in a dark room for weeks; the correct pattern is brief relative rest, then graded activity.
Case. A 24 year old man three weeks after a severe TBI is on an inpatient rehabilitation unit. He pulls at his feeding tube, shouts, cannot attend to a task for more than a minute and tries to climb out of bed. He cannot recall the therapist from the previous session.
Reasoning: Agitation, confusion and inability to process information place him at Rancho level IV. The best plan: treat him in a quiet room or his own room, with one consistent therapist, short sessions of familiar gross motor activity such as walking with close guarding, simple one step commands, and redirection when he becomes agitated. An enclosed bed or floor bed is preferable to restraints. Wrong choices: teaching new compensatory strategies (he cannot retain them yet), a busy gym session, or confronting him about his behavior. Safety point: guard closely for falls and protect lines and tubes, and step back and call for help if he becomes aggressive.
Key point

TBI severity is graded by GCS (mild 13 to 15, moderate 9 to 12, severe 3 to 8), loss of consciousness and post traumatic amnesia. The Rancho levels guide therapy, and level IV demands a calm, consistent, low stimulation approach. Acutely, avoid activities that raise intracranial pressure and keep CPP near 60 to 70 mmHg. After concussion, remove the athlete from play, screen for red flags, use brief relative rest then subsymptom aerobic exercise, and progress through the graded steps with medical clearance before contact.

Section 4Spinal cord injury

Traumatic spinal cord injury (SCI) most often follows motor vehicle crashes and falls (falls dominate in older adults), followed by violence and sports such as diving. Injuries cluster at the mobile cervical spine (especially C5 and C6) and the thoracolumbar junction. Tetraplegia means impairment of the cervical segments, affecting the arms, trunk, legs and pelvic organs; paraplegia means impairment of thoracic, lumbar or sacral segments, sparing the arms. Immediately after injury, spinal shock causes flaccid paralysis, areflexia and loss of autonomic function below the lesion; it usually resolves over days to weeks, signaled by the return of reflexes such as the bulbocavernosus reflex, after which spasticity and hyperreflexia appear below an upper motor neuron level.

Classifying the injury

The International Standards for Neurological Classification of SCI (the ASIA examination) test 10 key muscles on each side (graded 0 to 5) and 28 key sensory points on each side for light touch and pin prick (0 absent, 1 altered, 2 normal), plus an anorectal examination. Useful sensory landmarks: C4 over the acromioclavicular joint, C5 lateral antecubital fossa, C6 thumb, C7 middle finger, C8 little finger, T1 medial antecubital fossa, T4 nipple line, T10 umbilicus, L1 inguinal area, L3 medial femoral condyle, L4 medial malleolus, L5 dorsum of the foot at the third metatarsophalangeal joint, S1 lateral heel, and S4 to S5 perianal area.

The motor level is the lowest key muscle with a grade of at least 3, provided all key muscles above it are 5. The sensory level is the lowest dermatome with normal light touch and pin prick. The neurological level of injury is the most caudal segment with normal sensory and antigravity motor function on both sides. An injury is complete when there is no sacral sparing: no sensation at S4 to S5, no deep anal pressure and no voluntary anal contraction. In a complete injury, partially preserved segments below the level form the zone of partial preservation.

LevelKey muscle groupWhat it adds C3 to C5Diaphragm (phrenic nerve)Breathing off a ventilator (C4 and below) C5Elbow flexorsFeeding with setup and adaptive devices C6Wrist extensorsTenodesis grasp; sliding board transfers C7Elbow extensorsDepression transfers; manual chair C8Finger flexors (middle finger)Grasp; full hand function begins T1Small finger abductorsFine hand use; independent ADLs L2Hip flexorsHousehold walking with KAFOs (T10 to L2) L3Knee extensorsCommunity walking with AFOs L4Ankle dorsiflexorsToe clearance in swing L5Long toe extensorsImproved swing and foot control S1Ankle plantarflexorsPush off in terminal stance Red line: arm key muscles above, leg key muscles below (T2 to L1 are judged by sensation).
Figure 6.4 Key muscles of the ASIA examination and the main functional gain each level adds. A muscle counts toward the motor level at grade 3 or better when the level above is grade 5.
ASIA Impairment ScaleDefinition
A CompleteNo sensory or motor function preserved in the sacral segments S4 to S5
B Sensory incompleteSensory but no motor function preserved below the neurological level, including S4 to S5, and no motor function more than three levels below the motor level on either side
C Motor incompleteMotor function preserved below the neurological level, and more than half of key muscles below the neurological level have a grade less than 3
D Motor incompleteMotor function preserved below the neurological level, and at least half of key muscles below the neurological level have a grade of 3 or more
E NormalSensation and motor function normal in all segments in a person who had prior deficits

Incomplete cord syndromes

SyndromeTypical causeFindingsPrognosis
Central cord (most common)Cervical hyperextension in an older adult with spondylosisUpper extremities weaker than lower (cervical fibers lie more centrally in the lateral corticospinal tract); variable sensory loss; sacral sparingGood for walking and bladder; hand function recovers least
Brown-SequardHemisection, often a stab or gunshot woundIpsilateral motor loss and loss of vibration and proprioception; contralateral loss of pain and temperature a level or two belowBest of the syndromes; most walk
Anterior cordFlexion injury, disc or bone retropulsion, or anterior spinal artery occlusion (for example after aortic surgery)Bilateral loss of motor function and of pain and temperature; proprioception, vibration and deep touch preservedPoorest for motor recovery
Posterior cordRare; posterior compression, vitamin B12 deficiency (subacute combined degeneration), tabes dorsalisLoss of proprioception and vibration; motor, pain and temperature preserved; wide based, watched, high stepping gaitWalking possible using vision to compensate
Conus medullarisInjury at about T12 to L1Sacral cord damage: areflexic bladder and bowel, saddle anesthesia; mixed UMN and LMN leg signsVariable
Cauda equinaInjury below L1 (nerve roots), large central disc herniationLMN pattern: flaccid, areflexic, often asymmetric leg weakness; saddle anesthesia; bowel and bladder dysfunctionRoots can regenerate; urgent surgical decompression for acute compression
Posterior (dorsal) is at the top of each section; red marks the damaged region Central cordBrown-SequardAnterior cordPosterior cord Arms weakerthan legsSacral sparing Same side: motor,position, vibrationOpposite side:pain, temperature Lost: motor, pain,temperatureKept: position,vibration Lost: position,vibrationKept: motor, pain,temperature Good for walkingBest prognosisPoorest prognosisRare
Figure 6.5 The incomplete spinal cord syndromes. The region damaged determines which tracts are lost: the center of the cord in central cord syndrome, one half in Brown-Sequard syndrome, the anterior two thirds in anterior cord syndrome and the dorsal columns in posterior cord syndrome.

Functional expectations by level

Expected outcomes for a complete injury at each level, assuming no complications, guide goals, equipment and discharge planning. Incomplete injuries often exceed them.

LevelKey new functionExpected outcome
C1 to C3Neck movementVentilator dependent (or diaphragm pacing); power wheelchair with head, chin or sip and puff control; directs all care; total assist for ADLs
C4Diaphragm, upper trapeziusMay breathe independently; power wheelchair with head or chin control; power recline or tilt for pressure relief; directs care
C5Elbow flexion, shoulder movementPower chair with hand control; manual chair with rim modifications for short level distances; feeds with setup and adaptive devices; dependent transfers; drives a specially adapted van
C6Wrist extension (tenodesis)Manual wheelchair on level surfaces; may achieve independent sliding board transfers; independent feeding and upper body dressing with equipment; drives with hand controls
C7 to C8Elbow extension, finger flexionIndependent transfers to level surfaces (depression transfers); manual chair; independent in most ADLs; drives with hand controls
T1 to T9Full upper extremities; increasing trunk controlIndependent in all ADLs and wheelchair skills including wheelies and curbs; standing with a frame or KAFOs for exercise only
T10 to L2Abdominal and more trunk controlHousehold ambulation possible with KAFOs and walker or crutches (high energy cost); wheelchair for community
L3 to S5Knee extension and belowCommunity ambulation with AFOs and crutches or canes; wheelchair for long distances in some

Tenodesis is the passive finger flexion that occurs when the wrist is actively extended (and finger opening when the wrist flexes), because the long finger flexors are slightly shortened over the wrist. It provides a functional grasp for C6 and C7 injuries. To preserve it, never stretch the finger flexors with the wrist extended: range the fingers with the wrist flexed and the wrist with the fingers flexed. For long sitting, which is needed for dressing and bed mobility, hamstring length of about 100 to 110 degrees of straight leg raise is required, but avoid overstretching the low back extensors, which provide passive trunk stability.

Board tip. Expect level by function questions. C5 is the first level with elbow flexion and is not independent in transfers; C6 is the classic tenodesis level and the first that can be independent in many tasks with equipment; C7 is the key level for independent transfers and living alone with minimal assistance. The anterior cord syndrome has the worst motor prognosis and Brown-Sequard the best.
Case. A 23 year old man has a C6 ASIA A injury after a diving accident. On examination, wrist extensors are 4/5 bilaterally and triceps are 1/5. His family asks whether he will be able to transfer himself and feed himself. A student begins stretching his fingers into full extension with the wrist extended to "prevent contracture."
Reasoning: At C6 complete, expected outcomes include independent feeding with a universal cuff or tenodesis splint, manual wheelchair propulsion on level surfaces with projection rims, and possibly independent sliding board transfers with practice; he will need some assistance for lower body care. The student's stretch is wrong because it overlengthens the finger flexors and destroys tenodesis; stretch the fingers with the wrist flexed instead. Do not promise ambulation. Safety point: at C6 he is at risk of autonomic dysreflexia and orthostatic hypotension, so monitor blood pressure and symptoms with every position change.
Key point

Classify SCI with the key muscles, the sensory points and sacral sparing: AIS A complete, B sensory incomplete, C and D motor incomplete split by whether half the key muscles below the level reach grade 3. Central cord affects arms more than legs, Brown-Sequard splits motor and pain loss by side, anterior cord spares the dorsal columns and has the worst prognosis. Predict function by level (C6 tenodesis, C7 independent transfers, T10 to L2 household walking with KAFOs) and protect tenodesis.

Section 5Medical complications of SCI and neurologic injury

Many complications after spinal cord and brain injury are preventable, and some are emergencies that a therapist may be the first to see. The exam rewards fast recognition and the correct first action.

Autonomic dysreflexia

Autonomic dysreflexia (AD) is a potentially life threatening rise in blood pressure in people with injuries at T6 and above. A noxious stimulus below the lesion triggers a massive sympathetic reflex through the intact cord below the injury, causing vasoconstriction in the large splanchnic vascular bed. Baroreceptors detect the hypertension and the brain responds with vagal slowing of the heart and attempts at vasodilation, but the descending inhibitory signals cannot pass the injury, so the pressure keeps rising. Above the lesion, the body shows the brain's response; below it, the body shows the sympathetic storm.

  • Triggers: bladder distension or a blocked or kinked catheter (most common), bowel distension or impaction, pressure injury, tight clothing or leg bag straps, ingrown toenail, sunburn, sexual activity, menstruation and labor, fractures and other painful stimuli.
  • Signs: systolic pressure 20 to 40 mmHg above the person's baseline (often baseline is low, around 90 to 110 systolic, so 140 may already be dangerous), pounding headache, flushing and sweating above the lesion, nasal congestion, blurred vision, anxiety, bradycardia (sometimes), and pale, cool skin with goosebumps below the lesion.
  • Management: sit the patient upright and lower the legs (orthostatic pooling lowers pressure), loosen clothing, binders and straps, check the bladder and catheter for kinks or blockage, check for bowel distension and other triggers, monitor blood pressure every 2 to 5 minutes, and call for medical help. If the pressure remains high (commonly a systolic of 150 mmHg or more) after removing the trigger, medication is given by the medical team. Never lay the patient flat.
Injury at T6 or above Above the lesionBradycardia, headache,flushing, sweating Brain respondsBaroreceptors sensehigh blood pressure Noxious stimulusFull bladder, bowel,pressure, tight strap Sympathetic surgeVasoconstriction, pale,cool skin below lesion Severe hypertension SBP 20 to 40 mmHg above baseline signal downis blocked Act now 1. Sit upright,lower the legs 2. Loosen clothing,binders, straps 3. Check catheterand bladder 4. Check bowel,skin, other triggers 5. BP every2 to 5 minutes 6. Call for medicalhelp
Figure 6.6 Autonomic dysreflexia. A stimulus below the lesion drives unopposed sympathetic vasoconstriction; the brain's attempt to correct it cannot pass the injury, so signs differ above and below the lesion. Removing the trigger is the definitive treatment.

Orthostatic hypotension

Orthostatic hypotension is a fall in systolic pressure of at least 20 mmHg or in diastolic pressure of at least 10 mmHg within three minutes of moving upright. It is common after SCI above T6 (loss of sympathetic vasoconstriction and of the muscle pump), and after prolonged bed rest, stroke and TBI. Symptoms include lightheadedness, blurred vision, nausea, yawning and loss of consciousness. Prevent it with gradual elevation (head of bed, then reclining wheelchair, then tilt table), compression stockings, an abdominal binder, adequate hydration, and medications such as midodrine prescribed by the physician. If symptoms occur, recline the patient or tilt the wheelchair back and elevate the legs. Note the contrast with AD: in hypotension, lie back and raise the legs; in AD, sit up and lower them.

Heterotopic ossification

Heterotopic ossification (HO) is the formation of bone in soft tissue around joints, typically 1 to 6 months after SCI or TBI. It occurs below the level of SCI, most often at the hip, then the knee; after TBI it also affects the shoulder and elbow. Early signs are warmth, swelling, erythema and decreasing range of motion, sometimes with fever; serum alkaline phosphatase rises and a bone scan detects it early. Because it mimics deep vein thrombosis and cellulitis, a swollen warm leg needs medical evaluation, including Doppler ultrasound, before therapy continues. Management includes medications (bisphosphonates such as etidronate, or NSAIDs) and gentle range of motion within the pain free range to maintain function; avoid forceful stretching, which may worsen the process. Surgical excision is considered after the bone matures.

Pressure injury

Loss of sensation, immobility, moisture, poor nutrition and spasticity make pressure injuries a lifelong risk after SCI. The usual sites are the ischial tuberosities (sitting), sacrum and coccyx (supine and semireclined), heels, trochanters and the occiput. Prevention: turn at least every 2 hours in bed; perform wheelchair pressure relief every 15 to 30 minutes for about 1 to 2 minutes (push ups, side leans or forward leans, or power tilt of at least about 30 to 45 degrees); use pressure redistributing cushions and mattresses; inspect the skin twice daily with a mirror; manage moisture; and optimize protein and calorie intake. Push ups are less effective than forward and side leans and stress the shoulders.

StageDescription
Stage 1Intact skin with nonblanchable erythema (may look different in darkly pigmented skin)
Stage 2Partial thickness loss with exposed dermis; pink, moist wound bed or intact or ruptured serum filled blister; no fat, slough or eschar
Stage 3Full thickness skin loss; fat visible; slough or eschar may be present; may have undermining and tunneling; no exposed fascia, muscle, tendon or bone
Stage 4Full thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage or bone
UnstageableFull thickness loss whose depth is obscured by slough or eschar
Deep tissue pressure injuryIntact or nonintact skin with persistent nonblanchable deep red, maroon or purple discoloration, or a blood filled blister

Spasticity management

Spasticity after SCI, stroke, TBI and MS is not always harmful: extensor tone can assist standing and transfers, and muscle activity helps maintain bulk and venous return. Treat it when it interferes with function, hygiene, positioning, sleep or skin, or causes pain or contracture. A sudden increase in spasticity is a warning sign of a new noxious stimulus, such as a urinary tract infection, pressure injury, ingrown toenail or fracture, and should prompt a search for the cause.

ApproachExamplesNotes for therapists
PhysicalDaily prolonged stretching, positioning, weight bearing (standing frame), serial casting, splinting, cold, NMES of antagonistsFoundation of every program; serial casting for dynamic contracture
Oral medicationsBaclofen (GABA-B agonist), tizanidine (alpha-2 agonist), dantrolene (acts on muscle), diazepamDrowsiness and weakness common; dantrolene can be hepatotoxic; abrupt baclofen withdrawal can cause seizures and hallucinations
Focal injectionBotulinum toxin (blocks acetylcholine release at the neuromuscular junction), phenol or alcohol nerve blocksPeak effect in about 2 to 6 weeks, lasting about 3 months; combine with stretching, casting and strengthening of antagonists
IntrathecalIntrathecal baclofen pumpFor severe generalized spasticity; pump failure causes withdrawal: rebound spasticity, itching, fever, altered mental status, which is an emergency
SurgicalTendon lengthening, selective dorsal rhizotomyFor fixed deformity or selected children with cerebral palsy

Other complications

  • Deep vein thrombosis and pulmonary embolism: highest risk in the first weeks to months after SCI; prevention with anticoagulants and compression. Suspect DVT with unilateral calf or thigh swelling, warmth or pain (often painless when sensation is absent); hold the session and notify the physician. Patients can generally be mobilized once therapeutically anticoagulated, per the physician's orders.
  • Respiratory: the diaphragm is innervated by C3 to C5; injuries at C5 and above reduce vital capacity, and the loss of abdominal and intercostal muscles impairs cough in tetraplegia and high paraplegia. Train assisted (quad) coughing, diaphragmatic and glossopharyngeal breathing and inspiratory muscle training, and use an abdominal binder. Avoid manual abdominal thrusts after recent abdominal surgery or with an inferior vena cava filter. Pneumonia is a leading cause of death after SCI.
  • Thermoregulation: above T6, impaired sweating and vasomotor control make patients vulnerable to hyperthermia and hypothermia; dress appropriately and avoid exercise in heat.
  • Bladder and bowel: injuries above the sacral cord produce a reflexive (spastic, UMN) bladder and bowel; conus and cauda equina injuries produce areflexic (flaccid, LMN) organs. Intermittent catheterization and a scheduled bowel program reduce infections and AD triggers.
  • Bone loss: rapid osteoporosis below the lesion raises fracture risk, often at the distal femur and proximal tibia during transfers or stretching; use gentle technique.
  • Shoulder pain from years of transfers and wheelchair propulsion in paraplegia: teach efficient long, smooth push strokes, level transfers when possible and rotator cuff and scapular strengthening.
Board tip. The first actions differ by emergency. Autonomic dysreflexia: sit up, lower the legs, loosen clothing, check the bladder. Orthostatic hypotension: recline, elevate the legs. Suspected DVT: stop, do not massage or exercise the limb, notify the physician. Intrathecal baclofen withdrawal (fever, itching, rebound spasticity, confusion): emergency medical care.
Case. A 30 year old woman with a T4 ASIA A injury is doing mat exercises in outpatient therapy. She suddenly reports a pounding headache and blurry vision. Her face is flushed and sweaty, her heart rate is 54, and her blood pressure is 168/96; her usual pressure is 98/62.
Reasoning: A T4 injury is above T6, and severe headache, flushing above the lesion, relative bradycardia and a systolic pressure about 70 mmHg above baseline define autonomic dysreflexia. Sit her up immediately with legs lowered, loosen her clothing and leg bag straps, check her catheter for kinks and her bladder for distension, look for other triggers, recheck blood pressure every 2 to 5 minutes and call for medical help. The trap answers are laying her supine to "treat the headache," which raises pressure further, and assuming 168/96 is only mildly high: relative to her baseline it is dangerous. Safety point: AD can cause stroke, seizures and death, so it is managed as an emergency, and she should carry information about it.
Key point

Autonomic dysreflexia (T6 and above) is a hypertensive emergency: sit up, lower the legs, remove the trigger and monitor. Orthostatic hypotension is treated the opposite way, with recline and leg elevation, and prevented with gradual tilting, compression and binders. Watch for heterotopic ossification (warm, swollen joint, falling range, usually the hip), pressure injury (relief every 15 to 30 minutes, staging by depth), DVT and respiratory decline, and manage spasticity only when it interferes with function, always searching for a new noxious trigger first.

The chapter in one breath

  • MCA stroke: face and arm greater than leg, with aphasia (dominant) or neglect (nondominant); ACA: leg greater than arm with bladder and behavior changes; PCA: hemianopia with macular sparing and thalamic pain.
  • Vertebrobasilar strokes give crossed signs, vertigo, dysphagia and ataxia; lacunar strokes are pure motor or pure sensory without cortical signs.
  • Classify aphasia by fluency, comprehension and repetition; treat pusher syndrome with visual feedback of vertical, not force.
  • Brunnstrom stages move from flaccidity through synergy and peak spasticity (stage 3) to isolated movement; elbow flexion and shoulder adduction with internal rotation are the strongest UE synergy components.
  • Protect the hemiplegic shoulder, avoid overhead pulleys, and respect blood pressure limits: below 180/105 after thrombolysis, permissive up to about 220/120 without it.
  • GCS: 13 to 15 mild, 9 to 12 moderate, 3 to 8 severe; Rancho IV (confused, agitated) needs a calm, consistent, low stimulation approach.
  • Concussion: no same day return, screen red flags, brief relative rest, subsymptom aerobic exercise and a graded six step return with clearance before contact.
  • ASIA: A complete, B sensory incomplete, C and D motor incomplete split by half the key muscles below the level at grade 3; sacral sparing defines incompleteness.
  • Central cord: arms weaker than legs; Brown-Sequard: best prognosis; anterior cord: worst motor prognosis with preserved proprioception.
  • C6 gives tenodesis, C7 independent transfers, T10 to L2 household walking with KAFOs, L3 and below community walking with AFOs.
  • Autonomic dysreflexia (T6 and above): sit up, lower the legs, find the trigger, monitor blood pressure every 2 to 5 minutes.
  • Watch for heterotopic ossification, pressure injury, DVT and respiratory compromise; a sudden rise in spasticity signals a new noxious stimulus.

Words worth knowing

TermWhat it means
AbuliaLack of initiative, will or spontaneity, typical of medial frontal (ACA) lesions.
AnosognosiaUnawareness of one's own deficits, typical of nondominant parietal stroke; a major safety risk.
Autonomic dysreflexiaA sudden, dangerous rise in blood pressure triggered by a noxious stimulus below an SCI at T6 or above.
Brown-Sequard syndromeCord hemisection with ipsilateral motor and position sense loss and contralateral pain and temperature loss.
Central cord syndromeIncomplete SCI, usually from hyperextension, with arms weaker than legs and sacral sparing.
Cerebral perfusion pressureMean arterial pressure minus intracranial pressure; kept around 60 to 70 mmHg after brain injury.
Contrecoup injuryBrain contusion on the side opposite the point of impact as the brain rebounds inside the skull.
Decerebrate posturingExtension of all four limbs from a brainstem lesion below the red nucleus; worse prognosis than decorticate.
Decorticate posturingUpper extremity flexion with lower extremity extension from a lesion above the red nucleus.
Diffuse axonal injuryWidespread shearing of axons from rotational acceleration, causing prolonged coma.
DysarthriaA motor speech disorder of articulation with normal language, unlike aphasia.
HemianopiaLoss of half of the visual field in each eye; homonymous means the same side in both eyes.
Heterotopic ossificationFormation of bone in soft tissues around a joint after neurologic injury, most often at the hip.
Lacunar strokeA small deep infarct from occlusion of a penetrating artery, producing pure motor or pure sensory syndromes.
Neurological level of injuryThe most caudal spinal segment with normal sensory and antigravity motor function on both sides.
Post traumatic amnesiaThe period after brain injury during which new memories are not formed; its length predicts outcome.
Pusher syndromeA disorder of perceived verticality in which the patient pushes toward the hemiparetic side and resists correction.
Sacral sparingPreserved sensation or motor function at S4 to S5, which makes an SCI incomplete.
Second impact syndromeRapid, often fatal brain swelling after a second head injury before recovery from a first concussion.
Spinal shockTemporary flaccid paralysis, areflexia and autonomic loss below a new SCI.
SynergyA stereotyped mass movement pattern in which one joint cannot move without the others in the pattern.
TenodesisPassive finger flexion produced by active wrist extension, used as a functional grasp after C6 to C7 SCI.
Thalamic pain syndromeSevere, burning contralateral pain after a thalamic stroke, usually in the PCA territory.
Zone of partial preservationSegments below the neurological level with some preserved function in a complete SCI.

Check yourself

A patient has right hemiparesis worse in the arm and face, right homonymous hemianopia and nonfluent speech with good comprehension. Which artery and which hemisphere?
Answer. The left middle cerebral artery. Face and arm greater than leg weakness indicates the MCA, and nonfluent speech with relatively intact comprehension is Broca aphasia from the dominant inferior frontal gyrus.
A patient with a stroke has dizziness, dysphagia, hoarseness, left facial numbness, left Horner syndrome, left limb ataxia and loss of pain and temperature on the right body. What is the syndrome?
Answer. Left lateral medullary (Wallenberg) syndrome from the left vertebral or posterior inferior cerebellar artery. Ipsilateral face and contralateral body loss is a crossed pattern, and there is no major weakness because the pyramids are spared.
A patient after stroke speaks fluently but with nonsense words, cannot follow commands and cannot repeat a phrase. Which communication strategy is best?
Answer. This is Wernicke aphasia. Use short, simple phrases with demonstration, gestures and visual cues, and do not rely on the patient's verbal confirmation of understanding.
When a patient with hemiplegia raises the arm, the shoulder abducts and externally rotates, the elbow flexes and the forearm supinates. What Brunnstrom stage is suggested if the patient can move only this way?
Answer. Stage 3: voluntary movement is possible only within the flexion synergy, and spasticity is at its peak. Stage 4 would show some movements out of synergy.
A patient on day one after thrombolysis for ischemic stroke has a blood pressure of 192/108 when seated. What should the therapist do?
Answer. Stop the activity, return the patient to a supported position, recheck and notify the medical team. Within 24 hours after thrombolysis, pressure is kept below 180/105 mmHg because of bleeding risk.
A patient opens his eyes to pain, makes incomprehensible sounds and withdraws from a painful stimulus. What is the GCS score and severity?
Answer. Eye 2, verbal 2, motor 4, for a total of 8: severe brain injury (8 or less).
A high school soccer player was hit in the head 3 days ago. She now has no symptoms at rest but gets a headache with light jogging. What is the most appropriate plan?
Answer. Continue graded activity at a level that does not more than mildly worsen symptoms (subsymptom threshold aerobic exercise), prioritize return to learn, and progress through the stepwise return to sport, at least 24 hours per step, with medical clearance before full contact. She is not ready for practice or play.
A patient after SCI has elbow flexors 5/5, wrist extensors 5/5, elbow extensors 4/5, finger flexors 2/5 bilaterally, normal sensation through C7 and none below, and no sacral sparing. What is the classification?
Answer. C7 ASIA A. The motor level is C7 (grade 3 or more with the levels above at 5), the sensory level is C7, and the absence of sacral sparing makes it complete.
A 70 year old man falls forward and hits his chin. He has marked weakness of both hands and arms, milder leg weakness and preserved perianal sensation. What is the likely syndrome and prognosis?
Answer. Central cord syndrome from a hyperextension injury on a spondylotic cervical spine. Prognosis for walking and bladder control is good; fine hand function recovers least.
Ten weeks after a T10 SCI, a patient's hip is warm and swollen and hip flexion range has dropped from 110 to 80 degrees. What should the therapist suspect and do?
Answer. Heterotopic ossification (or DVT, which must be ruled out). Notify the physician for evaluation (Doppler, alkaline phosphatase, bone scan) and, once DVT is excluded, continue gentle range of motion within the pain free range without forceful stretching.
Chapter 7 · Neuromuscular

Neuromuscular: Progressive, Peripheral and Vestibular Disorders

Progressive neurologic disease asks the physical therapist not only how to restore function, but how to protect it, pace it and plan for the losses ahead. The exam leans on these conditions because the right answer depends on the diagnosis: avoiding overwork weakness in Guillain Barre syndrome, cooling the patient with multiple sclerosis, timing exercise to the levodopa dose, or choosing the maneuver for the involved canal.

By the end of this chapter you can

  • Describe the cardinal signs of Parkinson disease, stage the disease with Hoehn and Yahr, and plan cueing and amplitude based training for freezing and bradykinesia.
  • Distinguish the clinical courses of multiple sclerosis, apply heat sensitivity and fatigue precautions, and teach energy conservation.
  • Explain why ALS produces both upper and lower motor neuron signs and set prognosis based goals across its stages.
  • Localize weakness to the anterior horn cell, peripheral nerve, neuromuscular junction or muscle, and manage Guillain Barre syndrome, diabetic neuropathy, post polio syndrome, myasthenia gravis and the muscular dystrophies.
  • Identify the involved canal in BPPV from the nystagmus pattern and choose the correct repositioning maneuver.
  • Separate peripheral from central vestibular signs, recognize vertigo red flags, and prescribe gaze stabilization, habituation and substitution exercises.
  • Differentiate Bell palsy from a central facial palsy and protect the eye.
  • Examine and treat cerebellar ataxia and plan safe care for Huntington disease.

Section 1Parkinson disease and movement disorders

What goes wrong in the basal ganglia

Parkinson disease (PD) is a progressive neurodegenerative disorder in which dopamine producing neurons of the substantia nigra pars compacta die, and the surviving neurons contain clumps of alpha synuclein called Lewy bodies. By the time motor signs appear, more than half the nigral neurons are often lost. Dopamine normally facilitates the direct pathway of the basal ganglia and inhibits the indirect pathway, which brakes movement. Without it, the internal globus pallidus overinhibits the thalamus, so movement becomes small (hypokinesia), slow (bradykinesia), hard to start (akinesia), and shrinks as it is repeated.

Typical onset is after age 60, men are affected slightly more often than women, and signs begin on one side. Nonmotor features often come first: loss of smell, constipation, REM sleep behavior disorder, depression, orthostatic hypotension, fatigue and, later, dementia.

The cardinal signs

The four classic motor signs are remembered as TRAP:

  • Tremor at rest: a 4 to 6 Hz "pill rolling" tremor of the thumb and fingers that is present at rest, lessens with voluntary movement, worsens with stress, and disappears in sleep. About a quarter of patients never develop it.
  • Rigidity: increased resistance to passive movement that is the same in both directions and does not depend on velocity. Smooth resistance is lead pipe rigidity; when tremor is superimposed the resistance catches and releases in a ratchet pattern called cogwheel rigidity. This is the key contrast with spasticity, which is velocity dependent and usually greater in one direction.
  • Akinesia and bradykinesia: poverty and slowness of movement, including reduced blinking, a masked face (hypomimia), soft speech (hypophonia), small handwriting (micrographia), reduced arm swing and difficulty turning in bed.
  • Postural instability: impaired righting and protective reactions, especially backward (retropulsion). It appears later in the disease, responds poorly to levodopa, and is a major cause of falls.

Posture becomes flexed, extension and rotation range are lost, and kyphosis lowers vital capacity. Dysphagia raises the risk of aspiration pneumonia, a leading cause of death in late PD.

Parkinsonian gait and freezing

The gait is slow with a short step length, reduced foot clearance, decreased hip and knee excursion, reduced or absent arm swing, a narrow base and en bloc turning (the head, trunk and pelvis turn as one unit, with many small steps). Festination is an involuntary acceleration of progressively shorter steps as the center of mass falls ahead of the feet; the patient appears to chase the center of mass. Freezing of gait is a brief, episodic inability to step despite the intention to walk, as if the feet were glued to the floor. It is provoked by starting to walk, turning, passing through doorways or narrow spaces, approaching a destination, dual tasking and stress, and it is strongly associated with falls.

Hoehn and Yahr staging and the PT emphasis Stage 1Unilateral signsLittle or nodisability Stage 2Bilateral signsBalance intact(pull test normal) Stage 3Bilateral, mild tomoderateBalance impairedStill independent Stage 4Severe disabilityWalks or standswithout help, butvery limited Stage 5Wheelchair orbed boundunless aided Aerobic fitnessBig movements Posture, rotationDual task gait Fall preventionCues for freezing Assistive deviceCaregiver skills Positioning, ROMSkin, breathing Bar height = disability; bottom row = PT emphasis
Figure 7.1 Hoehn and Yahr staging. Notice that postural instability defines stage 3, which is the point where fall prevention and cueing move to the center of the plan, while early stages emphasize vigorous exercise.

Medications and timing therapy

Carbidopa levodopa is the most effective drug; carbidopa blocks peripheral conversion of levodopa so more reaches the brain and nausea is reduced. Dopamine agonists, MAO B inhibitors and COMT inhibitors supplement it. After several years many patients develop motor fluctuations: a wearing off of benefit before the next dose, unpredictable on off switching, and peak dose dyskinesias, which are involuntary writhing or choreiform movements caused by too much dopamine effect, not by the disease itself. Watch for orthostatic hypotension, hallucinations and confusion.

Schedule therapy during the on period, typically about 45 to 60 minutes after a dose, when mobility is best and learning is easiest. Record the time of the last dose; a patient who varies from week to week may simply arrive at a different point in the dose cycle.

Examination and outcome measures

The disease specific scale is the Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS), whose part III is the motor examination. Recommended measures include the Mini BESTest, Berg Balance Scale, Timed Up and Go (with a dual task), Five Times Sit to Stand, gait speed and the Six Minute Walk Test. In the pull test (shoulders pulled briskly backward), more than two backward steps or needing to be caught is abnormal. Always measure orthostatic blood pressure: a drop of 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing defines orthostatic hypotension.

Intervention principles

Exercise improves fitness, gait, balance, strength and quality of life at every stage. The PD clinical practice guideline strongly supports aerobic exercise (including moderate to high intensity, roughly 60 to 85 percent of heart rate reserve), resistance training, balance training, and external cueing for gait.

  • Amplitude based training (for example the LSVT BIG approach and its speech counterpart LSVT LOUD) uses high effort, large amplitude, whole body movements repeated intensively (classically four sessions a week for four weeks) with recalibration of the patient's sense of normal size. Patients perceive their small movements as normal; the training teaches them that "big" feels exaggerated but looks normal.
  • External cueing bypasses the defective internal timing of the basal ganglia by using cortical and cerebellar circuits. Visual cues include transverse lines or tape on the floor at the desired step length and laser lines projected from a walker or shoe. Auditory cues include a metronome or music set near or slightly above the comfortable cadence. Attentional cues ask the patient to think "big step" or to step over an imagined line. Somatosensory cues include rhythmic tapping.
  • Freezing strategies: stop, stand tall, shift weight side to side, then step big over a real or imagined line; turn in a wide arc rather than pivoting; count steps aloud; avoid carrying objects while walking through doorways.
  • Flexibility and posture: spinal extension and rotation, hip extension, and pectoral, hamstring and hip flexor length.
  • Treadmill and dual task training once single task walking is safe; movement strategy training breaks complex tasks into conscious steps in advanced disease.
Board tip. Rigidity is velocity independent and bidirectional; spasticity is velocity dependent. When a question describes a patient with PD whose performance differs dramatically between sessions, look for the timing of the levodopa dose. Peak dose dyskinesia means too much medication effect, not that the disease is worse.

Other movement disorders

ConditionKey featuresClue that separates it
Essential tremorBilateral action and postural tremor of the hands, head (yes yes or no no) or voice; often familialTremor with use, not at rest; improves with small amounts of alcohol; no bradykinesia or rigidity
Progressive supranuclear palsyParkinsonism with early falls (often backward), axial rigidity with an extended neckVertical gaze palsy (especially downward); poor levodopa response
Multiple system atrophyParkinsonism or cerebellar ataxia plus autonomic failureSevere orthostatic hypotension, bladder dysfunction early; poor levodopa response
Normal pressure hydrocephalusGait disturbance, urinary incontinence, dementia ("wet, wobbly and wacky")Wide based, "magnetic" gait; may improve after lumbar drainage or shunt
Case. A 71 year old man with Parkinson disease (Hoehn and Yahr stage 3) is seen in outpatient therapy. He freezes in doorways and on turns and has fallen twice at home. He took carbidopa levodopa 50 minutes ago. Which intervention is most appropriate to address freezing?
Reasoning: Freezing reflects defective internally generated movement, so the best answer uses external cues: transverse floor lines at the target step length, a metronome near his cadence, or a "step over the line" attentional cue, combined with practice of wide arc turns and approaching doorways. Strengthening or a standard cane does not address the timing problem, and a wheeled walker without cues can worsen festination. He is in the on period, the right time to train. Safety point: his two falls and stage 3 status call for a home safety assessment and a gait belt during training.
Key point

Parkinson disease removes dopamine from the basal ganglia, so movement becomes small, slow and poorly initiated. Treat it with vigorous aerobic and resistance exercise early, large amplitude practice, external cues for freezing, and fall prevention once postural instability appears at stage 3, timing sessions to the on phase of levodopa.

Section 2Multiple sclerosis, ALS and other progressive diseases

Multiple sclerosis: mechanism and presentation

Multiple sclerosis (MS) is an immune mediated inflammatory disease of the central nervous system in which T cells and B cells attack myelin and oligodendrocytes, leaving plaques of demyelination and, over time, axonal loss. Because only the CNS is affected, peripheral nerves and the neuromuscular junction are spared. Lesions are scattered in time and space (periventricular white matter, optic nerves, brainstem, cerebellum, cervical cord). Onset is usually at 20 to 40 years, women are affected two to three times as often, and risk rises with distance from the equator, low vitamin D, smoking and prior Epstein Barr virus infection.

Symptoms include:

  • Fatigue, the most common and often most disabling symptom, frequently worse in the afternoon.
  • Sensory changes: numbness, tingling, a band like feeling around the trunk, and Lhermitte sign (an electric sensation down the spine and limbs with neck flexion, a sign of cervical cord involvement).
  • Optic neuritis (painful unilateral vision loss, often the first event) and internuclear ophthalmoplegia.
  • Motor: weakness and spasticity with upper motor neuron signs, typically in the legs.
  • Cerebellar: ataxia, intention tremor, dysmetria, scanning speech and nystagmus (the classic Charcot triad is nystagmus, intention tremor and scanning speech).
  • Heat sensitivity: the Uhthoff phenomenon is a temporary worsening of symptoms when core temperature rises (exercise, hot weather, a hot bath, fever). Heat slows conduction in demyelinated axons; it resolves with cooling.

Clinical courses

CoursePatternProportion and notes
Relapsing remitting (RRMS)Clear relapses with full or partial recovery; stable between relapsesAbout 85 percent at onset; the type most responsive to disease modifying therapy
Secondary progressive (SPMS)Begins as RRMS, then steady progression with or without occasional relapsesMany untreated RRMS patients convert over 10 to 20 years
Primary progressive (PPMS)Steady worsening from onset without distinct relapsesAbout 10 to 15 percent; older onset, equal sex ratio, more spinal cord involvement

The older label progressive relapsing MS is now folded into primary progressive disease described as active. Disability is commonly graded with the Expanded Disability Status Scale (EDSS, 0 to 10 in half steps). Anchor points worth knowing: 4.0 means fully ambulatory without aid for about 500 meters; 6.0 means a unilateral assistive device is needed to walk about 100 meters; 6.5 means bilateral assistance; 7.0 means essentially restricted to a wheelchair; 10 is death due to MS.

Relapsing remittingSecondary progressivePrimary progressive Disability Disability Disability TimeTimeTime About 85% begin hereRelapse, then recovery Follows RRMS in manySteady decline later About 10 to 15%Worse from onset
Figure 7.2 Clinical courses of multiple sclerosis. Each spike in relapsing remitting disease is a relapse; notice that incomplete recovery leaves a stepwise rise in baseline disability, while progressive forms climb steadily.

Examination and intervention in MS

Useful measures include the Timed 25 Foot Walk, the Six Minute Walk Test (speed falling in later minutes shows motor fatigability), the 12 item MS Walking Scale, the Modified Fatigue Impact Scale, the Berg Balance Scale and the Modified Ashworth Scale.

Exercise is safe and beneficial in MS and does not trigger relapses. Current guidance supports moderate intensity aerobic exercise (for example about 30 minutes at moderate intensity two or three times a week, built up gradually) and resistance training two or three times a week, plus balance training, flexibility and task specific gait training. Practical precautions:

  • Prevent overheating: exercise in a cool, air conditioned room, early in the day, with fans, cooling vests, cold drinks and pre cooling. Aquatic therapy should use cool water, generally below about 84 to 85 degrees Fahrenheit (about 29 degrees Celsius); avoid hot tubs and warm therapy pools.
  • Use interval training and rest breaks; schedule sessions in the morning when fatigue is lowest.
  • Do not exercise vigorously during an acute relapse, especially while receiving high dose corticosteroids; shift to positioning, gentle ROM and maintaining function, then resume a graded program as the relapse settles.
  • Manage spasticity with daily stretching and positioning; leg spasticity sometimes aids standing, so treat it when it interferes.

Energy conservation is taught explicitly, often as the four Ps: plan the day and week, pace activities with rest before fatigue sets in, prioritize what truly matters, and position the body and the environment for efficiency (sitting to dress, keeping items within reach).

Board tip. If a patient with MS becomes weaker and blurrier during a session in a warm gym and recovers after cooling, that is the Uhthoff phenomenon, not a relapse. A true relapse lasts at least 24 hours without fever or infection. Look for answers that cool the patient and modify intensity rather than stop exercise permanently.
Case. A 34 year old woman with relapsing remitting MS (EDSS 3.5) is referred for fatigue and reduced walking endurance. She walks without a device and reports that a hot shower makes her legs "rubbery" for an hour. Which plan is most appropriate?
Reasoning: She needs a graded aerobic and resistance program at moderate intensity, done early in the day in a cool environment with pre cooling or a cooling vest, plus energy conservation education (plan, pace, prioritize, position). A tempting wrong answer is to avoid exercise to protect against fatigue; deconditioning worsens fatigue, and exercise does not cause relapses. Warm water aquatic therapy would provoke heat sensitivity. Safety point: if new symptoms last more than 24 hours, ask about fever or infection and notify the neurologist because she may be having a relapse.

Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive degeneration of both upper motor neurons (motor cortex and corticospinal tracts) and lower motor neurons (anterior horn cells and motor cranial nerve nuclei). About 10 percent of cases are familial; onset is usually in the late 50s to 60s. The patient shows a mixed picture: weakness, atrophy, fasciculations and cramps (lower motor neuron) together with spasticity, hyperreflexia and a Babinski sign (upper motor neuron), often in the same limb. Onset is usually asymmetric in a hand or foot; bulbar onset (dysarthria, dysphagia, tongue fasciculations) carries a worse prognosis.

ALS characteristically spares sensation, eye movements, and bowel and bladder control, and most patients keep their cognition, although a minority develop frontotemporal dementia. Median survival is about three to five years from symptom onset, and death is usually from respiratory failure. Riluzole and edaravone modestly slow progression.

Physical therapy goals follow the stage and the prognosis:

  • Early (mild weakness): moderate, submaximal aerobic and resistance exercise without exhaustion, only for muscles with at least antigravity strength. Weaker muscles may suffer overwork; fatigue lasting over about 30 minutes, or weakness the next day, means the dose was too high.
  • Middle (some limbs severely weak): ROM and stretching, energy conservation, orthoses (ankle foot orthosis, cervical collar, wrist hand orthoses) and assistive devices.
  • Late (dependent): positioning, skin protection, airway clearance, caregiver training, hospital bed, lift, and a tilt in space power wheelchair with head support.

Anticipate equipment: start the power wheelchair evaluation months before it is needed, with controls adaptable to future hand weakness. Monitor respiratory function: forced vital capacity below about 50 percent of predicted, orthopnea, morning headaches or disturbed sleep signal the need to discuss noninvasive ventilation. Teach assisted cough and breathing strategies.

Key point

Multiple sclerosis is a CNS demyelinating disease marked by fatigue, heat sensitivity and a relapsing or progressive course; exercise is safe if the patient stays cool and paced. ALS mixes upper and lower motor neuron signs with spared sensation and a short prognosis, so goals shift from moderate exercise to compensation, equipment and respiratory care, always avoiding overwork of weak muscles.

Section 3Peripheral neuropathies and neuromuscular disease

Localizing weakness along the motor unit

A motor unit is one lower motor neuron and all the muscle fibers it supplies. Disease can strike the cell body (anterior horn cell), the axon or its myelin (peripheral nerve), the synapse (neuromuscular junction), or the muscle fiber itself. Each site leaves a recognizable fingerprint, and identifying the site is often the first step to the right answer.

SiteExamplesWeakness patternReflexesSensationOther clues
Anterior horn cellALS (plus UMN signs), polio, post polio syndrome, spinal muscular atrophyAsymmetric, patchyReduced (brisk in ALS)NormalFasciculations, atrophy
Peripheral nerveGuillain Barre, CIDP, diabetic polyneuropathyUsually distal; ascending in GBSReduced or absent earlyImpaired (stocking glove)Paresthesias, autonomic signs
Neuromuscular junctionMyasthenia gravis, Lambert Eaton syndrome, botulismFatigable; ocular and bulbar in MG; proximalNormal in MG; reduced in Lambert EatonNormalWorse with use (MG); better with use (Lambert Eaton)
MuscleDuchenne and Becker dystrophy, myotonic dystrophy, inflammatory myopathyUsually proximal and symmetricNormal until lateNormalElevated CK, Gowers sign, pseudohypertrophy
1 Anterior horn cellALS (with UMN), polio,post polio, SMA 2 Peripheral nerveGuillain Barre, CIDP,diabetic neuropathy 3 Neuromuscular junctionMyasthenia gravis (post)Lambert Eaton (pre) 4 Muscle fiberDuchenne, Becker,myotonic, FSH dystrophy Localizing clues Fasciculations and atrophy: anterior horn cell Sensory loss: peripheral nerve only Fatigable weakness: neuromuscular junction Proximal weakness, Gowers sign: muscle
Figure 7.3 The motor unit and its four sites of disease. Notice that sensation is lost only when the peripheral nerve is involved; the other three sites produce purely motor weakness.

Guillain Barre syndrome

Guillain Barre syndrome (GBS) is an acute immune mediated polyneuropathy, most often the demyelinating form (acute inflammatory demyelinating polyradiculoneuropathy). About two thirds of patients report a respiratory or gastrointestinal infection one to four weeks earlier; Campylobacter jejuni is the classic trigger.

  • Presentation: rapidly progressive, relatively symmetric weakness that usually starts in the legs and ascends, with distal paresthesias, back or limb pain, and areflexia. Cranial nerves (especially bilateral facial weakness) and respiratory muscles may be involved.
  • Autonomic instability: fluctuating blood pressure, arrhythmias, tachycardia or bradycardia, and orthostatic hypotension.
  • Course: weakness peaks within four weeks, plateaus, then recovers over months in a descending order. Most patients walk independently within a year; about 20 percent keep significant disability.
  • Diagnosis: high cerebrospinal fluid protein with a normal cell count (albuminocytologic dissociation) and slowed nerve conduction.
  • Treatment: intravenous immunoglobulin or plasma exchange, which shorten the course when given early. Corticosteroids are not effective.

About a quarter of patients need mechanical ventilation. Monitor vital capacity: a falling value (below about 20 mL/kg is a commonly cited threshold for intubation), weak cough, and difficulty counting to 20 in one breath are warnings. In the acute phase, the therapist focuses on positioning, gentle passive and active assisted ROM, splinting to prevent contracture (for example resting ankle splints), pressure injury prevention, chest physical therapy and airway clearance, and gradual tilt to upright with blood pressure monitoring.

In recovery, exercise must avoid overwork of reinnervating muscles. Use low intensity, low repetition, frequently rested exercise and progress slowly, watching for increased weakness, cramping or prolonged fatigue in the following 24 hours. Chronic inflammatory demyelinating polyneuropathy (CIDP) progresses for more than eight weeks and, unlike GBS, responds to corticosteroids.

Case. A 45 year old man is in the intensive care unit four days after the onset of Guillain Barre syndrome. Weakness is still progressing; he has 3/5 hip flexors, absent reflexes, and his blood pressure has swung from 90/60 to 170/100 today. Which plan is most appropriate?
Reasoning: He is still in the progressive phase with autonomic instability, so the priorities are protection and prevention: positioning, passive and active assisted ROM, splinting, skin care, airway clearance, and careful monitoring of vital signs and vital capacity. A progressive resistive exercise program or prolonged ambulation would risk overwork and hemodynamic instability. Safety point: report falling vital capacity, a weak cough or new dysphagia immediately, because respiratory failure can develop within hours.

Diabetic and other polyneuropathies

Diabetic peripheral neuropathy is the most common neuropathy in developed countries. The usual form is a distal symmetric sensorimotor polyneuropathy that begins in the toes and spreads proximally in a stocking and glove distribution, because the longest axons fail first. Small fiber loss causes burning pain; large fiber loss causes loss of vibration and proprioception, reduced ankle reflexes and a positive Romberg test. Intrinsic foot weakness produces claw toes. Autonomic neuropathy causes dry, cracked skin, orthostatic hypotension, resting tachycardia and a blunted heart rate response to exercise.

The key screening test is the 5.07 (10 gram) Semmes Weinstein monofilament: inability to feel it at tested plantar sites indicates loss of protective sensation and a high risk of ulceration. Combine it with vibration testing (128 Hz tuning fork), ankle reflexes and a foot inspection. Management includes daily foot inspection, depth shoes and insoles, never walking barefoot, balance training, and exercise with glucose monitoring. Weight bearing exercise is acceptable with proper footwear if there is no active ulcer; choose non weight bearing exercise (cycling, swimming) when an ulcer or acute Charcot foot is present. Because autonomic neuropathy blunts the heart rate response, use RPE rather than target heart rate.

A warm, red, swollen foot with intact skin in a person with neuropathy should be treated as an acute Charcot neuroarthropathy until proven otherwise; it needs immediate offloading (total contact cast) and referral, not exercise.

Post polio syndrome

Poliomyelitis destroys anterior horn cells; surviving neurons sprout to adopt orphaned muscle fibers, creating giant motor units. Decades later (typically 15 or more years after the acute illness), these overextended units begin to fail. Post polio syndrome presents with new weakness, often in previously affected muscles, unusual fatigue, muscle and joint pain, cold intolerance, and sometimes new breathing or swallowing problems. Management centers on pacing: nonfatiguing, submaximal exercise with frequent rests, energy conservation, weight control, and lightweight orthoses and devices to unload overused muscles.

Board tip. Guillain Barre syndrome, post polio syndrome and ALS share one exercise rule: avoid overwork weakness. Signs that the dose was too high include a loss of strength, fasciculations or cramps, or fatigue that persists into the next day. In all three, the correct answer is usually submaximal, frequently rested exercise rather than progressive heavy resistance.

Myasthenia gravis and Lambert Eaton syndrome

Myasthenia gravis (MG) is an autoimmune disease in which antibodies attack the postsynaptic acetylcholine receptors at the neuromuscular junction (some patients have antibodies against MuSK instead). Fewer functional receptors means each nerve impulse has less safety margin, so strength fades with repeated use. Hallmarks are fatigable weakness that worsens through the day and with activity and improves with rest, ptosis and diplopia (ocular muscles are involved in most patients and are often first), bulbar weakness (dysarthria, dysphagia, a nasal voice, difficulty chewing), and proximal limb and neck extensor weakness. Sensation and reflexes are normal. Thymus abnormalities are common, and thymectomy is part of treatment.

Treatment includes acetylcholinesterase inhibitors (pyridostigmine), corticosteroids and other immunosuppressants, and IVIG or plasma exchange for crises. Two emergencies matter:

  • Myasthenic crisis: respiratory and bulbar failure, often triggered by infection, surgery or drugs such as aminoglycosides.
  • Cholinergic crisis: weakness from excess anticholinesterase drug, with salivation, sweating, diarrhea, small pupils and bradycardia.

For therapy, schedule exercise when the medication is at peak effect (commonly about one to two hours after a pyridostigmine dose) and when fatigue is low (often the morning). Use short bouts with rest, avoid exhaustion and heat, and monitor breathing and swallowing; moderate exercise is safe in stable MG.

Lambert Eaton myasthenic syndrome is an autoimmune attack on presynaptic voltage gated calcium channels, so less acetylcholine is released. Strength and reflexes briefly improve with repeated effort (facilitation), the weakness is proximal and in the legs, autonomic symptoms such as dry mouth are common, and about half the cases are associated with small cell lung cancer. A patient with new proximal weakness, dry mouth and a smoking history needs referral to look for a tumor.

Muscular dystrophies

DystrophyGeneticsOnset and patternKey points for PT
Duchenne (DMD)X linked recessive; dystrophin absent; boysAge 2 to 5; proximal weakness (hips first), Gowers sign, calf pseudohypertrophy, toe walking, lumbar lordosis, waddling gaitLoss of ambulation commonly between about 10 and 14 years (later with corticosteroids); scoliosis, cardiomyopathy and respiratory failure; avoid eccentric and high resistance exercise
BeckerX linked recessive; dystrophin reduced or abnormalLater onset (often 5 to 15) and slower courseUsually walks beyond age 16, often into adulthood; cardiomyopathy may dominate
Myotonic dystrophy type 1Autosomal dominant (CTG repeat)Adolescence or adulthood; distal and facial weakness, myotonia (delayed relaxation of grip), ptosisCataracts, cardiac conduction defects, insulin resistance, frontal balding
FacioscapulohumeralAutosomal dominantTeens to adulthood; facial weakness (cannot whistle or close eyes tightly), scapular winging, weak biceps and tricepsOften asymmetric; normal life span; shoulder orthoses and scapular stabilization

In Duchenne muscular dystrophy, the absence of dystrophin leaves the membrane fragile, so contraction, especially eccentric, tears fibers that are replaced by fat and connective tissue. Creatine kinase is markedly elevated. The Gowers sign (climbing up the thighs to stand) reflects hip extensor weakness. Plan ahead:

  • Prevent contractures: daily stretching of heel cords, hamstrings, hip flexors and iliotibial bands, night resting ankle foot orthoses, and standing programs.
  • Exercise: submaximal swimming, cycling and play; avoid eccentric work and exhaustion. Muscle pain or dark urine after exercise signals overwork.
  • Mobility, spine and breathing: knee ankle foot orthoses may prolong standing; then a power wheelchair with postural support. Monitor scoliosis, teach assisted cough, and support cardiac and vital capacity monitoring.
Key point

Localize first: fasciculations point to the anterior horn cell, stocking glove sensory loss to the peripheral nerve, fatigable weakness to the neuromuscular junction, and proximal weakness with a Gowers sign to muscle. Then dose exercise to the disease: avoid overwork in GBS, ALS, post polio syndrome and dystrophy, time it to medication in myasthenia, and protect insensate feet in diabetic neuropathy.

Section 4Vestibular disorders

The vestibular system in brief

Each inner ear contains three semicircular canals (anterior, posterior and horizontal) that sense angular acceleration, and two otolith organs (utricle and saccule) that sense linear acceleration and head tilt relative to gravity. The utricle contains calcium carbonate crystals called otoconia. The canals work in push pull pairs: turning the head right excites the right horizontal canal. Vestibular signals drive the vestibulo ocular reflex (VOR), which moves the eyes opposite to the head to keep images stable on the retina, and the vestibulospinal reflexes, which keep the body upright. A mismatch between the two sides produces vertigo (an illusion of movement) and nystagmus, a rhythmic eye movement with a slow drift and a fast corrective beat. Nystagmus is named by the direction of its fast phase.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Otoconia dislodge from the utricle and move into a semicircular canal. In canalithiasis, the debris floats freely in the canal and drags the endolymph when the head moves into the plane of that canal, causing brief vertigo with a short latency. In cupulolithiasis, debris sticks to the cupula and makes it gravity sensitive, causing vertigo and nystagmus that persist as long as the head stays in the provoking position.

Spells of spinning vertigo last seconds and are triggered by rolling in bed, lying down or looking up; hearing and the neurologic examination are normal.

  • Posterior canal BPPV is by far the most common (roughly 80 to 90 percent), because the posterior canal is the lowest part of the labyrinth when upright and supine.
  • Horizontal (lateral) canal BPPV accounts for most of the rest.
  • Anterior canal BPPV is rare.

Positional tests and treatment by canal

The Dix-Hallpike test examines the posterior (and anterior) canal. The patient sits long sitting on the table, the head is rotated 45 degrees toward the side being tested, and the patient is brought quickly back to supine with the neck extended about 20 degrees over the end of the table. The examiner watches the eyes for 30 to 60 seconds. Posterior canal canalithiasis produces upbeating and torsional nystagmus (top of the eye beating toward the down, affected ear) after a few seconds of latency, lasting under 60 seconds and fatiguing with repetition. The side-lying test is an alternative when neck extension is unsafe.

The supine roll test examines the horizontal canal: with the patient supine and the head flexed about 30 degrees, the head is rotated quickly about 90 degrees to each side. Horizontal canal BPPV produces horizontal nystagmus on both sides.

  • Geotropic nystagmus (beating toward the ground on each side) indicates canalithiasis; the side with the stronger nystagmus and symptoms is the affected side.
  • Apogeotropic nystagmus (beating away from the ground) indicates cupulolithiasis (or debris near the cupula); the side with the weaker response is usually the affected side.
CanalTestNystagmusTreatment
Posterior, canalithiasisDix-Hallpike or side-lyingUpbeating and torsional toward the affected (down) ear; latency, under 60 seconds, fatigableCanalith repositioning maneuver (Epley) or Semont liberatory maneuver
Posterior, cupulolithiasisDix-HallpikeSame direction but persists more than 60 seconds while the position is heldSemont liberatory maneuver (or modified Epley)
Horizontal, canalithiasisSupine roll testGeotropic horizontal; stronger toward the affected sideRoll maneuver toward the unaffected side (barbecue or Lempert roll), Gufoni maneuver, or prolonged positioning lying on the unaffected side
Horizontal, cupulolithiasisSupine roll testApogeotropic horizontal; persistent; weaker toward the affected sideGufoni or modified maneuvers to free debris, then treat as canalithiasis
AnteriorDix-Hallpike (either side) or deep head hangingDownbeating with a torsional componentDeep head hanging maneuver; rule out central causes of downbeat nystagmus

The Epley canalith repositioning maneuver for right posterior canal BPPV proceeds through four positions, holding each until the nystagmus stops (generally at least 30 seconds to a minute): (1) from sitting, head turned 45 degrees to the right, recline into the right Dix-Hallpike position; (2) turn the head 90 degrees to the left so it is 45 degrees to the left, keeping the neck extended; (3) roll the body onto the left side while turning the head another 90 degrees so the face points toward the floor; (4) return to sitting with the head slightly flexed. The goal is to move the otoconia around the canal and out into the utricle. One or two maneuvers resolve the problem in most patients. Post maneuver restrictions are no longer routinely recommended; Brandt-Daroff exercises are a less effective home option.

Board tip. Name the nystagmus by its fast phase and match it to the canal: upbeating torsional on Dix-Hallpike means posterior canal; horizontal on roll test means horizontal canal; downbeating means anterior canal or a central lesion. Brief nystagmus with latency means canalithiasis; nystagmus that lasts as long as the position is held means cupulolithiasis. BPPV is not treated with gaze stabilization exercises.
Case. A 68 year old woman has had brief spinning spells for two weeks when she rolls onto her left side in bed or looks up at a high shelf. In the left Dix-Hallpike position, after a 3 second delay, she develops upbeating nystagmus with a torsional fast phase toward the left ear that stops after 20 seconds. The right Dix-Hallpike test is negative. What is the best intervention?
Reasoning: The pattern (latency, duration under 60 seconds, upbeating torsional nystagmus toward the down ear) identifies left posterior canal canalithiasis, so the treatment is a left canalith repositioning maneuver (Epley), starting in the left Dix-Hallpike position. Gaze stabilization exercises treat hypofunction, not BPPV, and a right sided maneuver treats the wrong ear. Safety point: screen the neck and vertebral arteries before extending and rotating the neck, have her sit for a few minutes before standing, and guard her because she may feel unsteady.

Unilateral vestibular hypofunction

Sudden loss of function in one labyrinth or vestibular nerve creates a large imbalance between the two sides. Vestibular neuritis (inflammation of the vestibular nerve, presumed viral) presents with acute, continuous, severe vertigo lasting days, nausea and vomiting, imbalance (veering toward the affected side), and spontaneous horizontal torsional nystagmus beating away from the affected ear. The nystagmus follows Alexander's law (stronger when gazing in the direction of the fast phase) and is suppressed by visual fixation. Hearing is normal. Labyrinthitis produces the same picture plus hearing loss. Vestibular schwannoma (acoustic neuroma) causes slowly progressive one sided hearing loss, tinnitus and imbalance.

The head impulse test (head thrust) checks the VOR: the examiner turns the patient's head quickly through a small angle while the patient looks at the examiner's nose. With a normal VOR the eyes stay on target. With hypofunction, turning toward the affected side produces a corrective saccade back to the target. Also measure dynamic visual acuity (losing more than two lines with head movement is abnormal), the Dizziness Handicap Inventory and the Functional Gait Assessment.

Recovery depends on central compensation, which is driven by error signals created by moving the head. Vestibular suppressants help in the first days but slow compensation if continued. Vestibular rehabilitation uses four types of exercise:

  • Adaptation (gaze stabilization): VOR times 1 (the target stays still and the head moves side to side or up and down while keeping the target in focus) and VOR times 2 (head and target move in opposite directions, a harder task). Progress speed, duration, background and posture while the target stays clear.
  • Habituation: repeated, graded exposure to movements or visual environments that provoke mild symptoms, so the brain learns to reduce its response. Best for motion provoked dizziness and visual motion sensitivity.
  • Substitution: using vision and somatosensation, or eye movements and saccades, to replace lost vestibular input; most important with bilateral loss.
  • Balance and gait training with varied surfaces, vision and head turns.

The vestibular rehabilitation clinical practice guideline recommends gaze stabilization exercises for both acute and chronic hypofunction, with a typical minimum dose of about three times per day totaling at least 12 minutes per day in acute and subacute cases, and three to five times per day totaling about 20 minutes per day in chronic cases, plus about 20 minutes per day of balance and gait exercise. A mild, short lived increase in symptoms during exercise is expected.

Bilateral vestibular hypofunction

Loss on both sides, most often from aminoglycoside ototoxicity (gentamicin), causes oscillopsia (the visual world bounces with head movement and walking), marked imbalance, especially in the dark or on uneven ground, and a high fall risk. Vertigo is usually absent because the loss is symmetric. The head impulse test is abnormal in both directions. Rehabilitation emphasizes gaze stabilization, substitution with vision and somatosensation, balance training, night lights and often a cane. Recovery is slower and less complete, and the guideline dose is higher (about three to five times per day totaling 20 to 40 minutes per day).

Meniere disease

Meniere disease (endolymphatic hydrops) produces episodic attacks of vertigo lasting about 20 minutes to 12 hours, with fluctuating low frequency sensorineural hearing loss, tinnitus and aural fullness in the affected ear. Management is medical (low sodium diet, diuretics, procedures). Vestibular rehabilitation does not help during attacks but helps once the deficit is stable.

Central versus peripheral signs

Not every dizzy patient has an ear problem. A stroke in the brainstem or cerebellum can mimic vestibular neuritis. In a patient with acute continuous vertigo and nystagmus, the bedside HINTS examination (head impulse, nystagmus, test of skew) is more sensitive for stroke than early MRI when performed by a trained examiner. A normal head impulse in an acutely vertiginous patient is a worrying sign, because the peripheral VOR is intact and the lesion is probably central.

FeaturePeripheral (labyrinth or nerve)Central (brainstem or cerebellum)
Nystagmus directionUnidirectional horizontal torsional, beats away from the lesionDirection changing with gaze, or pure vertical or pure torsional
Effect of visual fixationSuppressed by fixationNot suppressed
Head impulse testAbnormal (corrective saccade) toward the lesionUsually normal
Skew deviation (alternate cover test)AbsentMay be present (vertical eye misalignment)
HearingMay be lost (labyrinthitis, Meniere)Usually normal (exception: AICA stroke)
ImbalanceMild to moderate; can walkOften severe; may be unable to stand or walk
Other neurologic signsNoneDiplopia, dysarthria, dysphagia, ataxia, numbness, weakness
Dizzy patient: screen red flags firstNew neuro signs, sudden severe headache, new hearing loss Brief positional spellsseconds, under 1 minutetriggered by lying, rolling Acute continuous vertigolasting days, withspontaneous nystagmus Episodic attacks20 minutes to hours,hearing loss, tinnitus Dix-Hallpike andsupine roll test HINTS: head impulse,nystagmus, test of skew Audiogram andENT referral BPPVrepositioning maneuverfor the involved canal Abnormal impulse:peripheral, start VRTNormal impulse or skew:central, urgent referral Meniere diseasemedical care; VRTbetween attacks
Figure 7.4 Sorting the dizzy patient by timing and trigger. Notice that red flags come first, and that a normal head impulse test in a patient with acute continuous vertigo points toward a central cause that needs urgent referral.
Key point

BPPV is diagnosed by positional testing and treated with a maneuver matched to the canal and the type of debris. Unilateral and bilateral hypofunction are treated with gaze stabilization, habituation, substitution and balance training that drive central compensation. Central signs (direction changing nystagmus, a normal head impulse, skew deviation, severe imbalance, other neurologic deficits) require urgent referral.

Section 5Cerebellar, cranial nerve and other neurologic conditions

Bell palsy

Bell palsy is an acute, idiopathic, unilateral lower motor neuron paralysis of the facial nerve (cranial nerve VII), thought to result from swelling of the nerve in the facial canal, often linked to herpes simplex reactivation, and more common in pregnancy and diabetes. Weakness develops over hours to about three days and involves the entire half of the face: the patient cannot wrinkle the forehead, close the eye completely, smile symmetrically or puff the cheek. There may also be loss of taste on the anterior two thirds of the tongue, hyperacusis (stapedius paralysis) and pain behind the ear.

The key distinction is from a central (upper motor neuron) facial palsy, such as after a stroke. The upper face receives corticobulbar input from both hemispheres, so a unilateral cortical lesion weakens only the lower face on the opposite side and spares the forehead. A lower motor neuron lesion (Bell palsy) affects the upper and lower face on the same side.

Right Bell palsy (LMN, CN VII)Left central palsy (UMN) patient asked to close eyes, raise brows, smileafter a right hemisphere stroke Patient's rightPatient's leftPatient's rightPatient's left Right forehead smooth (cannot raise)Right eye cannot close: protect corneaRight mouth corner droopsWhole right face, same side as lesion Forehead spared on both sidesEye closure preservedLeft lower face droopsOpposite the cortical lesion
Figure 7.5 Lower versus upper motor neuron facial palsy, drawn as the examiner sees the patient (the patient's right is on the viewer's left). Notice that only the lower motor neuron lesion paralyzes the forehead and eye closure.

Most patients recover: about 70 percent fully, and as many as 85 percent or more show improvement within three weeks. Incomplete paralysis at onset, early improvement and younger age predict a good outcome. Oral corticosteroids started within 72 hours improve recovery; antivirals may be added in severe cases. The House Brackmann scale grades facial function from I (normal) to VI (total paralysis).

Physical therapy priorities:

  • Protect the eye: incomplete closure (lagophthalmos) and reduced tearing risk corneal drying and ulceration. Teach artificial tears by day, lubricating ointment and taping or a moisture chamber at night, and sunglasses outdoors.
  • Facial neuromuscular retraining: slow, small, symmetric, isolated movements in front of a mirror (mirror biofeedback), gentle massage and stretching of the affected side, and functional tasks (eating, drinking, speaking).
  • Avoid mass action: forceful, maximal grimacing and gross exercises can encourage synkinesis, the unwanted linked movements (for example the eye closing when the patient smiles) that follow aberrant regeneration. Teach the patient to suppress synkinesis by moving gently and in isolation.
  • Electrical stimulation is not recommended routinely for Bell palsy, because evidence is weak and there is concern that it may promote synkinesis.
  • Refer if there is no improvement by three to four months, or if weakness is bilateral, progressive or joined by other cranial nerve signs.
Case. A 39 year old woman woke two days ago with drooping of the right side of her mouth. She cannot raise her right eyebrow or fully close her right eye, and food collects in her right cheek. Her arms and legs are normal. She asks whether she has had a stroke. What is the most appropriate response and first intervention?
Reasoning: Whole right face weakness including the forehead indicates a lower motor neuron lesion, Bell palsy; a stroke spares the forehead. Because she is within 72 hours, she should see her physician promptly about corticosteroids. The first physical therapy priority is eye protection (lubricating drops, night taping), then gentle mirror based retraining. Vigorous grimacing exercises or routine electrical stimulation are wrong because they may promote synkinesis. Safety point: any additional neurologic sign, bilateral weakness or ear vesicles calls for urgent medical evaluation.

Other cranial nerve conditions

Nerve or conditionFindingWhat it suggests or what to do
CN III (oculomotor) palsyEye down and out, ptosis, dilated pupilA dilated pupil with ptosis can mean a compressing aneurysm or rising intracranial pressure: urgent referral
CN XI (spinal accessory) injuryWeak shoulder shrug, lateral scapular winging, drooping shoulderCommon after posterior triangle lymph node surgery; scapular strengthening and support

Cerebellar ataxia

The cerebellum compares intended with actual movement and corrects errors. Damage (stroke, tumor, MS, alcohol, hereditary ataxias) produces ataxia, poorly scaled and timed movement. Cerebellar signs appear on the same side as the lesion, because the pathways cross twice. A lesion of the midline vermis produces truncal ataxia, a wide based staggering gait and titubation (head and trunk oscillation); a lesion of a cerebellar hemisphere produces limb ataxia on the same side.

SignDescriptionTest
DysmetriaOvershooting (hypermetria) or undershooting a targetFinger to nose, heel to shin
Intention (kinetic) tremorTremor that increases as the hand approaches a targetFinger to nose, finger to examiner's finger
DysdiadochokinesiaInability to perform rapid alternating movements smoothlyRapid forearm pronation and supination, foot tapping
Rebound phenomenonFailure to check a limb when resistance is suddenly releasedRelease of resisted elbow flexion (guard the face)
Ataxic gaitWide base, irregular step length and timing, veering, staggeringGait observation, tandem walk

Unlike sensory ataxia from dorsal column or large fiber neuropathy, cerebellar ataxia is not much worse with the eyes closed, so the Romberg test is typically negative or only mildly worse; a markedly positive Romberg points to proprioceptive loss. The Scale for the Assessment and Rating of Ataxia (SARA) is the disease specific measure.

The best supported intervention is intensive, task oriented balance and coordination training with a progressively narrower base, perturbations and varied gait. Classic approaches include Frenkel exercises (slow, repetitive, visually guided movements progressing from lying to sitting to standing) and PNF techniques such as rhythmic stabilization and alternating isometrics to build proximal stability. Light weights may damp tremor during a task but do not train lasting control. Practice must be high in volume; gains fade if training stops.

Board tip. Cerebellar lesions produce ipsilateral signs; cortical lesions produce contralateral signs. A positive Romberg (much worse with eyes closed) indicates proprioceptive (sensory) ataxia, not cerebellar ataxia. For a LMN facial palsy remember "the whole half face"; for an UMN facial palsy remember "forehead spared."

Huntington disease

Huntington disease (HD) is an autosomal dominant neurodegenerative disease caused by an expanded CAG trinucleotide repeat in the huntingtin gene on chromosome 4. Each child of an affected parent has a 50 percent risk, and longer repeats cause earlier onset. Neurons of the caudate and putamen (striatum) degenerate, reducing the brake on movement and producing excessive involuntary movement. Onset is typically between 30 and 50 years, and the disease progresses over roughly 15 to 20 years to death, often from aspiration pneumonia or complications of falls.

The classic triad is:

  • Motor: chorea (brief, irregular, flowing, dance like involuntary movements), impaired voluntary movement and saccades, motor impersistence (inability to sustain a grip or tongue protrusion), dysarthria, dysphagia, and a wide based, irregular gait with sudden lurches. Late in the disease chorea often lessens and rigidity, bradykinesia and dystonia dominate. Juvenile onset (Westphal variant) presents with rigidity rather than chorea.
  • Cognitive: executive dysfunction, slowed processing and eventually dementia.
  • Psychiatric: depression, irritability, apathy, impulsivity, obsessive behavior and an elevated suicide risk.

Therapy moves from aerobic, strength, balance and fall prevention work early, to devices, home safety and caregiver training in the middle stage, to seating, padding, positioning and skin and respiratory care late. Chorea is treated with tetrabenazine, which can worsen depression. Keep instructions simple and routine, and screen for depression and suicidal thoughts.

Vertigo and dizziness red flags

Most dizziness is benign, but some presentations demand immediate referral. Before cervical manual therapy or positional testing, screen for cervical artery dysfunction with the familiar mnemonic of the 5 Ds and 3 Ns: dizziness, diplopia, dysarthria, dysphagia, drop attacks, and nausea, numbness, nystagmus, plus ataxia of gait.

Red flagConcernAction
Vertigo with new diplopia, dysarthria, dysphagia, facial numbness, limb weakness or ataxiaPosterior circulation stroke or TIAEmergency services
Sudden severe headache or new neck pain with dizziness, especially after neck trauma or manipulationVertebral or carotid artery dissection, hemorrhageEmergency evaluation; no neck manual therapy
Sudden hearing loss in one ear with or without vertigoSudden sensorineural hearing loss, labyrinthine infarctSame day medical referral; steroids are time sensitive
Dizziness with chest pain, palpitations, syncope or exertionCardiac arrhythmia or structural heart diseaseMedical evaluation; check vital signs
Lightheadedness when standing, with a blood pressure dropOrthostatic hypotension (medication, dehydration, autonomic failure)Measure orthostatic vitals, communicate with the physician

Distinguish vertigo (a spinning or moving illusion, usually vestibular) from presyncope (lightheadedness, near fainting, usually cardiovascular or orthostatic) and disequilibrium (imbalance without a head sensation, often from neuropathy, cerebellar or multisensory loss).

Key point

Bell palsy is a lower motor neuron facial palsy involving the whole half face; protect the eye and retrain gently to avoid synkinesis. Cerebellar ataxia produces ipsilateral dysmetria, intention tremor and a wide based gait and responds to intensive balance and coordination practice. Huntington disease combines chorea, cognitive decline and psychiatric change, and dizziness with any neurologic or vascular red flag needs immediate referral.

The chapter in one breath

  • Parkinson disease causes rest tremor, rigidity (velocity independent), bradykinesia and postural instability; postural instability marks Hoehn and Yahr stage 3.
  • Train PD patients during the on phase with vigorous aerobic exercise, amplitude based training, and external cues (visual, auditory, attentional) for freezing.
  • Multiple sclerosis is CNS demyelination with fatigue and heat sensitivity (Uhthoff); exercise in a cool setting with rest breaks and teach the four Ps of energy conservation.
  • ALS shows both UMN and LMN signs with spared sensation, eye movements and continence; avoid overwork, anticipate equipment, and monitor vital capacity.
  • Localize weakness: fasciculations (anterior horn), stocking glove sensory loss (nerve), fatigable weakness (NMJ), proximal weakness with Gowers sign (muscle).
  • The 10 gram monofilament detects loss of protective sensation; a hot swollen insensate foot is Charcot until proven otherwise.
  • Myasthenia gravis weakens with use and improves with rest (exercise at peak drug effect); Lambert Eaton improves with use and suggests small cell lung cancer.
  • Posterior canal BPPV gives upbeating torsional nystagmus on Dix-Hallpike and is treated with the Epley maneuver; horizontal canal BPPV is tested with the supine roll test.
  • Gaze stabilization (VOR times 1 and times 2), habituation and substitution treat hypofunction; a normal head impulse with acute vertigo suggests a central cause.
  • Bell palsy involves the forehead (LMN); a central palsy spares it. Protect the eye and avoid mass action exercise that promotes synkinesis.

Words worth knowing

TermWhat it means
BradykinesiaSlowness of movement, with progressive reduction in amplitude and speed during repeated movement; a cardinal sign of Parkinson disease.
FestinationInvoluntary acceleration of short, shuffling steps as the patient tries to keep up with a forward shifted center of mass.
Freezing of gaitA brief, sudden inability to start or continue stepping despite the intention to walk, often at doorways and turns.
Uhthoff phenomenonTemporary worsening of MS symptoms with a rise in body temperature that resolves with cooling.
FasciculationA visible spontaneous twitch of a group of muscle fibers from one motor unit, a lower motor neuron sign.
Overwork weaknessA loss of strength after excessive exercise of muscles with reduced motor unit reserve, as in ALS, GBS and post polio syndrome.
Albuminocytologic dissociationHigh protein with a normal white cell count in cerebrospinal fluid, typical of Guillain Barre syndrome.
Loss of protective sensationInability to feel the 10 gram monofilament on the foot, indicating high risk for unnoticed injury and ulcers.
Gowers signUsing the hands to climb up the thighs when rising from the floor, from hip extensor weakness.
CanalithiasisFree floating otoconia in a semicircular canal that cause brief positional vertigo after a short latency.
CupulolithiasisOtoconia attached to the cupula, causing positional nystagmus that persists while the position is held.
Dix-Hallpike testA positional test for posterior and anterior canal BPPV with the head turned 45 degrees and extended below horizontal.
Canalith repositioning maneuverA sequence of head positions (such as the Epley maneuver) that moves otoconia out of a canal into the utricle.
Vestibulo ocular reflexThe reflex that moves the eyes equally and opposite to head movement to keep vision stable.
Gaze stabilization exerciseAdaptation exercise in which the patient keeps a target in focus while moving the head (VOR times 1 or times 2).
Head impulse testA quick small head rotation that reveals a corrective saccade when the VOR on that side is deficient.
Skew deviationVertical misalignment of the eyes from a brainstem or cerebellar lesion, a central sign.
SynkinesisUnwanted movement accompanying a voluntary movement after nerve regeneration, such as eye closure with smiling after Bell palsy.
DysmetriaInaccurate range or force of movement, overshooting or undershooting a target, from cerebellar dysfunction.
ChoreaBrief, irregular, flowing involuntary movements, the hallmark motor sign of Huntington disease.

Check yourself

A patient with Parkinson disease has bilateral signs and needs two backward steps plus help from the examiner to recover on the pull test, but lives independently. What is the Hoehn and Yahr stage, and what becomes a main focus of therapy?
Answer. Stage 3. Postural instability with physical independence defines stage 3, so fall prevention, balance training and cueing strategies move to the center of the plan.
Why should physical therapy for a patient with Parkinson disease usually be scheduled about an hour after a carbidopa levodopa dose?
Answer. That is the on period, when the medication is effective, mobility is best and motor learning is easiest. Performance during wearing off periods is poorer and fall risk is higher.
A patient with MS becomes weak and has blurred vision after 15 minutes on a bike in a warm gym. Symptoms resolve 30 minutes after resting in a cool room. What happened, and how should the program change?
Answer. The Uhthoff phenomenon, a temporary heat related conduction block in demyelinated axons, not a relapse. Continue exercise in a cool setting with pre cooling and interval rest.
Which findings in ALS point to the upper motor neuron and which to the lower motor neuron, and which functions are typically spared?
Answer. Upper motor neuron: spasticity, hyperreflexia, Babinski sign. Lower motor neuron: weakness, atrophy, fasciculations, cramps. Sensation, eye movements, and bowel and bladder control are usually spared.
During the plateau phase of Guillain Barre syndrome, which exercise approach is safest, and what sign means the dose was too high?
Answer. Low intensity, low repetition, frequently rested exercise with gradual progression. Increased weakness, cramping or fatigue that persists into the next day indicates overwork.
A patient has ptosis and diplopia that worsen in the evening and improve after rest. Strength is normal in the morning. Where is the lesion, and when should exercise be scheduled?
Answer. The postsynaptic neuromuscular junction (myasthenia gravis). Schedule exercise in the morning and near the peak effect of pyridostigmine, about one to two hours after a dose, with frequent rests.
On the right Dix-Hallpike test, a patient develops upbeating nystagmus with a torsional fast phase toward the right ear that lasts 2 minutes and does not fade while the head is held in position. What is the diagnosis?
Answer. Right posterior canal cupulolithiasis, because the nystagmus persists for more than 60 seconds while the position is held. A Semont liberatory maneuver is typically chosen.
The supine roll test produces geotropic horizontal nystagmus on both sides, stronger with the head turned to the left. Which canal and side are involved?
Answer. Left horizontal canal canalithiasis. With geotropic nystagmus the side with the stronger response is affected; treat with a roll maneuver toward the unaffected (right) side or the Gufoni maneuver.
A patient with gentamicin toxicity reports that signs seem to bounce when she walks and that she falls in the dark. What is the condition, and which exercise types are emphasized?
Answer. Bilateral vestibular hypofunction with oscillopsia. Emphasize gaze stabilization to use remaining function, substitution with vision and somatosensation, balance and gait training on varied surfaces, and safety measures such as night lights and a cane.
How do you distinguish Bell palsy from a facial palsy caused by stroke at the bedside?
Answer. Ask the patient to raise the eyebrows. Bell palsy (lower motor neuron) paralyzes the forehead and eye closure on the same side; a stroke (upper motor neuron) spares the forehead because the upper face has bilateral cortical input, and affects the lower face opposite the lesion.
Chapter 8 · Cardiopulmonary

Cardiovascular and Pulmonary Foundations: Physiology, Examination and Monitoring

Every exercise prescription is a request for more oxygen, and the heart, lungs and blood decide whether the body can meet it. On the licensing exam, cardiovascular and pulmonary questions rarely ask for physiology for its own sake: they ask whether a patient is safe to treat, when to stop, and what a number or rhythm means for the session in front of you. This chapter builds the physiology, monitoring, ECG, auscultation, imaging, pulmonary function, blood gas and laboratory knowledge that lets you answer those questions with confidence.

By the end of this chapter you can

  • Trace the cardiac cycle and conduction system and explain cardiac output, preload, afterload and the Frank Starling mechanism.
  • Define the lung volumes and capacities, explain ventilation perfusion matching, and calculate oxygen content and delivery.
  • State normal vital signs and the normal and abnormal responses to exercise, including rate pressure product and RPE.
  • Manage common lines and tubes and oxygen delivery devices safely in acute care.
  • Recognize normal sinus rhythm, atrial fibrillation, PVCs, ventricular tachycardia, heart blocks and ischemic ST changes, and decide when to stop exercise.
  • Interpret breath sounds, chest radiograph findings and obstructive versus restrictive pulmonary function patterns.
  • Analyze arterial blood gases step by step.
  • Apply laboratory values (hemoglobin, hematocrit, platelets, INR, glucose, potassium, troponin) and termination criteria to exercise decisions.

Section 1Cardiac and pulmonary physiology for the clinician

The cardiac cycle

The cardiac cycle has two main phases. During systole the ventricles contract: first with all valves closed (isovolumetric contraction), then, once ventricular pressure exceeds aortic and pulmonary pressure, with the semilunar valves open (ejection). During diastole the ventricles relax with all valves closed (isovolumetric relaxation), then the atrioventricular valves open and the ventricles fill, first passively and finally with the atrial kick, which supplies about 15 to 30 percent of filling and is lost in atrial fibrillation.

  • S1 is closure of the mitral and tricuspid valves at the start of systole; S2 is closure of the aortic and pulmonic valves at the start of diastole.
  • S3 (ventricular gallop, "Ken-tuc-ky") occurs in early diastole from rapid filling of a volume overloaded ventricle; it is a classic sign of heart failure in adults (normal in children and young athletes).
  • S4 (atrial gallop, "Ten-nes-see") occurs just before S1 as the atrium pushes blood into a stiff ventricle (hypertension, hypertrophy, ischemia).
  • Murmurs come from turbulent flow across stenotic or leaking valves. Aortic stenosis causes a systolic murmur and can produce exertional syncope, angina and dyspnea; severe symptomatic aortic stenosis is a contraindication to exercise.

The coronary arteries fill mainly during diastole, so tachycardia, which shortens diastole, reduces supply at the same time it raises demand. The right coronary artery usually supplies the right ventricle, the inferior wall, the SA node (in about 60 percent of people) and the AV node (in most), which is why inferior infarctions often cause bradycardia and heart block. The left anterior descending artery supplies the anterior wall and most of the septum, and the circumflex supplies the lateral wall.

Cardiac output and its determinants

Cardiac output (CO) is heart rate times stroke volume, about 4 to 8 L/min at rest (roughly 5 L/min). Stroke volume depends on three factors:

  • Preload: ventricular stretch at the end of diastole (end diastolic volume). By the Frank Starling mechanism, more stretch produces a stronger contraction, up to a limit; a failing heart is on the flat part of the curve.
  • Afterload: the resistance the ventricle must overcome, mainly arterial pressure and aortic valve resistance. Hypertension and aortic stenosis raise afterload.
  • Contractility: the intrinsic force of contraction at a given preload, increased by sympathetic stimulation and inotropes such as dobutamine.

Ejection fraction (EF) is stroke volume divided by end diastolic volume; normal is about 55 to 70 percent. Heart failure with reduced EF is defined by an EF of 40 percent or less, and heart failure with preserved EF by 50 percent or more. Blood pressure equals cardiac output times total peripheral resistance. Mean arterial pressure (MAP) is approximately diastolic pressure plus one third of the pulse pressure; a MAP of at least about 65 mmHg is needed to perfuse vital organs.

Conduction

The sinoatrial (SA) node is the normal pacemaker, firing 60 to 100 times per minute. The impulse spreads through the atria to the atrioventricular (AV) node, which delays it (the PR interval) so the atria can finish emptying, then travels down the bundle of His, the right and left bundle branches and the Purkinje fibers. If higher pacemakers fail, lower tissues take over at slower intrinsic rates: AV junction about 40 to 60 per minute and ventricles about 20 to 40 per minute. Sympathetic stimulation raises rate and contractility; vagal (parasympathetic) stimulation slows the SA node and AV conduction.

Lung volumes and ventilation

Four volumes add up to total lung capacity, and capacities are sums of two or more volumes. Residual volume cannot be measured by simple spirometry (it requires body plethysmography or gas dilution), so neither can FRC or TLC.

Volume or capacityDefinitionTypical adult valueChange in disease
Tidal volume (TV)Air moved in a normal breathAbout 500 mLFalls in restrictive disease; rapid shallow breathing
Inspiratory reserve volume (IRV)Extra air inhaled after a normal inspirationAbout 3,000 mLReduced in both patterns
Expiratory reserve volume (ERV)Extra air exhaled after a normal expirationAbout 1,100 to 1,200 mLReduced in obesity and restriction
Residual volume (RV)Air left after maximal expirationAbout 1,200 mLIncreased in obstruction (air trapping)
Vital capacity (VC)IRV + TV + ERVAbout 4,800 mLReduced in both, most in restriction
Functional residual capacity (FRC)ERV + RV; volume at rest after quiet expirationAbout 2,400 mLIncreased in obstruction, decreased in restriction
Inspiratory capacity (IC)TV + IRVAbout 3,600 mLReduced with hyperinflation
Total lung capacity (TLC)All four volumesAbout 6,000 mLNormal or increased in obstruction, decreased in restriction
Lung volumes and capacities (healthy young adult) Tidal breathingMaximal inspirationMaximal expirationBottom line = 0 mL (no air); bars drawn to scale IRV 3,100 mLTV 500 mLERV 1,200 mLRV 1,200 mL IC 3,600 mLFRC 2,400 mL VC 4,800 mLTLC 6,000 mL
Figure 8.1 Lung volumes and capacities. Notice that residual volume never leaves the lungs, so spirometry alone cannot measure RV, FRC or TLC, and that FRC is the resting level at the end of a quiet breath.

Minute ventilation is tidal volume times respiratory rate, about 6 L/min at rest. Only the part that reaches perfused alveoli takes part in gas exchange: alveolar ventilation equals (tidal volume minus dead space) times rate. Anatomic dead space is about 150 mL (roughly 1 mL per pound of ideal body weight), so rapid shallow breathing wastes a larger share of each breath. Pursed lip and diaphragmatic breathing slow the rate and increase tidal volume, improving alveolar ventilation.

Inspiration is active (mainly the diaphragm, innervated by the phrenic nerve, C3 to C5, with the external intercostals); quiet expiration is passive elastic recoil. Accessory inspiratory muscles (sternocleidomastoid, scalenes, upper trapezius, pectorals) are recruited in distress and in hyperinflation, and forced expiration uses the abdominals and internal intercostals.

Ventilation and perfusion

In the upright lung, both ventilation and perfusion are greater at the bases than the apices, because gravity pulls blood down and the dependent alveoli are on a steeper, more compliant part of their pressure volume curve. Perfusion changes more steeply than ventilation, so the V/Q ratio is highest at the apex (about 3) and lowest at the base (about 0.6); the whole lung averages about 0.8. The two extremes of mismatch are:

  • Dead space (ventilation without perfusion, V/Q approaching infinity), as in pulmonary embolism.
  • Shunt (perfusion without ventilation, V/Q of zero), as in atelectasis, pneumonia filling alveoli or pulmonary edema. Hypoxemia from a true shunt responds poorly to supplemental oxygen.

Positioning uses gravity: in an adult with unilateral lung disease, placing the good lung down sends more blood and ventilation to the healthy lung and improves oxygenation. Exceptions include a lung abscess or pulmonary hemorrhage (keep the affected lung down so material does not spill into the good lung) and infants, in whom ventilation favors the uppermost lung.

Oxygen transport

Almost all oxygen in blood is bound to hemoglobin. Arterial oxygen content (CaO2) = (1.34 × Hb × SaO2) + (0.003 × PaO2), about 20 mL O2 per 100 mL of blood normally. Oxygen delivery = cardiac output × CaO2. The equation explains why anemia, low saturation and low cardiac output each limit exercise. The Fick equation states that oxygen consumption (VO2) = cardiac output × arteriovenous oxygen difference; training raises VO2max through both larger stroke volume and better extraction.

The oxyhemoglobin dissociation curve is S shaped. A PaO2 of 60 mmHg corresponds to an SaO2 of about 90 percent, at the shoulder of the curve; below that, small falls in PaO2 cause large falls in saturation. A right shift (lower affinity, easier unloading to tissues) is caused by increased temperature, increased CO2, acidosis (increased H+) and increased 2,3-BPG, all of which occur in exercising muscle. A left shift (higher affinity) occurs with alkalosis, hypothermia, carbon monoxide and fetal hemoglobin.

Board tip. Remember "60 equals 90": PaO2 60 mmHg is about SpO2 90 percent, the threshold usually used for supplemental oxygen. A right shift helps muscles unload oxygen ("CADET, face right": CO2, acid, 2,3-DPG, exercise, temperature). Ventilation and perfusion are both greatest at the bases, but the V/Q ratio is greatest at the apex.
Case. A 66 year old man in the ICU has right lower lobe pneumonia. His SpO2 is 88 percent supine on 4 L/min oxygen by nasal cannula. The nurse asks how to position him to improve oxygenation.
Reasoning: Consolidated alveoli create a shunt. In side lying, gravity sends more perfusion to the dependent lung, so placing the healthy left lung down (right side up) matches blood flow to ventilated alveoli and usually raises saturation; it also places the involved lobe uppermost to help drainage. Lying on the right side would send more blood to the shunt and worsen oxygenation. The exception would be an abscess or bleeding, where you keep the affected lung down. Safety point: watch SpO2, heart rate and the tolerance of the position, and return to a safer position if saturation falls.
Key point

Cardiac output is heart rate times stroke volume, and stroke volume depends on preload, afterload and contractility. The lungs are divided into four volumes that build four capacities; ventilation and perfusion are greatest at the bases, with dead space and shunt at the extremes of mismatch. Oxygen delivery depends on cardiac output, hemoglobin and saturation, and PaO2 60 equals SaO2 about 90 percent.

Section 2Vital signs and monitoring

Resting values

MeasureNormal adult valueNotes for the therapist
Heart rate60 to 100 bpmBelow 60 is bradycardia (normal in trained athletes and with beta blockers); above 100 is tachycardia. Infants about 100 to 160; children decline toward adult values.
Respiratory rate12 to 20 breaths/minAbove 20 at rest (tachypnea) is an early sign of deterioration; infants 30 to 60
Blood pressureNormal below 120/80 mmHgElevated 120 to 129 and below 80; stage 1 hypertension 130 to 139 or 80 to 89; stage 2 at least 140 or at least 90; crisis above 180 and/or above 120
Oxygen saturation (SpO2)95 to 100 percentBelow 90 percent usually needs oxygen; some patients with COPD have a prescribed target of 88 to 92 percent
TemperatureAbout 97 to 99.5 degrees F (36.1 to 37.5 C)Fever (often defined as 100.4 F, 38 C, or higher) raises heart rate and oxygen demand
Pain0 to 10 numeric scaleOften called the fifth vital sign; reassess with activity

Measure blood pressure with the patient seated, back supported, feet flat, arm supported at heart level, after five minutes of rest, with a cuff whose bladder encircles about 80 percent of the arm. A cuff that is too small gives a falsely high reading. Do not take blood pressure in an arm with a PICC line, arteriovenous fistula, lymphedema risk after node dissection, or an arterial line. Orthostatic hypotension is a fall of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing, often with dizziness and a compensatory rise in heart rate; it is common after bed rest, with dehydration, diuretics, antihypertensives, Parkinson disease and spinal cord injury.

Normal and abnormal exercise responses

During graded aerobic exercise:

  • Heart rate rises roughly linearly with workload (about 10 bpm per MET in an untrained person) until near maximum. Age predicted maximum is 220 minus age; the Tanaka formula, 208 minus 0.7 times age, is more accurate in older adults.
  • Systolic blood pressure rises roughly 8 to 12 mmHg per MET (about 10), often reaching 160 to 220 mmHg at peak.
  • Diastolic blood pressure stays about the same or changes by no more than about 10 mmHg, because peripheral resistance falls as muscle vessels dilate.
  • Respiratory rate and tidal volume rise; SpO2 stays stable in healthy people.

Abnormal responses that signal a problem include a fall in systolic pressure of more than 10 mmHg as workload increases (suggesting the heart cannot raise output, as with ischemia or severe heart failure), a failure of systolic pressure to rise (flat response), a hypertensive response (systolic above 250 mmHg or diastolic above 115 mmHg is the usual stopping point), a rise in diastolic pressure of more than 10 mmHg, an excessive or inappropriately low heart rate response (chronotropic incompetence), and a fall in SpO2 below about 88 to 90 percent.

Cardiovascular response to graded exercise RestPeakWorkload (METs) Response (schematic) Systolic BPHeart rateAbnormal: SBPfalls, stopDiastolic BP HR rises about 10 bpm per MET; SBP rises about 10 mmHg per MET; DBP stays within about 10 mmHg. Stop for SBP falling more than 10 mmHg, SBP over 250, or DBP over 115 mmHg.
Figure 8.2 Normal and abnormal blood pressure and heart rate responses to graded exercise. Notice that diastolic pressure stays nearly flat, and that a systolic pressure that falls as work rises is a reason to stop.

Intensity tools: heart rate reserve, RPE and METs

The Karvonen (heart rate reserve) method: target HR = [(HRmax minus HRrest) × intensity] + HRrest. Moderate intensity is about 40 to 59 percent of heart rate reserve and vigorous about 60 to 89 percent. For a 60 year old with a resting HR of 70: HRmax 160, reserve 90, and 50 percent intensity gives 45 + 70 = 115 bpm.

Beta blockers blunt resting and exercise heart rate (and blood pressure), so heart rate targets from age formulas are invalid; use RPE, a target from a medicated exercise test, or a heart rate rise above resting. The Borg RPE scale runs from 6 to 20 (roughly heart rate divided by 10 in healthy adults); 12 to 13 ("somewhat hard") is moderate intensity and 11 to 13 is a common target in cardiac rehabilitation. The Borg CR10 scale runs from 0 to 10, where 3 to 4 is moderate. The talk test is a practical check: at moderate intensity a person can talk but not sing. Dyspnea scales (0 to 4 or the modified Borg) and angina scales (1 to 4) guide symptom limited exercise.

One MET is the resting oxygen consumption, about 3.5 mL O2/kg/min. Self care is about 1 to 3 METs, walking at 3 mph about 3.3 METs, and stair climbing about 4 to 8 METs.

Rate pressure product

The rate pressure product (RPP, double product) is heart rate times systolic blood pressure. It is an index of myocardial oxygen demand. A patient with stable angina has symptoms at a fairly reproducible RPP, the ischemic threshold, so keeping exercise below that RPP prevents angina. Training lowers the HR and blood pressure at any submaximal workload, so the patient can do more work before reaching the threshold. Nitroglycerin and beta blockers raise the work achievable before angina by lowering demand.

Board tip. For a patient on a beta blocker, choose RPE (11 to 13) rather than an age predicted target heart rate. The rate pressure product (HR × SBP) reflects myocardial oxygen demand, and it, not heart rate alone, predicts when angina will start. A drop in systolic pressure with increasing work is always abnormal.

Pulse oximetry

The pulse oximeter estimates arterial saturation from light absorption. It is unreliable with poor perfusion (cold hands, shock, vasoconstriction), motion, dark nail polish, and carbon monoxide poisoning, which produces falsely normal readings because carboxyhemoglobin is read as oxyhemoglobin. It can overestimate saturation in people with darker skin pigmentation. It says nothing about CO2; trust it only with a good waveform.

Lines, tubes and oxygen in acute care

DevicePurposePT implications
Peripheral IVFluids and drugsAvoid tension on tubing; watch for infiltration (swelling, coolness) and keep the pump with the patient
Arterial lineContinuous blood pressure and blood draws, usually radialDislodgement causes brisk bleeding; avoid excessive wrist motion; no cuff on that arm
Central venous catheter, PICCLong term medications, nutrition, central pressureNo blood pressure cuff on the PICC arm; avoid pulling; risk of air embolism if open
Pulmonary artery (Swan Ganz) catheterPulmonary artery and wedge pressures, cardiac outputActivity often limited; avoid hip flexion with a femoral insertion; coordinate with nursing
Intracranial pressure monitorMeasures ICP (normal about 5 to 15 mmHg)Head of bed about 30 degrees, neutral neck; avoid activity that raises ICP above about 20 mmHg
Chest tubeDrains air (pneumothorax) or fluid (effusion, blood)Keep the drainage unit upright and below the chest; do not clamp; tidaling is normal, continuous bubbling in the water seal suggests an air leak
Endotracheal tube and mechanical ventilationAirway and ventilatory supportEarly mobility is safe with team coordination; avoid tension on the tube; watch SpO2, rate and synchrony
Nasogastric or feeding tubeFeeding, drainageKeep the head of bed at least 30 degrees during feeds; pause feeds before lying flat per protocol
Urinary (Foley) catheterBladder drainageKeep the bag below bladder level and off the floor; avoid kinks

Oxygen delivery devices differ in flow and fraction of inspired oxygen (FiO2). A nasal cannula runs at 1 to 6 L/min (each liter adds roughly 3 to 4 percent above room air's 21 percent, up to about 44 percent). A simple face mask uses 5 to 10 L/min (about 35 to 55 percent). A Venturi mask delivers a precise FiO2 (about 24 to 50 percent), useful in COPD. A nonrebreather mask with reservoir at 10 to 15 L/min delivers high concentrations (roughly 60 to 90 percent or more). High flow nasal cannula delivers heated humidified gas at up to about 60 L/min with FiO2 up to 100 percent. Oxygen is a prescribed drug: during exercise the therapist may adjust within the order (often to keep SpO2 at or above 90 percent, or the prescribed range) but not beyond it.

Case. A 58 year old woman on a cardiac step down unit, taking metoprolol, walks 150 feet with a therapist. Her resting HR is 64 bpm and BP 128/76; after walking, HR is 78, BP 112/74, and she reports feeling lightheaded with an RPE of 15. What should the therapist do?
Reasoning: A drop in systolic pressure of 16 mmHg with increased activity plus lightheadedness is an abnormal response suggesting inadequate cardiac output or ischemia, and the high RPE shows the workload is too hard; the modest HR rise is expected with a beta blocker and is not reassuring. The therapist should stop, sit her down, recheck vital signs, and notify the nurse or physician. Continuing because her heart rate is "only 78" is the tempting wrong answer. Safety point: on beta blockers, rely on blood pressure, symptoms and RPE, not heart rate alone.
Key point

Know the normal ranges cold, and know the normal exercise response: heart rate and systolic pressure rise with workload while diastolic pressure stays flat. A falling systolic pressure, a hypertensive response, symptoms, or desaturation below about 88 to 90 percent mean stop. Use RPE when beta blockers blunt heart rate, RPP to understand angina thresholds, and respect every line and tube.

Section 3ECG basics for physical therapists

Waves, intervals and the paper

The electrocardiogram records the heart's electrical activity, not its pumping. On standard paper running at 25 mm/s, each small box is 1 mm, 0.04 seconds wide and 0.1 mV tall; each large box (five small boxes) is 0.20 seconds. Five large boxes equal one second.

ComponentWhat it representsNormal value
P waveAtrial depolarizationUpright before each QRS; up to about 0.10 s
PR intervalStart of atrial depolarization to start of ventricular depolarization (includes AV node delay)0.12 to 0.20 s (3 to 5 small boxes)
QRS complexVentricular depolarization (atrial repolarization is hidden here)Under 0.12 s, usually 0.06 to 0.10 s
ST segmentEarly ventricular repolarization; should be at the baselineIsoelectric; deviation suggests ischemia or injury
T waveVentricular repolarizationUpright in most leads
QT intervalTotal ventricular depolarization and repolarizationCorrected QT under about 0.44 s (varies with rate and sex); prolonged QT risks torsades de pointes

To find the heart rate of a regular rhythm, divide 300 by the number of large boxes between two R waves (or 1,500 by the number of small boxes). The sequence 300, 150, 100, 75, 60, 50 gives the rate for R waves one to six large boxes apart. For an irregular rhythm, count the QRS complexes in a 6 second strip and multiply by 10.

Read systematically: rate, regularity, a P before every QRS, PR and QRS widths, then ST segments and T waves.

PQRST ST PR 0.12 to 0.20 sQRS under 0.12 sQT interval Small box0.04 sLarge box0.20 s Rate (regular rhythm)300 divided by the numberof large boxes from R to R What each wave meansP: atria depolarizeQRS: ventricles depolarizeT: ventricles repolarizeST: should sit on baseline
Figure 8.3 The normal ECG complex and paper. Notice that the PR interval runs from the start of the P wave to the start of the QRS, and that the ST segment should sit at the same level as the baseline before the P wave.

Rhythms the exam expects you to recognize

RhythmECG featuresSignificance and PT action
Sinus bradycardiaNormal complexes, rate under 60Normal in athletes and with beta blockers; concerning if symptomatic (dizziness, fatigue, hypotension)
Sinus tachycardiaNormal complexes, rate over 100Look for the cause: pain, fever, anemia, dehydration, hypoxemia, anxiety, heart failure, PE
Atrial fibrillationNo P waves, wavy baseline, irregularly irregular QRSLoss of atrial kick and stroke risk (anticoagulation). Exercise is acceptable if the rate is controlled and the patient is stable; a resting rate over about 100 to 110 or symptoms call for caution. Use RPE.
Atrial flutterSawtooth flutter waves, often 2:1 or 4:1 conductionSimilar precautions to atrial fibrillation
Premature ventricular contraction (PVC)Early, wide, bizarre QRS without a P wave, T wave opposite to QRS, compensatory pauseIsolated PVCs are common. Concern rises with frequency, couplets, bigeminy, multifocal PVCs, and PVCs that increase with exercise. Three or more in a row is ventricular tachycardia.
Ventricular tachycardia (VT)Run of wide, fast QRS complexes, rate usually over 100Stop exercise; check responsiveness and pulse. Pulseless VT needs CPR and defibrillation.
Ventricular fibrillationChaotic, irregular waves with no QRSCardiac arrest: call for help, CPR, AED
AsystoleFlat line (check leads)Cardiac arrest: CPR; not shockable
Normal sinusAtrialfibrillationPVCVentriculartachycardia P before every QRSirregular, no Pearly wide beat,then a pausewide, fast: stop
Figure 8.4 Four rhythm strips. Notice the irregular spacing and absent P waves of atrial fibrillation, the early wide complex and compensatory pause of a PVC, and the run of wide complexes in ventricular tachycardia.

Heart blocks

  • First degree AV block: PR interval longer than 0.20 s, every P conducted. Usually benign; common with beta blockers, calcium channel blockers and digoxin.
  • Second degree type I (Wenckebach, Mobitz I): the PR interval lengthens progressively until a P wave is not followed by a QRS, then the cycle repeats. Usually at the AV node, often benign.
  • Second degree type II (Mobitz II): a constant PR interval with sudden dropped QRS complexes. Below the AV node, can progress to complete block; do not exercise and notify the physician, as a pacemaker is often needed.
  • Third degree (complete) heart block: P waves and QRS complexes are independent (AV dissociation), with a slow ventricular escape rhythm. It is a contraindication to exercise and usually requires a pacemaker.

A new bundle branch block (QRS 0.12 s or wider with a characteristic shape) during exercise is a relative reason to stop.

Ischemia and infarction

The ST segment is the key to ischemia:

  • ST depression of 1 mm or more (horizontal or downsloping, measured about 80 ms after the J point) suggests subendocardial ischemia, the typical finding in exercise induced ischemia. More than 2 mm of horizontal or downsloping depression is a reason to stop exercise.
  • ST elevation in contiguous leads suggests transmural injury, as in ST elevation myocardial infarction (STEMI), a medical emergency. New ST elevation of more than 1 mm during exercise in leads without Q waves is an absolute reason to stop.
  • T wave inversion can reflect ischemia; pathologic Q waves (wide and deep) indicate an old, completed infarction.

Angina may be typical (pressure or squeezing behind the sternum that may radiate to the jaw, left arm or back, provoked by exertion and relieved by rest or nitroglycerin) or atypical. Women, older adults and people with diabetes more often present with dyspnea, fatigue, nausea, epigastric discomfort or no pain at all (silent ischemia). Stable angina occurs at a predictable workload; unstable angina (new, at rest, or worsening) is a contraindication to exercise and requires referral.

Pacemakers and implantable defibrillators

Pacemakers are described by a code: the first letter is the chamber paced, the second the chamber sensed, the third the response, and an R in the fourth position indicates rate responsiveness (the device raises the rate with activity). A paced beat shows a sharp spike before the P or QRS. Know the patient's programmed lower and upper rate limits; a patient with a fixed rate device depends on stroke volume to increase cardiac output, so monitor blood pressure and RPE. After implantation, the arm on the device side is commonly restricted from overhead motion (above about 90 degrees of flexion or abduction) and heavy lifting for about four to six weeks so the leads can anchor.

An implantable cardioverter defibrillator (ICD) detects VT or fibrillation and delivers pacing or a shock. Learn its detection rate and keep the exercise heart rate at least about 10 to 20 bpm below it, so sinus tachycardia during exercise does not trigger an inappropriate shock. If the patient receives a shock, stop, assess, and follow the facility protocol (more than one shock, or symptoms, needs emergency evaluation).

Board tip. Three or more PVCs in a row is ventricular tachycardia: stop. Mobitz II and third degree block are not safe for exercise; first degree and Wenckebach usually are. ST depression means ischemia, ST elevation means injury, and Q waves mean an old infarct.
Case. A 70 year old man in phase II cardiac rehabilitation, eight weeks after a myocardial infarction, is cycling at a moderate workload. The monitor, which showed occasional isolated PVCs at rest, now shows frequent PVCs including several couplets and one run of three wide complexes in a row. He feels "fluttery." What should the therapist do?
Reasoning: PVCs that increase in frequency with exercise, couplets, and a run of three (nonsustained ventricular tachycardia) are signs of electrical instability. Stop exercise, have him sit or lie down, monitor rhythm, blood pressure and symptoms, and notify the physician. Reducing the resistance and continuing is the tempting wrong answer, and isolated resting PVCs were not the problem. Safety point: be ready to start CPR and use the AED if he becomes unresponsive or pulseless.
Key point

Read every strip the same way: rate, regularity, P before QRS, intervals, then ST and T. Know the dangerous patterns (ventricular tachycardia and fibrillation, Mobitz II and complete block, PVCs that increase with exercise, ST changes) that mean stop or call for help, and keep exercise heart rate well below an ICD's detection rate.

Section 4Auscultation, chest imaging and pulmonary function tests

Breath sounds

Auscultate with the diaphragm on bare skin as the patient breathes through an open mouth, comparing side to side. Normal sounds depend on location:

  • Vesicular: soft and low pitched, heard over most of the lung periphery; inspiration is longer than expiration.
  • Bronchovesicular: intermediate, heard over the mainstem bronchi (between the scapulae and near the sternum); inspiration and expiration about equal.
  • Bronchial (tracheal): loud, high pitched and hollow, heard over the manubrium and trachea, with expiration longer than inspiration. Bronchial sounds heard over the periphery are abnormal and suggest consolidation, because solid lung transmits sound from the large airways.

Decreased or absent breath sounds occur with hyperinflation (emphysema), pneumothorax, pleural effusion, atelectasis with an obstructed airway, shallow breathing and obesity.

SoundDescriptionTypical causes
Fine crackles (rales)Discontinuous, brief popping, usually late inspiratory; do not clear with coughAtelectasis, pulmonary fibrosis, pulmonary edema in heart failure, early pneumonia
Coarse cracklesDiscontinuous, louder, lower pitched, in early inspiration and expirationSecretions in larger airways (bronchiectasis, bronchitis); may change with cough
WheezesContinuous, musical, high pitched, usually expiratoryNarrowed airways: asthma, COPD, bronchospasm, heart failure ("cardiac asthma")
RhonchiContinuous, low pitched, snoring qualitySecretions in large airways; often clear after coughing or airway clearance
StridorLoud, high pitched, mainly inspiratory, heard best over the neckUpper airway obstruction (croup, epiglottitis, foreign body, post extubation swelling): emergency
Pleural friction rubGrating or creaking in both phases, localizedInflamed pleura (pleurisy, pneumonia, pulmonary embolism)

Voice sounds are increased over consolidation: egophony ("ee" heard as "ay"), bronchophony (spoken words louder and clearer) and whispered pectoriloquy (whispers heard clearly). The same rule applies to tactile fremitus and percussion: consolidation increases fremitus and is dull; air or fluid between lung and wall (pneumothorax, effusion) decreases fremitus, with effusion dull and pneumothorax or emphysema hyperresonant. The trachea shifts away from a tension pneumothorax or large effusion and toward lobar collapse or a pneumonectomy.

The chest radiograph

Dense structures absorb x rays and appear white (bone, fluid, consolidated lung, heart); air appears black. Patterns to know:

  • Consolidation (pneumonia): white patch in a lobar or segmental pattern, often with air bronchograms (dark airways outlined by surrounding white alveoli).
  • Pleural effusion: blunting of the costophrenic angle and a meniscus shaped fluid line on an upright film.
  • Pneumothorax: a visible pleural line with no lung markings beyond it; tension pneumothorax shifts the mediastinum away.
  • Atelectasis: increased density with volume loss, shifting fissures, the diaphragm or trachea toward the collapse.
  • COPD (emphysema): hyperinflation with flattened diaphragms, increased anteroposterior diameter, increased retrosternal air, and a narrow vertical heart.
  • Heart failure: cardiomegaly (cardiothoracic ratio over 0.5 on a posteroanterior film), vascular redistribution to the upper lobes, Kerley B lines, perihilar "bat wing" edema and effusions.

CT pulmonary angiography is the usual test for pulmonary embolism; a V/Q scan, showing a perfusion defect in a ventilated region, is the alternative.

Pulmonary function tests

Spirometry measures how much and how fast air can be exhaled after a maximal breath. The forced vital capacity (FVC) is the total volume exhaled forcefully; the FEV1 is the volume exhaled in the first second. Their ratio, FEV1/FVC, separates the two main patterns:

MeasureObstructive (COPD, asthma, bronchiectasis, cystic fibrosis)Restrictive (fibrosis, neuromuscular weakness, chest wall deformity, obesity)
FEV1Markedly reducedReduced in proportion to FVC
FVCNormal or reduced (air trapping)Reduced
FEV1/FVCReduced (below 0.70 in the usual definition)Normal or increased
TLCNormal or increased (hyperinflation)Reduced (the defining finding)
RV and FRCIncreased (air trapping)Reduced
DLCO (diffusing capacity)Reduced in emphysema; normal in asthma and chronic bronchitisReduced in interstitial lung disease; normal in neuromuscular and chest wall causes
Flow volume loopScooped (concave) expiratory limbNarrow, tall loop ("witch's hat")

COPD severity by airflow limitation (the GOLD grades, applied when FEV1/FVC is below 0.70) uses FEV1 as a percent of predicted: grade 1 (mild) 80 percent or more, grade 2 (moderate) 50 to 79 percent, grade 3 (severe) 30 to 49 percent, and grade 4 (very severe) below 30 percent. In asthma, an increase in FEV1 of at least 12 percent and 200 mL after a bronchodilator shows significant reversibility. Peak expiratory flow, measured with a handheld meter, tracks asthma control at home. In neuromuscular disease, a falling FVC (and especially a fall from sitting to supine, which signals diaphragm weakness) helps time ventilatory support.

Forced expiration: volume against time 012345 1 s (FEV1)3 s5 sTime (seconds) Volume exhaled (L) NormalFVC 4.8 L, ratio 0.81 ObstructiveFVC 3.8 L, ratio 0.50 RestrictiveFVC 2.8 L, ratio 0.89 Obstructive: slowemptying, low ratioRestrictive: smallvolume, fast emptying
Figure 8.5 Spirometry patterns. Notice that obstruction slows emptying so FEV1 falls far more than FVC (low ratio), while restriction shrinks the total volume but empties quickly (normal or high ratio).

Arterial blood gases

ValueNormal rangeMeaning
pH7.35 to 7.45Below 7.35 acidemia; above 7.45 alkalemia
PaCO235 to 45 mmHgRespiratory component (an acid); rises with hypoventilation
HCO3−22 to 26 mEq/LMetabolic component (a base)
PaO280 to 100 mmHgOxygenation; falls with age; below 60 is significant hypoxemia
SaO295 to 100 percentHemoglobin saturation

Interpret in steps. (1) Look at the pH: acidosis or alkalosis? (2) Which component explains it? If PaCO2 moves in the opposite direction to pH (pH low, CO2 high), the cause is respiratory; if HCO3 moves in the same direction as pH (pH low, HCO3 low), the cause is metabolic. The mnemonic ROME captures this: Respiratory Opposite, Metabolic Equal. (3) Is there compensation? If the other component has moved to oppose the change, the disorder is partially compensated; if the pH has returned to normal, it is fully compensated (the pH usually stays on the side of the original problem). The lungs compensate within minutes to hours; the kidneys take days.

  • Respiratory acidosis (hypoventilation): COPD exacerbation, sedation or opioids, neuromuscular weakness (GBS, ALS), obesity hypoventilation, chest wall restriction.
  • Respiratory alkalosis (hyperventilation): anxiety, pain, early pulmonary embolism, early asthma attack, high altitude, overventilation on a ventilator.
  • Metabolic acidosis: diabetic ketoacidosis, lactic acidosis, renal failure, severe diarrhea, some poisonings; the patient breathes deeply and rapidly (Kussmaul respiration) to blow off CO2.
  • Metabolic alkalosis: vomiting, nasogastric suction, diuretics, excess antacids; often with low potassium.
Board tip. FEV1/FVC below 0.70 means obstruction; a reduced TLC confirms restriction. For blood gases use ROME. A rising PaCO2 in a tiring patient with asthma or COPD is an ominous sign of fatigue and impending respiratory failure, even if the pH is still normal.
Case. A 72 year old woman with COPD is admitted with an exacerbation. Her blood gas shows pH 7.31, PaCO2 58 mmHg, HCO3 29 mEq/L and PaO2 56 mmHg on 2 L/min oxygen. Breath sounds are diminished with scattered expiratory wheezes, and the radiograph shows flattened diaphragms. What does the gas show, and what is the safest plan for the first session?
Reasoning: The pH is low and the PaCO2 is high (opposite directions), so this is respiratory acidosis; the raised HCO3 shows partial metabolic compensation, typical of chronic CO2 retention with an acute worsening. She is hypoxemic. The first session should emphasize positioning (forward lean sitting), pursed lip and diaphragmatic breathing, energy conservation and short bouts of low intensity mobility, titrating oxygen within the order to keep SpO2 in the prescribed range (often 88 to 92 percent in CO2 retainers). Pushing vigorous endurance exercise, or turning her oxygen up well above the order, are the tempting errors. Safety point: increasing drowsiness, confusion or a rising CO2 indicate respiratory failure and need immediate notification.
Key point

Breath sounds, fremitus, percussion and the radiograph together locate consolidation, effusion, collapse and hyperinflation. Spirometry separates obstruction (low FEV1/FVC, air trapping) from restriction (low TLC). Read blood gases with pH first, then ROME to find the cause, then compensation, and recognize rising CO2 as a danger sign.

Section 5Laboratory values and termination criteria

Why lab values matter to the therapist

Laboratory values tell you whether the body can tolerate activity: enough hemoglobin to carry oxygen, enough clotting function to prevent bleeding, enough glucose, stable electrolytes and no ongoing heart injury. Check the chart before each acute care session, look at the trend rather than one number, and always put the value next to the patient's symptoms and vital signs. Reference ranges vary slightly by laboratory; the values below are the commonly taught ones.

TestTypical normal rangePT implications
Hemoglobin (Hgb)Men about 13.5 to 17.5 g/dL; women about 12 to 16 g/dLLow values cause fatigue, tachycardia, dyspnea and reduced exercise tolerance; see tiers below
Hematocrit (Hct)Men about 41 to 50 percent; women about 36 to 44 percentRoughly three times the hemoglobin; low with anemia and bleeding, high with dehydration
Platelets150,000 to 450,000 per microliterBelow 150,000 is thrombocytopenia: bruising, bleeding and fall risk; see tiers below
White blood cellsAbout 4,500 to 11,000 per microliter (often taught 5,000 to 10,000)High with infection or steroids; low (especially neutrophils below about 1,000) needs infection precautions
INRAbout 0.9 to 1.1 without anticoagulation; 2.0 to 3.0 therapeutic on warfarin (2.5 to 3.5 with some mechanical valves)Higher values raise bleeding risk; fall prevention and gentle handling
PT and aPTTPT about 11 to 13.5 s; aPTT about 25 to 35 saPTT monitors unfractionated heparin; prolonged values mean bleeding risk
Fasting glucose70 to 99 mg/dL (100 to 125 prediabetes; 126 or more diabetes)Check before exercise in patients on insulin or insulin secretagogues
HbA1cBelow 5.7 percent (5.7 to 6.4 prediabetes; 6.5 or more diabetes)Reflects about three months of glucose control; high values slow healing
Potassium (K+)3.5 to 5.0 mEq/LLow or high values cause weakness and arrhythmias
Sodium (Na+)135 to 145 mEq/LLow sodium causes confusion, lethargy, seizures and falls
Creatinine; BUNAbout 0.6 to 1.2 mg/dL; 7 to 20 mg/dLRising values mean kidney impairment; fluid and drug dosing issues
TroponinBelow the laboratory's 99th percentile cutoffElevated or rising values mean myocardial injury: hold exercise beyond what the team allows
BNPBelow about 100 pg/mLElevated in heart failure; trends track decompensation
D-dimerBelow about 500 ng/mLSensitive but not specific; a normal value helps rule out DVT and PE in low risk patients
Albumin3.5 to 5.0 g/dLLow values signal poor nutrition and impaired wound healing, and contribute to edema

Hemoglobin and hematocrit

Hemoglobin determines oxygen carrying capacity. With anemia, the heart compensates by raising heart rate and cardiac output, so the patient reaches exercise limits sooner and may have exertional tachycardia, dyspnea, dizziness or angina. Older references used firm cutoffs, such as withholding exercise below 8 g/dL; current acute care guidance emphasizes the patient's symptoms, the trend and the medical plan rather than a single number. A practical teaching scheme: at or above about 10 g/dL, usual progression; about 8 to 10 g/dL, proceed with closer monitoring of symptoms and vital signs; below about 8 g/dL, activity is symptom limited and focused on essential mobility after discussion with the team; below about 7 g/dL, transfusion is commonly considered. A falling value over hours (active bleeding) is more worrisome than a stable low value in chronic anemia. Hematocrit is high in dehydration and polycythemia, which increase blood viscosity and clot risk.

Platelets and anticoagulation

Low platelets raise the risk of spontaneous bleeding, bruising and hemorrhage after minor trauma. Commonly taught activity tiers (sources differ slightly on the exact cutoffs):

  • Above about 50,000: progressive exercise as tolerated; avoid high impact or contact activity when counts are below normal.
  • About 20,000 to 50,000: light exercise, active range of motion and walking; no heavy resistance.
  • Below about 20,000: essential activities and mobility only, after consulting the medical team; prevent falls, avoid resisted exercise and anything that raises bleeding risk. Some protocols use 10,000 as the threshold for spontaneous bleeding.

Watch for petechiae, bruising, bleeding and any new headache or neurologic change, and avoid firm manual pressure.

For patients on warfarin, the INR is the guide: a therapeutic range of 2.0 to 3.0 is expected and does not prevent activity. Many references advise holding or discussing activity when the INR is above about 4 (some say 3.5 to 5), and emphasize fall prevention at any elevated value. Direct oral anticoagulants (apixaban, rivaroxaban, dabigatran) are not monitored with INR. Unexplained bruising, black stools, or a new severe headache in an anticoagulated patient require prompt medical evaluation.

ProceedCautionHold or consult HemoglobinPlateletsINR (warfarin)Glucose g/dLper microlitertherapeutic 2 to 3mg/dL 10 or higherusual progression 8 to 10monitor symptoms Below 8symptom limited, consult Over 50,000progress as tolerated 20,000 to 50,000light, no resistance Below 20,000essential mobility only Up to 3.0fall precautions 3.0 to about 4bleeding watch, gentle Above about 4hold, contact team 100 to 250exercise is fine Below 100carbohydrate first Below 70, or over 250with ketones: hold Commonly taught thresholds; sources differ. Always pair the number with symptoms and trend.
Figure 8.6 Commonly taught lab thresholds for activity decisions. Notice that the middle column still allows activity with closer monitoring; the right column means stop and talk with the medical team.

Glucose

Exercise lowers blood glucose by increasing muscle uptake, and the effect lasts for hours. For patients using insulin or sulfonylureas, check glucose before exercise:

  • Below 70 mg/dL is hypoglycemia: do not start. Treat with the rule of 15 (15 g of fast carbohydrate such as 4 ounces of juice or glucose tablets, recheck in 15 minutes, repeat if still below 70), then eat a snack before resuming.
  • 70 to about 100 mg/dL: give about 15 to 30 g of carbohydrate before exercise.
  • About 100 to 250 mg/dL: exercise is appropriate.
  • Above 250 mg/dL: check for ketones (especially in type 1 diabetes); if ketones are present, postpone exercise because it can worsen ketoacidosis. Without ketones, light to moderate exercise can proceed with caution if the person feels well and is hydrated. Many therapy references advise against exercise above about 300 mg/dL.

Hypoglycemia causes sweating, shakiness, tachycardia and hunger (masked by beta blockers), then confusion, slurred speech and seizures. Hyperglycemia causes thirst, polyuria and fatigue, and ketoacidosis adds fruity breath and Kussmaul respirations. Delayed hypoglycemia can occur hours after exercise, so teach patients to monitor that evening. Avoid injecting insulin into a limb that is about to be exercised heavily, because uptake speeds up.

Potassium, sodium and calcium

Hypokalemia (below 3.5 mEq/L), often from diuretics, vomiting or diarrhea, causes muscle weakness, cramps, fatigue, flattened T waves, U waves, PVCs and other arrhythmias, and increases digoxin toxicity. Hyperkalemia (above 5.0 mEq/L), often from kidney failure, potassium sparing diuretics or ACE inhibitors, causes weakness, peaked T waves, a widened QRS, bradycardia and risk of cardiac arrest. Exercise is generally deferred with significantly abnormal potassium or ECG changes until it is corrected. Hyponatremia (below 135) causes confusion, headache, lethargy and falls. Low calcium causes tetany and cramps; high calcium causes weakness, lethargy and kidney stones.

Cardiac markers

Troponin (I or T) is the most sensitive and specific marker of myocardial injury. It begins to rise within a few hours of injury (earlier with high sensitivity assays), peaks at about 12 to 24 hours or later, and stays elevated for about 7 to 14 days. A rising troponin means ongoing injury, and exercise beyond basic bedside activity is held until the team confirms the patient is stable; a troponin that has peaked and is trending down in a patient without symptoms usually allows progressive mobility per the cardiac protocol. CK-MB rises and falls faster and is less used. BNP (or NT-proBNP) is released by stretched ventricles and is elevated in heart failure.

Board tip. Pair every number with the patient: a stable hemoglobin of 8 in an asymptomatic patient is safer than a value that fell from 11 to 9 overnight. Glucose below 70: treat first; over 250 with ketones: postpone. INR 2 to 3 on warfarin is therapeutic, not a reason to stop. A rising troponin means active myocardial injury.

Exercise contraindications and termination criteria

Absolute contraindications to exercise (commonly listed) include: acute myocardial infarction within about two days, unstable angina, uncontrolled symptomatic arrhythmias, symptomatic severe aortic stenosis, decompensated heart failure, acute pulmonary embolism or DVT that has not been treated, acute myocarditis or pericarditis, acute aortic dissection, and any acute systemic illness or fever. Relative contraindications include resting blood pressure above about 200/110 mmHg, significant electrolyte abnormalities, tachyarrhythmias or bradyarrhythmias, hypertrophic cardiomyopathy with outflow obstruction, high degree AV block, and conditions that limit cooperation.

Stop exercise forDetails
SymptomsModerate to severe angina, marked dyspnea, dizziness, lightheadedness, confusion, ataxia, near syncope, nausea, unusual fatigue, claudication that limits the session
Signs of poor perfusionPallor, cyanosis, cold clammy skin, diaphoresis
Blood pressureSystolic fall of more than 10 mmHg with increasing work; systolic above 250 or diastolic above 115 mmHg
Heart rateInappropriate rise or fall; exceeding the prescribed limit; approaching an ICD threshold
RhythmVentricular tachycardia, increasing or multifocal PVCs, couplets, new atrial fibrillation with rapid rate, second degree type II or third degree block, new bundle branch block
ECGST depression above 2 mm horizontal or downsloping; ST elevation above 1 mm in leads without Q waves
OxygenationSpO2 below about 88 to 90 percent (or below the prescribed target) that does not recover with rest or allowed oxygen titration
Patient request or equipment failureAlways stop when the patient asks or monitoring fails

For early inpatient cardiac rehabilitation, a traditional guide caps the heart rate rise at about 20 bpm above resting after myocardial infarction and about 30 bpm above resting after cardiac surgery, with an RPE of 13 or less, progressing as tolerated. After cardiac surgery through a median sternotomy, follow sternal precautions (traditionally no lifting more than about 5 to 10 pounds and no pushing up with the arms for about six to eight weeks; many programs now use activity based "keep your move in the tube" guidance).

Red flags that need medical attention

  • Myocardial infarction: chest pressure lasting more than a few minutes, unrelieved by rest or nitroglycerin, with diaphoresis, nausea or dyspnea. Stop, call for help, and activate emergency services.
  • Deep vein thrombosis: unilateral calf swelling, tenderness, warmth and pitting edema, especially after surgery or immobility; the Wells criteria estimate probability. Hold exercise of that limb and notify the physician.
  • Pulmonary embolism: sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea, falling SpO2, hemoptysis or syncope: emergency.
  • Decompensated heart failure: weight gain of more than about 2 to 3 pounds in a day or 5 pounds in a week, worsening edema, orthopnea, paroxysmal nocturnal dyspnea, new S3 or crackles.
  • Hypertensive crisis: blood pressure above 180/120 mmHg with headache, chest pain, vision change or neurologic signs.
Case. A 64 year old man is two days after a total knee arthroplasty. Today's labs: hemoglobin 8.6 g/dL (10.4 yesterday), platelets 182,000, INR 1.3, potassium 3.9 mEq/L. At rest his HR is 104 bpm and BP 102/64; he says he feels "washed out." Which action is most appropriate before gait training?
Reasoning: The single value of 8.6 is in a caution range, but the drop of nearly 2 g/dL in a day with resting tachycardia and soft blood pressure suggests ongoing bleeding or hypovolemia. The best action is to communicate with the nurse or surgeon before progressing, then provide only bedside activity with close monitoring if cleared. Proceeding with full gait training because 8.6 is "above 8" ignores the trend; refusing to see him at all ignores that bedside mobility may still be appropriate. The platelets, INR and potassium are acceptable. Safety point: check for signs of a wound hematoma or DVT and recheck vitals with any position change.
Key point

Lab values guide but do not replace clinical judgment: interpret them against symptoms, vital signs and trends. Know the core ranges (hemoglobin, platelets, INR, glucose, potassium, troponin) and the commonly taught activity thresholds, respect absolute contraindications such as unstable angina and decompensated heart failure, and stop for symptoms, abnormal blood pressure, dangerous rhythms, ischemic ST changes or desaturation.

The chapter in one breath

  • Cardiac output = HR × SV; stroke volume depends on preload, afterload and contractility; normal EF is about 55 to 70 percent.
  • The coronary arteries fill in diastole; the RCA usually supplies the SA and AV nodes and the inferior wall.
  • TLC is about 6 L; RV cannot be measured by spirometry; FRC rises with air trapping.
  • Ventilation and perfusion are greatest at the bases; V/Q is highest at the apex; put the good lung down for unilateral disease in adults.
  • PaO2 60 equals SaO2 about 90; a right shift unloads oxygen to working muscle.
  • With exercise, HR and SBP rise and DBP stays flat; a falling SBP means stop. Use RPE with beta blockers; RPP reflects myocardial oxygen demand.
  • No BP cuff over a PICC, arterial line or fistula; keep chest tube drainage below the chest and never clamp it.
  • ECG paper: small box 0.04 s, large box 0.20 s; PR 0.12 to 0.20 s, QRS under 0.12 s; rate is 300 divided by large boxes.
  • Ventricular tachycardia, Mobitz II, complete heart block and PVCs increasing with exercise mean stop; ST depression is ischemia, ST elevation is injury.
  • Crackles, wheezes, rhonchi, stridor and rubs point to specific problems; consolidation increases fremitus and bronchial sounds.
  • FEV1/FVC below 0.70 is obstruction; low TLC is restriction; read gases with ROME.
  • Know hemoglobin, platelet, INR, glucose, potassium and troponin thresholds, and always weigh the trend and symptoms.

Words worth knowing

TermWhat it means
PreloadThe stretch on the ventricle at the end of diastole, set mainly by venous return and end diastolic volume.
Ejection fractionThe percentage of end diastolic volume ejected with each beat, normally about 55 to 70 percent.
Mean arterial pressureThe average arterial pressure over a cycle, about diastolic plus one third of pulse pressure; at least about 65 mmHg is needed for organ perfusion.
Functional residual capacityThe volume left in the lungs after a quiet exhalation, equal to expiratory reserve plus residual volume.
Dead spaceVentilated airway or alveoli that receive no blood flow, so no gas exchange occurs.
ShuntBlood flow through lung regions that are not ventilated, causing hypoxemia that responds poorly to oxygen.
Oxyhemoglobin dissociation curveThe S shaped relationship between PaO2 and hemoglobin saturation, shifted right by heat, CO2, acid and 2,3-BPG.
METMetabolic equivalent; resting oxygen use of about 3.5 mL O2/kg/min, used to express activity intensity.
Rate pressure productHeart rate times systolic blood pressure, an index of myocardial oxygen demand.
Rating of perceived exertionA patient rated scale of effort (Borg 6 to 20 or 0 to 10) used when heart rate is unreliable.
Orthostatic hypotensionA fall of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing.
Premature ventricular contractionAn early, wide QRS arising in the ventricle without a preceding P wave.
Mobitz II blockSecond degree AV block with a constant PR interval and suddenly dropped QRS complexes; can progress to complete block.
ST depressionA ST segment below baseline, a sign of subendocardial ischemia.
Implantable cardioverter defibrillatorA device that detects ventricular tachycardia or fibrillation and delivers pacing or a shock.
EgophonyAn "ee" spoken by the patient heard as "ay" over consolidated lung.
FEV1/FVC ratioThe fraction of vital capacity exhaled in the first second; below 0.70 indicates obstruction.
DLCODiffusing capacity for carbon monoxide, a measure of gas transfer that falls in emphysema and interstitial disease.
Respiratory acidosisA low pH caused by CO2 retention from hypoventilation.
INRInternational normalized ratio, a standardized clotting time used to monitor warfarin; 2 to 3 is the usual target.
ThrombocytopeniaA platelet count below about 150,000 per microliter, raising the risk of bleeding.
TroponinA cardiac muscle protein released into blood with myocardial injury; the preferred marker of infarction.

Check yourself

Which heart sound suggests a volume overloaded, failing left ventricle in an older adult, and when does it occur?
Answer. S3, the ventricular gallop, occurs in early diastole during rapid filling. It is a classic sign of heart failure in adults, while S4 (just before S1) reflects a stiff ventricle.
A patient's total lung capacity is 6,000 mL, residual volume 1,200 mL and expiratory reserve volume 1,200 mL. What is the functional residual capacity, and can spirometry measure it?
Answer. FRC = ERV + RV = 2,400 mL. Spirometry cannot measure it, because it includes residual volume; body plethysmography or gas dilution is needed.
An adult has a large left lower lobe pneumonia and low SpO2. In which side lying position should the patient be placed to improve oxygenation?
Answer. Right side lying (good lung down), which sends more perfusion to the healthy, ventilated right lung and improves V/Q matching.
Calculate the Karvonen target heart rate at 60 percent intensity for a 50 year old with a resting heart rate of 80 bpm, using 220 minus age.
Answer. HRmax 170; heart rate reserve 90; 60 percent is 54; target = 54 + 80 = 134 bpm. If the patient takes a beta blocker, use RPE instead.
During graded exercise a patient's systolic blood pressure rises from 130 to 150 mmHg, then falls to 136 mmHg as the workload increases further. What should you do?
Answer. Stop exercise. A fall in systolic pressure of more than 10 mmHg with increasing work is an abnormal response suggesting ischemia or left ventricular dysfunction; monitor and notify the physician.
R waves on a regular strip are four large boxes apart. What is the heart rate?
Answer. 300 divided by 4 = 75 bpm.
The ECG shows a constant PR interval of 0.18 s with occasional P waves not followed by a QRS. What is the rhythm, and is exercise appropriate?
Answer. Second degree AV block type II (Mobitz II). It can progress to complete heart block, so exercise is not appropriate; notify the physician.
Spirometry shows FEV1 1.4 L, FVC 3.2 L and an increased residual volume. What pattern is this, and what is the FEV1/FVC ratio?
Answer. Obstructive pattern; the ratio is about 0.44 (below 0.70), with air trapping shown by the increased RV.
A blood gas shows pH 7.50, PaCO2 30 mmHg and HCO3 24 mEq/L in an anxious patient after surgery. Interpret it.
Answer. Uncompensated respiratory alkalosis: pH high and CO2 low (opposite directions, so respiratory), HCO3 normal. Consider anxiety, pain or an early pulmonary embolism.
A patient with type 1 diabetes has a pre exercise glucose of 280 mg/dL and ketones in the urine. What should you do?
Answer. Postpone exercise, because exercise with ketosis can worsen ketoacidosis. Encourage fluids and contact the medical team per protocol.
Chapter 9 · Cardiopulmonary

Cardiovascular, Pulmonary and Lymphatic Conditions and Rehabilitation

Most patients a physical therapist sees, whatever the referral says, carry some cardiovascular or pulmonary diagnosis: the hip fracture patient with heart failure, the knee replacement on a beta blocker, the stroke survivor with chronic obstructive pulmonary disease. The exam rewards the therapist who can dose exercise safely around these conditions, recognize decompensation early and know which precautions follow which procedure. This chapter covers the major heart, lung, peripheral vascular and lymphatic conditions and the rehabilitation built around each.

By the end of this chapter you can

  • Distinguish stable angina, unstable angina and myocardial infarction, and explain what troponin and ECG findings mean for activity.
  • Recognize left sided and right sided heart failure, classify severity with the NYHA classes, and state the signs that call for stopping exercise.
  • Apply sternal precautions after median sternotomy and adapt treatment for pacemakers, ICDs, LVADs and heart transplant recipients.
  • Describe the phases of cardiac rehabilitation and write an exercise prescription using heart rate reserve, METs and RPE.
  • Predict how beta blockers, nitrates, diuretics, digoxin and other cardiac drugs change the exercise response.
  • Compare obstructive and restrictive lung disease, and select breathing retraining and airway clearance techniques with their contraindications.
  • Differentiate arterial from venous insufficiency, interpret the ankle brachial index, prescribe claudication walking and screen for DVT with the Wells criteria.
  • Stage lymphedema, measure limb volume, and describe the two phases of complete decongestive therapy and its contraindications.

Section 1Coronary disease, heart failure and cardiac surgery

Coronary artery disease and the ischemic spectrum

Coronary artery disease (CAD) is atherosclerotic narrowing of the epicardial coronary arteries. Plaque builds over decades through endothelial injury, lipid deposition, macrophage infiltration and a fibrous cap. The clinical problem is a mismatch between myocardial oxygen supply and demand. Demand rises with heart rate, contractility and wall tension (afterload and preload), which is why the rate pressure product (heart rate times systolic pressure) tracks myocardial oxygen use and why a patient with fixed narrowing develops symptoms at a reproducible rate pressure product called the ischemic threshold.

The ischemic syndromes form a spectrum:

  • Stable angina: chest pressure or tightness brought on by a predictable level of exertion, emotion, cold or a heavy meal, lasting a few minutes and relieved by rest or sublingual nitroglycerin. The plaque narrows the lumen but is not ruptured.
  • Unstable angina: new onset angina, angina at rest, or angina that is increasing in frequency, duration or intensity (crescendo). A plaque has ruptured or eroded and a partial thrombus has formed, but troponin is not elevated. It is a medical emergency, not a reason to modify exercise.
  • Myocardial infarction (MI): myocyte death proven by a rise and fall of cardiac troponin with symptoms or ECG change. A STEMI (ST elevation MI) usually reflects complete occlusion and full thickness (transmural) injury and needs emergency reperfusion. An NSTEMI has a troponin rise without ST elevation and usually involves subendocardial injury. Unstable angina, NSTEMI and STEMI together form the acute coronary syndromes.

Classic angina is retrosternal pressure radiating to the left arm, jaw or between the scapulae, with diaphoresis, dyspnea and nausea. Women, older adults and people with diabetes more often present atypically (fatigue, dyspnea, epigastric or jaw pain), and diabetic neuropathy can produce silent ischemia. Musculoskeletal chest pain is reproduced by palpation or movement and is not tied to exertional heart rate.

Troponin rises within about 3 to 4 hours, peaks near 24 hours and stays elevated for 7 to 14 days, so the trend matters more than one value. Programs hold mobility while troponin is rising and resume once it has peaked, with hemodynamic stability and no chest pain or new arrhythmia for about 8 hours.

SyndromeTrigger and timingTroponinECGPT action
Stable anginaPredictable exertion, relieved by rest or nitroglycerin within minutesNormalST depression during the episodeExercise below the ischemic threshold; patient carries nitroglycerin
Unstable anginaNew, at rest, or crescendo patternNormalST depression or T wave inversion, may be normalStop, do not exercise, activate medical care
NSTEMIProlonged pain, often at restElevatedST depression or T inversion, no ST elevationMobilize only after troponin peaks and patient is stable
STEMIProlonged severe pain, diaphoresisElevatedST elevation in contiguous leads, later Q wavesEmergency; after reperfusion, follow phase I progression

Revascularization is by percutaneous coronary intervention (PCI, usually with a drug eluting stent) or coronary artery bypass grafting (CABG). After femoral PCI the leg stays straight for a few hours (commonly 2 to 6) and the groin is checked for bleeding before walking; radial access allows walking almost at once. Dual antiplatelet therapy raises bleeding risk.

Board tip. Chest pain that appears at rest, is new, or is getting worse is unstable angina until proven otherwise. The best answer is never "decrease the intensity and continue"; it is stop activity and get medical help. If a patient with known stable angina develops pain, stop exercise, sit the patient down and have them take one sublingual nitroglycerin; current guidance is to call emergency services if pain is not improved or is worsening 5 minutes after the first dose.

Heart failure

Heart failure (HF) is a clinical syndrome in which the heart cannot pump enough blood to meet the body's needs, or can do so only at high filling pressures. It is classified by ejection fraction:

  • HF with reduced ejection fraction (HFrEF), EF 40% or less: systolic dysfunction from a weak ventricle (ischemic cardiomyopathy after MI, dilated cardiomyopathy).
  • HF with preserved ejection fraction (HFpEF), EF 50% or more: a stiff ventricle that fills poorly (diastolic dysfunction), typical of older adults with long standing hypertension, obesity and diabetes.
  • HF with mildly reduced EF, 41% to 49%, sits between the two.

Normal EF is about 55% to 70%. Fluid backs up behind the failing side. A failing left ventricle congests the lungs: exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, basilar crackles, frothy cough, an S3, and fatigue from low output. A failing right ventricle backs fluid into the systemic veins: jugular venous distension, dependent pitting edema of the ankles and sacrum, liver congestion with right upper quadrant fullness, ascites, and weight gain. The most common cause of right sided failure is left sided failure. Right sided failure caused by lung disease and pulmonary hypertension is called cor pulmonale.

Lungs pulmonary circulation Right heart RA and RV Left heart LA and LV Body systemic circulation Left failure backs up into the lungs dyspnea, orthopneaPND, cracklesS3, frothy cough Right failure backs up into the body JVD, liver congestionascites, ankle andsacral pitting edema gray arrows: normal flow
Figure 9.1 Fluid backs up behind the failing ventricle. Left ventricular failure congests the lungs (red arrow); right ventricular failure congests the systemic veins (blue arrow). Because left failure raises pulmonary pressure, it is the most common cause of right failure.

NYHA classes describe symptoms and can improve with treatment; ACC/AHA stages describe progression and never move backward.

NYHA classSymptomsACC/AHA stageDescription
INo limitation; ordinary activity causes no undue fatigue, dyspnea or palpitationsAAt risk (hypertension, diabetes, CAD) with no structural disease
IISlight limitation; comfortable at rest, ordinary activity causes symptomsBStructural disease (low EF, hypertrophy, prior MI) without symptoms
IIIMarked limitation; comfortable at rest, less than ordinary activity causes symptomsCStructural disease with current or prior symptoms
IVSymptoms at rest; any activity increases discomfortDRefractory HF needing advanced therapy (LVAD, transplant, hospice)

HFrEF medical therapy combines an ACE inhibitor, ARB or neprilysin inhibitor combination, a beta blocker, spironolactone and an SGLT2 inhibitor, with loop diuretics for congestion. Expect orthostatic hypotension, potassium shifts and a blunted heart rate response.

Exercise training is safe and recommended in stable HF. Screen every session: a daily weight gain of about 2 to 3 pounds in a day or 5 in a week (programs vary slightly) suggests fluid retention. New dyspnea at rest, new crackles or S3, rising JVD, increasing edema or resting HR above about 120 mean no exercise that day. An exertional drop in systolic pressure of more than 10 mmHg despite rising workload means the ventricle cannot keep up: stop.

Prescribe long warm ups and cool downs, intervals when deconditioned, RPE 11 to 14, progression of duration before intensity, and light resistance work while exhaling on effort (no Valsalva maneuver).

Case. A 74 year old man with HFrEF (EF 30%) is seen in home health. Today he reports he needed three pillows to sleep, his weight is up 4 pounds since two days ago, and you hear bibasilar crackles that were absent last week. Resting HR is 98, BP 108/70, SpO2 92% on room air.
Reasoning: Orthopnea, rapid weight gain and new crackles are classic signs of left sided decompensation with fluid overload. The best action is to hold the exercise session and contact the physician or nurse today, not to continue with lower intensity, and not to simply teach energy conservation. Tempting choices such as "perform the walking program at a lower RPE" ignore the fact that new crackles and weight gain mean the medical regimen needs adjustment. Safety point: in heart failure the daily weight and symptom check comes before any exercise.

Cardiac surgery and sternal precautions

CABG uses the left internal mammary (internal thoracic) artery, which has the best long term patency, usually to the left anterior descending artery, and saphenous vein or radial artery grafts to other vessels. Valve surgery repairs or replaces stenotic or regurgitant valves. Both are usually done through a median sternotomy, in which the sternum is split and wired together. The sternum takes about 6 to 8 weeks to unite, so sternal precautions protect it during that time.

Traditional sternal precautions, still the common exam answer, are:

  • No lifting, pushing or pulling more than about 5 to 10 pounds.
  • No pushing up with the arms from a chair or bed, and no pulling on bed rails or a walker to rise.
  • No bilateral or resisted reaching overhead or behind the back, and no unilateral end range shoulder motion that stresses the sternum.
  • Splint the chest with a pillow when coughing or sneezing.
  • No driving for about 4 weeks (airbag and steering forces, plus medications).

Many hospitals now use a less restrictive approach (keep the upper arms close to the body and move within pain limits); the safe exam answer still avoids pushing up with both arms and heavy lifting. Signs of sternal instability are clicking, sternal movement with coughing, or wound drainage; risk rises with obesity, diabetes, COPD with heavy cough and osteoporosis. Mobilization starts on postoperative day 0 or 1; watch for atelectasis, new atrial fibrillation (peaking about days 2 to 3) and orthostasis.

Severe symptomatic aortic stenosis (angina, syncope, dyspnea) contraindicates exercise training until corrected, and sudden vasodilation can drop pressure dangerously. TAVR avoids sternotomy and allows faster mobilization.

Case. A 66 year old woman is on postoperative day 3 after CABG via median sternotomy. She is obese, has diabetes and a chronic cough. While she is coughing during your session she reports a clicking feeling in her chest, and you see a small amount of drainage on the dressing.
Reasoning: Clicking with cough plus wound drainage in a patient with several risk factors suggests sternal instability or early wound infection. The best response is to stop the session, have her splint with a pillow, document, and notify the surgical team. Teaching an upper extremity strengthening program or "continuing with stricter sternal precautions" without reporting misses a possible dehiscence or mediastinitis. Safety point: report sternal clicking, instability or drainage promptly.

Devices: pacemakers, ICDs, LVADs and transplant

A pacemaker code gives the chamber paced, chamber sensed and response (for example DDD); a fourth letter R means rate responsive. A fixed rate device cannot raise heart rate, so monitor RPE and blood pressure. After lead placement, limit ipsilateral shoulder elevation to about 90 degrees and avoid heavy lifting for about 4 to 6 weeks, and keep electrical stimulation and diathermy away from the device.

An implantable cardioverter defibrillator (ICD) paces or shocks ventricular tachycardia or fibrillation. Know its detection rate and keep exercise heart rate at least 10 to 20 beats below it to avoid an inappropriate shock. One shock in a patient who feels well: stop and notify the cardiologist; repeated shocks or symptoms: emergency care.

A left ventricular assist device (LVAD) pumps blood from the left ventricle to the aorta as a bridge to transplant or destination therapy. With continuous flow there is often no palpable pulse, so pressure is taken with Doppler and a manual cuff and read as a mean arterial pressure (typically about 70 to 90 mmHg). Protect the driveline, never disconnect both power sources, avoid submersion, and use RPE; low flow alarms with exercise often mean dehydration.

A transplanted heart is denervated: resting rate is high (often 90 to 110), heart rate rises slowly with exercise through circulating catecholamines and stays up afterward, and angina is usually absent. Use long warm ups and cool downs and RPE. Immunosuppression and steroids add infection, osteoporosis and myopathy risk.

Board tip. In any question about a transplanted heart, a fixed rate pacemaker, or a patient on a beta blocker, the right intensity tool is the RPE scale, not a target heart rate from a formula. For an ICD, the key number is the device detection rate; keep training heart rate at least 10 to 20 beats below it.
Key point

Coronary disease ranges from stable angina (exercise below the ischemic threshold) to acute coronary syndromes (stop and get help). Heart failure is classified by EF, by NYHA symptom class and by ACC/AHA stage; daily weights, crackles, orthopnea and an exertional fall in systolic pressure are the warning signs. Sternotomy calls for sternal precautions for about 6 to 8 weeks, and each device changes how you monitor: Doppler MAP for an LVAD, detection rate for an ICD, RPE for denervated or paced hearts.

Section 2Cardiac rehabilitation

Who qualifies and the phases

Cardiac rehabilitation combines exercise training, risk factor modification, education and psychosocial support, and it lowers mortality and readmissions. Qualifying diagnoses include MI, CABG, PCI, stable angina, valve surgery, transplant and stable HFrEF.

Programs are described in phases:

  • Phase I, inpatient: from medical stability to discharge: counter bed rest, assess the response to self care and walking, teach, and plan discharge (about 1 to 4 METs).
  • Phase II, early outpatient: supervised, often ECG monitored, typically up to 36 sessions over about 12 weeks, prescribed from an exercise test.
  • Phase III, maintenance: community or home exercise for life (some texts add a phase IV).
time after event exercise capacity rises Phase I: inpatient self care, hall walkingstairs, educationabout 1 to 4 METsRPE 11 to 13 Phase II: outpatient supervised, ECG monitoredup to 36 sessionsabout 12 weeksprescription from GXT Phase III: maintenance community or homelifelong, self monitored HR rise limit: 20 above rest (MI) 30 above rest (surgery) 40 to 80% HRR, RPE 12 to 16 days weeks 1 to 12 months to years
Figure 9.2 The phases of cardiac rehabilitation. Phase I protects the patient with conservative heart rate limits relative to resting rate; phase II prescribes from an exercise test; phase III builds independent lifelong habits.

Phase I progression and monitoring

Check vitals, telemetry, symptoms and labs before each activity. Common upper limits during phase I are an increase in heart rate of no more than about 20 beats per minute above resting after MI and about 30 above resting after cardiac surgery, with RPE of 13 or less (somewhat hard) on the 6 to 20 Borg scale. Normally systolic rises and diastolic stays within about 10 mmHg. Abnormal responses that mean stop and report:

  • Angina, unusual dyspnea, dizziness, pallor, cyanosis, diaphoresis or confusion.
  • Systolic pressure falling by more than 10 mmHg with activity, or failing to rise.
  • Diastolic pressure above about 110 mmHg, or systolic well above the program limit.
  • Heart rate rising beyond the limits above, or new arrhythmia (frequent or multifocal PVCs, runs of ventricular tachycardia, new atrial fibrillation, new heart block).
  • ST segment change of about 1 mm or more on the monitor (horizontal or downsloping depression).

Exercise prescription in phase II and beyond

The prescription follows FITT (frequency, intensity, time, type) plus progression. A symptom limited graded exercise test gives peak heart rate, peak METs and, in some patients, the heart rate at which ischemia appears.

  • Frequency: aerobic exercise on most days, at least 3 and ideally 5 or more days per week.
  • Intensity: 40% to 80% of heart rate reserve (HRR) or of peak oxygen uptake, or RPE 12 to 16. If an ischemic threshold is known, set the upper limit at least 10 beats per minute below the heart rate at which ischemia (angina or 1 mm ST depression) appeared.
  • Time: 20 to 60 minutes, which can be accumulated in shorter bouts in deconditioned patients, plus 5 to 10 minutes each of warm up and cool down.
  • Type: rhythmic large muscle activity such as walking, cycling and arm ergometry; resistance training 2 to 3 days per week at about 40% to 60% of one repetition maximum, 10 to 15 repetitions.

The Karvonen method is the most tested calculation: Target HR = [(HRmax minus HRrest) times intensity] plus HRrest. Use the measured peak from an exercise test when available; 220 minus age is only an estimate and is meaningless on beta blockers. One MET is about 3.5 mL O2 per kg per minute; self care is 1 to 3 METs, walking at 3 mph about 3.3, and sexual activity about 3 to 5.

ToolHow it worksUse and limits
Heart rate reserve (Karvonen)(HRmax minus HRrest) times % plus HRrestBest HR method; needs a true max or a test on current drugs
Percent of HRmaxHRmax times %Simpler; 64% to 76% of HRmax is roughly moderate
Borg RPE 6 to 20Patient rates effort; 12 to 13 is somewhat hardWorks with beta blockers, transplant, pacemakers, atrial fibrillation
Modified Borg 0 to 10Rates dyspnea or effort; 3 to 4 is moderateCommon in pulmonary rehab for dyspnea
Talk testCan speak in sentences but not singSimple field check; correlates with ventilatory threshold
METsMultiples of resting VO2 (3.5 mL/kg/min)Match activities and home tasks to tested capacity
Case. A 58 year old man in phase II cardiac rehab after an MI has a resting HR of 70. His exercise test, taken on his usual beta blocker, reached a peak HR of 150, and 1.5 mm ST depression appeared at a HR of 130. You want to prescribe at 70% of HRR.
Reasoning: Karvonen gives (150 minus 70) times 0.7 plus 70 = 126. But ischemia appeared at 130, and the upper limit should be at least 10 beats below the ischemic threshold, so the top of the training range should be about 120. The best answer sets the ceiling at 120 and uses RPE 11 to 13 as a cross check. The tempting answer of 126 ignores the ischemic threshold, and using 220 minus age is wrong because a measured peak exists and he takes a beta blocker. Safety point: the ischemic threshold overrides any percentage formula.

Medications that change the exercise response

Medications appear constantly in cardiac questions because they change what you measure. The essentials:

Drug class (examples)Main actionEffect on exercise and PT implications
Beta blockers (metoprolol, carvedilol)Lower HR, contractility and BP; antianginal, antiarrhythmicBlunted resting and exercise HR and BP; use RPE; fatigue, orthostasis, may mask hypoglycemia in diabetes
Nitrates (nitroglycerin)Venodilate, lower preload; relieve anginaRaise exercise capacity before ischemia; headache, hypotension and reflex tachycardia; never with PDE5 inhibitors
Calcium channel blockers (diltiazem, verapamil, amlodipine)Vasodilate; some lower HRDiltiazem and verapamil lower HR; all can cause hypotension and ankle edema
ACE inhibitors and ARBs (lisinopril, losartan)Block renin angiotensin system; afterload reductionLittle HR effect; hypotension, dizziness; ACE inhibitor dry cough, angioedema; raise potassium
Diuretics (furosemide, hydrochlorothiazide)Remove fluidDehydration, orthostasis, cramps, low potassium and arrhythmia; plan sessions away from peak diuresis and near a bathroom
DigoxinIncreases contractility; slows AV conductionCan cause ST depression (false positive test); toxicity: nausea, vision changes (yellow halos), confusion, arrhythmias; low potassium raises toxicity
Antiarrhythmics (amiodarone)Rhythm controlBradycardia; amiodarone lung, thyroid and liver toxicity
Anticoagulants and antiplatelets (warfarin, DOACs, aspirin, clopidogrel)Prevent clotBleeding and bruising; fall prevention; caution with deep tissue work and vigorous manual techniques
StatinsLower LDL cholesterolMyalgia and, rarely, rhabdomyolysis: report new diffuse muscle pain, weakness or dark urine
Board tip. Beta blockers lower heart rate at rest and at every workload, so the patient reaches the same RPE at a lower heart rate. If a question gives a beta blocked patient a target heart rate from 220 minus age, that target is wrong. Also note the timing trap: exercise prescribed when a drug is at peak effect may be too hard when it wears off, so test and train at a consistent time relative to dosing.

Education covers risk factors (smoking, hypertension, dyslipidemia, diabetes, obesity, inactivity, depression), self monitoring with RPE, symptom recognition, nitroglycerin use and adherence. Screen for depression after MI, and avoid early exercise in temperature extremes, after large meals or with isometric straining.

Key point

Cardiac rehabilitation moves from inpatient phase I (heart rate rise of about 20 after MI or 30 after surgery, RPE 13 or less) through supervised phase II (40% to 80% of HRR, RPE 12 to 16, 10 beats below any ischemic threshold) to lifelong phase III. Karvonen is the core calculation, RPE replaces heart rate whenever drugs or denervation blunt the response, and a falling systolic pressure, angina, new arrhythmia or ST depression stops the session.

Section 3Obstructive and restrictive lung disease and pulmonary rehabilitation

Two patterns of disease

Lung diseases are grouped by what they do to airflow and volume. In obstructive disease the airways are narrowed or collapse on expiration, so air goes in but has trouble coming out. Expiratory flow falls, air is trapped, and residual volume and total lung capacity rise (hyperinflation). The defining spirometry finding is a reduced FEV1/FVC ratio, below 0.70 after a bronchodilator in COPD. In restrictive disease the lungs or chest wall cannot expand fully, so all volumes shrink (low total lung capacity, the defining finding, plus low FVC and vital capacity) while the FEV1/FVC ratio is normal or high because the stiff lungs empty quickly.

Time (seconds) Volume exhaled (L) 012345 12345 FEV1 measured at 1 s Normal FEV1 4.0, FVC 5.0 ratio about 0.80 Obstructive FEV1 low, FVC near normal ratio below 0.70 Restrictive FEV1 and FVC both low ratio normal or high
Figure 9.3 Volume time curves from forced spirometry. The obstructive curve climbs slowly and keeps rising (air trapping, low FEV1/FVC). The restrictive curve rises fast but plateaus at a small volume (low FVC with a preserved ratio).
FeatureObstructive (COPD, asthma, CF, bronchiectasis)Restrictive (ILD, chest wall, neuromuscular, obesity)
Core problemGetting air outGetting air in
FEV1/FVCReduced (below 0.70)Normal or increased
Total lung capacity, residual volumeIncreased (hyperinflation, air trapping)Decreased
Breathing patternProlonged expiration, pursed lips, accessory musclesRapid and shallow
Chest examBarrel chest, flattened diaphragm, wheezes or diminished sounds, hyperresonanceSmall volumes, fine end inspiratory crackles in fibrosis
Exercise limitationDynamic hyperinflation and dyspneaOxygen desaturation with exertion

COPD

Chronic obstructive pulmonary disease is persistent, usually progressive airflow limitation caused mainly by cigarette smoke, with occupational dusts, biomass smoke and alpha-1 antitrypsin deficiency as other causes. Two overlapping processes are involved. Chronic bronchitis is defined clinically by a productive cough for at least 3 months in each of 2 consecutive years; mucus hypersecretion, airway inflammation and hypoxemia lead to cyanosis and right heart failure, giving the old "blue bloater" picture. Emphysema is destruction of alveolar walls with loss of elastic recoil, so small airways collapse on expiration; the classic "pink puffer" is thin, breathes through pursed lips, uses accessory muscles and leans forward on the arms. Severity of airflow limitation is graded by FEV1 percent predicted:

Airflow grade (with FEV1/FVC below 0.70)FEV1 percent predicted
1, mild80% or more
2, moderate50% to 79%
3, severe30% to 49%
4, very severeBelow 30%

Hyperinflation flattens the diaphragm, putting it at a mechanical disadvantage, so accessory muscles take over. During exercise, rapid breathing leaves too little time to exhale and air builds up (dynamic hyperinflation), the main reason COPD patients stop exercising.

Long term oxygen is prescribed for resting SpO2 of 88% or lower (PaO2 55 mmHg or lower). The usual COPD target is SpO2 88% to 92%, because excess oxygen can worsen CO2 retention in some patients; titrate within the order, and never withhold oxygen from a patient in distress.

Asthma, cystic fibrosis and bronchiectasis

Asthma is airway inflammation with largely reversible obstruction (FEV1 improves 12% or more and 200 mL after bronchodilator). Exercise induced bronchoconstriction peaks 5 to 15 minutes after vigorous exercise; prevent it with a short acting beta agonist about 15 minutes before, a long warm up, and a scarf in cold air. Inability to speak in sentences, a quiet chest and cyanosis signal a severe attack and an emergency.

Cystic fibrosis is an autosomal recessive CFTR chloride channel defect: thick secretions, chronic infection (Pseudomonas), bronchiectasis, pancreatic insufficiency and salty sweat. Care centers on daily airway clearance and aerobic exercise; keep patients with CF at least about 6 feet apart, and add fluid and salt in heat. Bronchiectasis (permanent bronchial dilation with copious sputum) is also managed with airway clearance.

Restrictive lung disease

Interstitial lung disease (idiopathic pulmonary fibrosis, connective tissue disease, sarcoidosis, asbestos and silica) stiffens the lung and lowers diffusing capacity (DLCO), so patients desaturate quickly with exertion; use titrated oxygen, intervals and close SpO2 monitoring. Restriction also comes from chest wall deformity, obesity and neuromuscular weakness, where a falling vital capacity (toward about 15 to 20 mL/kg in Guillain Barre syndrome) warns of respiratory failure.

Board tip. The quickest way to sort a pulmonary function question: low FEV1/FVC means obstruction; low total lung capacity with a normal or high ratio means restriction. In COPD expect high residual volume and total lung capacity; in fibrosis expect everything small and a low DLCO with exertional desaturation.

Pulmonary rehabilitation

Pulmonary rehabilitation does not improve FEV1 but improves exercise capacity, dyspnea and quality of life and reduces hospital use. Programs of about 8 to 12 weeks combine exercise, education, breathing strategies and psychosocial support.

  • Endurance training: walking and cycling, 3 to 5 days per week, 20 to 60 minutes. Intensity is set by dyspnea (modified Borg 3 to 4, moderate to somewhat severe) or by 60% to 80% of peak work rate. Interval training lets severely limited patients accumulate more work.
  • Strength training: large muscle groups of the legs and arms; upper extremity work matters because daily tasks with unsupported arms quickly provoke dyspnea when accessory muscles must stabilize the shoulder girdle.
  • Inspiratory muscle training: resistive or threshold devices, often starting at about 30% of maximal inspiratory pressure, in patients with weak inspiratory muscles.
  • Outcome: the 6 minute walk test (about 30 meters is a commonly cited important change in COPD).

Stop for SpO2 below about 88% that does not recover, severe dyspnea, chest pain or dizziness.

Breathing retraining

  • Pursed lip breathing: inhale through the nose, exhale slowly through pursed lips for about twice as long as inspiration. The back pressure splints small airways open, slows respiratory rate, raises tidal volume and reduces air trapping. It is the most useful single technique in obstructive disease.
  • Diaphragmatic breathing: the patient relaxes the upper chest and lets the abdomen rise during inspiration. It helps postoperative and anxious patients and asthma. In severe COPD with a flattened diaphragm it can increase the work of breathing and dyspnea, so use it selectively.
  • Paced breathing coordinates breaths with activity: exhale during the effort phase (lifting, standing up, climbing a step).
  • Positions to relieve dyspnea: forward lean sitting with forearms on the thighs or a table, standing leaning on a counter, and the tripod position. Leaning forward pushes abdominal contents up against the flattened diaphragm, restoring some dome, and fixes the shoulder girdle so accessory muscles work better.
  • Segmental breathing and incentive spirometry encourage deep breaths and expansion of specific regions after surgery to prevent atelectasis.

Airway clearance

Airway clearance helps patients who produce excess or thick secretions (cystic fibrosis, bronchiectasis, some COPD, neuromuscular weakness with poor cough). Choose techniques the patient can do independently and will use.

TechniqueHow it worksNotes and cautions
Postural drainagePosition the involved segment so gravity drains it toward the central airways, typically 3 to 15 minutes per positionHead down positions are avoided with increased intracranial pressure, recent neurosurgery, uncontrolled hypertension, hemoptysis, GERD and aspiration risk, pulmonary edema, obesity or distended abdomen, recent esophageal surgery
PercussionRhythmic clapping with cupped hands over the segment during drainageAvoid over fractures, osteoporosis, coagulopathy or low platelets, unstable chest wall, tumor, fresh incisions, pacemaker site, spine, breast tissue and kidneys
Vibration and shakingOscillating compression on the chest wall during exhalationSimilar precautions to percussion; gentler
Active cycle of breathingBreathing control, thoracic expansion exercises, then forced expiration (huffs)Independent; huffing avoids airway collapse that forceful cough can cause
PEP and oscillating PEPExhale against resistance, with or without vibrating valveSplints airways open, moves mucus; portable
Assisted coughManual abdominal thrust timed with cough, or mechanical insufflation exsufflationFor weak cough in SCI and neuromuscular disease; avoid abdominal thrust after recent abdominal surgery or with IVC filter

Key drainage positions: upper lobe apical segments in sitting; right middle lobe and lingula supine with a quarter turn away from the involved side and the head lowered about 15 degrees; lower lobe superior segments prone flat; basal segments head down about 20 to 30 degrees (anterior in supine, lateral in sidelying on the opposite side, posterior in prone).

Case. A 68 year old woman with severe COPD (FEV1 38% predicted) begins pulmonary rehab. Walking at a moderate pace, she becomes very dyspneic within 2 minutes, her respiratory rate rises to 32, and SpO2 falls from 92% to 86% on her prescribed 2 L/min.
Reasoning: Rapid breathing in COPD causes dynamic hyperinflation, and her SpO2 fell below 88%. The best choice is to stop, use a forward lean position with pursed lip breathing to slow the rate and lengthen exhalation, let SpO2 recover, and then continue with interval training and oxygen titrated per the prescription range. Teaching diaphragmatic breathing alone is a weaker choice in severe hyperinflation, and simply "continuing at the same pace while monitoring" accepts unsafe desaturation. Safety point: keep SpO2 at about 88% or above during exercise and titrate oxygen only within the physician's order.
Key point

Obstruction lowers the FEV1/FVC ratio and traps air; restriction shrinks all volumes and causes exertional desaturation. COPD rehab targets dyspnea with pursed lip breathing, forward lean positions, interval training and oxygen kept near 88% to 92%. Asthma is reversible and preventable with a pre exercise bronchodilator and warm up. Airway clearance (postural drainage, percussion, ACBT, PEP) is daily care in cystic fibrosis and bronchiectasis, and every head down position and percussion has contraindications you must know.

Section 4Peripheral vascular disease

Arterial versus venous disease

Peripheral artery disease (PAD) is limb atherosclerosis, strongly linked to smoking and diabetes, and most patients also have coronary disease. Intermittent claudication is a cramping muscle ache brought on by a predictable walking distance and relieved within minutes by standing still; pain sits one level below the narrowing (calf for femoral or popliteal, buttock and thigh for aortoiliac). Advanced disease causes forefoot rest pain at night, relieved by dangling the foot.

Chronic venous insufficiency follows valve incompetence or obstruction (often after DVT), producing venous hypertension, edema, brown hemosiderin staining, dermatitis and lipodermatosclerosis, with aching that worsens with standing and improves with elevation.

FindingArterial insufficiencyVenous insufficiency
PainClaudication with walking, rest pain at night; worse with elevation, better dependentAching, heaviness; worse with dependency, better with elevation and walking
PulsesDiminished or absentUsually present (may be hard to feel through edema)
SkinThin, shiny, hairless, cool, thick nails; pallor on elevation, dependent ruborWarm, brown hemosiderin staining, dermatitis, lipodermatosclerosis
EdemaUsually absentPresent, often pitting
Capillary refillProlonged (more than 3 seconds)Normal
Typical woundToes, lateral malleolus, pressure points; round, punched out, pale dry base, little drainage, painfulMedial malleolus (gaiter area), shallow, irregular, red granular base, heavy drainage
CompressionContraindicated when severeCornerstone of treatment

Bedside tests: pulse grading (0 absent to 2+ normal to 4+ bounding), capillary refill (normal under about 3 seconds), the elevation pallor and dependent rubor test, and venous filling time (more than 20 seconds suggests arterial disease).

The ankle brachial index

The ankle brachial index (ABI) compares systolic pressure at the ankle with that in the arm. With the patient supine and rested for about 5 to 10 minutes, measure brachial systolic pressure in both arms and ankle systolic pressure in the dorsalis pedis and posterior tibial arteries of each leg with a Doppler. For each leg, divide the higher ankle pressure by the higher of the two brachial pressures.

ABI = higher ankle systolic higher brachial systolic Example: ankle 84, brachial 140, ABI = 0.60 00.400.901.001.40 Criticalrest pain,tissue loss PADclaudication; below 0.50,no sustained compression Borderline0.91 to 0.99 Normal1.00 to 1.40 Above 1.40calcified,use toe pressure Older texts call 0.90 to 1.30 normal; the decision points at 0.90 and 0.50 are the same
Figure 9.4 Calculating and interpreting the ankle brachial index. Values at or below 0.90 diagnose PAD; values above 1.40 mean the vessels are too stiff to compress, common in diabetes and kidney disease, and a toe brachial index is used instead.
Board tip. A patient with diabetes and an ABI of 1.5 does not have "super normal" circulation. Medial arterial calcification makes the vessels noncompressible and the ABI falsely high. The correct next step is a toe pressure or toe brachial index before applying compression or concluding that perfusion is adequate.

Claudication exercise

Supervised exercise therapy is a first line treatment for claudication and increases pain free and maximal walking distance as much as or more than revascularization in many patients. It works through better muscle oxidative capacity, improved endothelial function, collateral development and more efficient gait. The usual prescription:

  • Mode: treadmill or track walking, because walking provokes and trains the affected muscles. Cycling or arm ergometry can supplement.
  • Intensity: walk at a speed and grade that brings on claudication within about 3 to 5 minutes, continue until pain reaches moderate to moderately severe (about 3 to 4 on a 0 to 4 claudication scale), then rest until pain resolves completely, and repeat.
  • Time: accumulate 30 to 45 minutes of walking (excluding rests), progressing toward 50 to 60 minutes.
  • Frequency and duration: at least 3 sessions per week for at least 12 weeks.

Because PAD patients usually have coronary disease, monitor for angina, blood pressure response and dyspnea. Inspect the feet each session, especially in diabetes, and ensure footwear protects the skin. Smoking cessation is the single most important risk factor change.

Case. A 69 year old man who smokes reports cramping in his right calf after walking about two blocks; it eases within 3 minutes when he stands still. Right ABI is 0.65, left 0.95. He asks whether he should stop walking because it hurts.
Reasoning: This is classic intermittent claudication from femoral or popliteal disease. The best plan is a walking program to moderate to moderately severe claudication pain, rest to full relief, and repeat, for 30 to 45 minutes of walking at least 3 times per week for 12 weeks, plus smoking cessation counseling. Advising him to stop at the first sign of discomfort undertrains him, and stationary cycling alone is less effective than walking. Compression stockings for leg pain would be wrong for arterial disease. Safety point: monitor for angina, since PAD signals likely coronary disease, and watch his feet for skin breakdown.

Deep vein thrombosis and pulmonary embolism

Virchow triad: stasis (immobility, paralysis, travel), endothelial injury (surgery, trauma, lines) and hypercoagulability (cancer, pregnancy, estrogen, thrombophilia). Hip and knee surgery, hip fracture, major trauma and spinal cord injury carry the highest risk.

DVT signs are unilateral calf or leg swelling, pain or tenderness along the deep veins, warmth, erythema and pitting edema, but many DVTs are silent. Homans sign (calf pain on passive dorsiflexion) has poor sensitivity and specificity and should not be relied on. The Wells criteria estimate pretest probability:

Wells criterion for DVTPoints
Active cancer (treatment within 6 months or palliative)+1
Paralysis, paresis or recent plaster cast of the leg+1
Bedridden 3 days or more, or major surgery within 12 weeks+1
Localized tenderness along the deep venous system+1
Entire leg swollen+1
Calf swelling more than 3 cm compared with the other leg (10 cm below tibial tuberosity)+1
Pitting edema confined to the symptomatic leg+1
Collateral superficial veins (nonvaricose)+1
Previously documented DVT+1
Alternative diagnosis at least as likely as DVTminus 2

In the two level version, a score of 2 or more means DVT is likely and 1 or less means unlikely; in the three level version, 0 is low, 1 to 2 moderate and 3 or more high probability. For a physical therapist, a likely score means hold lower extremity exercise and manual work on that limb and communicate with the physician the same day; diagnosis is by compression ultrasound and D-dimer.

Pulmonary embolism (sudden dyspnea, pleuritic chest pain, tachycardia, falling SpO2, hemoptysis) is an emergency: stop, support the patient and activate emergency response.

After a confirmed DVT, practice guidance supports early mobilization once therapeutic anticoagulation is reached (usually within about 24 hours with heparin products or direct oral anticoagulants; warfarin targets INR 2 to 3), because walking does not raise PE risk.

Case. Four days after total knee arthroplasty, a 63 year old woman with breast cancer on treatment reports new right calf pain. The calf is warm and 3.5 cm larger than the left, with pitting edema limited to that leg. She is scheduled for gait training.
Reasoning: Wells points: active cancer (+1), major surgery within 12 weeks (+1), calf more than 3 cm larger (+1), pitting edema in the symptomatic leg (+1), localized tenderness likely (+1), giving 4 or more: DVT likely. The best action is to hold the session's lower extremity exercise and notify the physician immediately for ultrasound. Performing Homans sign to "confirm" is unreliable, and massage or compression of the calf is contraindicated until DVT is excluded. Safety point: if she develops sudden dyspnea or chest pain, treat it as a pulmonary embolism and call for emergency help.

Also know Raynaud phenomenon (cold induced digital vasospasm, white to blue to red), Buerger disease (inflammatory small vessel occlusion in young smokers), and abdominal aortic aneurysm (pulsatile mass with deep abdominal or back pain in older male smokers; sudden pain with hypotension is rupture).

Key point

Arterial disease causes claudication, cool hairless skin, weak pulses and painful punched out wounds, and it worsens with elevation; venous disease causes edema, staining, aching and shallow medial wounds and improves with elevation. ABI is the higher ankle pressure over the higher brachial pressure; 0.90 or less is PAD, below 0.50 rules out sustained compression, and above 1.40 is unreliable. Claudication walking to moderate pain for 12 weeks is first line care. Use Wells criteria rather than Homans sign to screen for DVT, and treat signs of PE as an emergency.

Section 5The lymphatic system and lymphedema

How the lymphatic system works

Lymphatics return filtered fluid and protein to the veins. Fluid enters blind ended initial lymphatics, then valved collectors whose segments (lymphangions) contract rhythmically, helped by muscle pumping and breathing. After regional nodes, the thoracic duct drains the legs, abdomen and left upper body into the left venous angle, and the right lymphatic duct drains the right arm and right side of the head and chest. Skin territories are separated by watersheds (trunk midline and a line near the umbilicus), and fluid can be moved across them through superficial anastomoses, the basis of manual lymph drainage.

Lymphedema: causes and staging

Lymphedema is protein rich interstitial fluid from lymphatic transport failure; the protein drives inflammation, fat deposition and fibrosis. Primary lymphedema is developmental: congenital, praecox (puberty to 35, the most common) or tarda (after 35). Secondary lymphedema follows damage: filariasis worldwide, and in the United States mainly cancer treatment (node dissection, radiation), trauma, venous disease and obesity. It can appear years after treatment.

ISL stageClinical pictureResponse to elevation
Stage 0, latentTransport is impaired but no visible swelling; heaviness may be reportedNot applicable
Stage I, spontaneously reversibleSoft, pitting swelling with protein rich fluidSubsides with elevation
Stage II, spontaneously irreversibleSwelling persists; tissue fibrosis begins; pitting early, harder to pit laterElevation alone rarely reduces it
Stage III, lymphostatic elephantiasisMarked swelling, nonpitting fibrosis, skin thickening, papillomas, deepened skin folds, hyperkeratosisNo response
Stage 0Stage IStage IIStage III no visible swelling,transport impaired pitting edema,reverses with elevation persists, early fibrosis,Stemmer sign positive nonpitting, folds,papillomas, hyperkeratosis papillomas fluid
Figure 9.5 International Society of Lymphology stages. Stage I fluid (blue) is soft and leaves with elevation; by stage II fibrosis keeps the limb enlarged; stage III adds skin changes such as deep folds and papillomas. Treatment is most effective in the early stages.

Examination and measurement

History covers cancer treatment, node surgery and radiation, infections, onset and progression, and what makes swelling better or worse. Inspection notes skin color, folds, texture, wounds, and lymphorrhea (leaking lymph). Palpation assesses pitting and fibrosis. The Stemmer sign is positive when the examiner cannot lift a fold of skin at the dorsal base of the second toe or middle finger; a positive sign supports lymphedema, but a negative sign does not exclude it, especially early.

  • Circumferential girth: tape measurements at fixed intervals (commonly every 4 cm, or at bony landmarks) on both limbs. A difference of about 2 cm or more at any point between limbs is a common threshold.
  • Volume calculation: girths converted to volume with the truncated cone formula; a difference of about 200 mL or a 10% interlimb volume difference is commonly used to diagnose arm lymphedema, and smaller changes (around 3% to 5%) flag early change. Exact cutoffs vary by source.
  • Water displacement (reference standard), perometry, and bioimpedance spectroscopy, which detects subclinical stage 0 fluid.

Lipedema is symmetric fat deposition in women that spares the feet with a negative Stemmer sign. Bilateral pitting edema suggests heart, kidney or liver disease. New swelling in a cancer survivor may be recurrence, and sudden unilateral swelling may be DVT; refer both.

Complete decongestive therapy

Complete decongestive therapy (CDT) is the standard treatment and has two phases.

  • Phase 1, intensive (reduction): usually daily, 5 days per week for about 2 to 4 weeks or until the limb plateaus. It combines manual lymph drainage, multilayer short stretch compression bandaging worn about 23 hours a day, decongestive exercise in the bandages, and meticulous skin and nail care.
  • Phase 2, self management (maintenance): the patient wears a fitted compression garment during the day, often bandages or a nighttime garment, performs self MLD and exercise, maintains skin care, and returns for remeasurement and new garments about every 6 months.

Manual lymph drainage (MLD) uses light, slow, rhythmic skin stretching (pressure of roughly 30 to 45 mmHg, enough to stretch the skin but not to compress underlying tissue). The sequence always starts proximally: clear the neck (terminus) and the healthy nodes and territories first, then move fluid from the trunk across watersheds toward working nodes, and only then work on the limb from proximal to distal, with strokes directed proximally. After left axillary dissection, left arm fluid is routed to the right axilla and left inguinal nodes.

Short stretch bandages have low resting and high working pressure: muscle contraction against the inelastic wrap pumps lymph, and resting pressure stays safe for night wear. They are applied with a distal to proximal gradient over padding. Garments (classes of about 20 to 30, 30 to 40 and 40 to 50 mmHg) are fitted only after reduction. Progressive resistance training, started light and supervised, is safe and does not worsen breast cancer related lymphedema. Intermittent pneumatic compression is an adjunct at low pressure after proximal clearing.

SituationMLD and compressionReason
Acute cellulitis or other acute infectionContraindicated until treated with antibioticsCan spread infection; refer for antibiotics
Acute DVTContraindicated until anticoagulated and clearedRisk of embolism
Decompensated heart failureContraindicatedMobilized fluid overloads the heart
Severe arterial disease (ABI below about 0.50)No sustained compression; modified only with physician input at moderate ABICompression further reduces arterial inflow
Active untreated cancer in the regionPrecaution; requires oncology inputConcern for disease, though MLD does not spread cancer by current evidence; palliative use is common
Renal failure, uncontrolled hypertension, peripheral neuropathy with sensory loss, unstable diabetesPrecautionFluid shifts and unrecognized pressure injury

Precautions and education

Cellulitis (spreading redness, warmth, pain, fever) is common in lymphedematous limbs: stop MLD and compression and refer for antibiotics. Teach daily skin inspection, moisturizing and careful nail care. Avoiding blood pressure readings and needle sticks in the at risk arm has weak evidence but remains a reasonable precaution when another limb is available. Healthy weight lowers risk, and early reporting of heaviness allows treatment at stage 0 or I.

Board tip. MLD always begins by clearing proximal, healthy territories and nodes, then moves fluid toward them across watersheds, then treats the limb from proximal to distal with proximally directed strokes. The common wrong answer begins distally at the hand or foot. Short stretch bandages are the compression of choice during the intensive phase because of high working and low resting pressure.
Case. A 52 year old woman who had a right mastectomy with axillary node dissection and radiation 2 years ago is in phase 1 CDT for stage II arm lymphedema. Today her right forearm is red, hot and tender, the redness has spread since yesterday, and her temperature is 38.4 C.
Reasoning: Spreading erythema, warmth, pain and fever in a lymphedematous limb indicate cellulitis. The best action is to stop MLD and bandaging and refer her for urgent medical evaluation and antibiotics; resume CDT after the infection is controlled. Continuing with lighter MLD, applying heat or switching to pneumatic compression would risk spreading infection. Safety point: infection is an absolute contraindication to MLD and compression in that limb until treated.
Key point

Lymphedema is protein rich swelling from lymphatic failure, staged 0 to III from latent to elephantiasis, with stage I reversing on elevation and stage II onward fibrotic. Measure with girth, calculated volume, perometry or bioimpedance, and use the Stemmer sign as support. Complete decongestive therapy pairs an intensive phase (MLD that clears proximal territories first, short stretch bandaging, exercise, skin care) with lifelong self management in fitted garments. Infection, acute DVT, decompensated heart failure and severe arterial disease stop treatment.

The chapter in one breath

  • Stable angina is predictable and relieved by rest or nitroglycerin; new, rest or crescendo angina is an acute coronary syndrome and ends the session.
  • Left heart failure floods the lungs (orthopnea, crackles, S3); right heart failure backs up into the body (JVD, edema, liver congestion); daily weight gain of 2 to 3 pounds in a day or 5 in a week is reportable.
  • NYHA classes I to IV describe symptoms and can improve; ACC/AHA stages A to D describe progression and never go backward.
  • Sternal precautions for about 6 to 8 weeks: no heavy lifting, no pushing up with the arms, splinted cough, and report clicking or drainage.
  • Use RPE for beta blockers, transplanted hearts and fixed rate pacemakers; keep heart rate 10 to 20 beats below an ICD detection rate; read LVAD pressure as a Doppler MAP.
  • Phase I limits heart rate rise to about 20 above rest after MI and 30 after surgery; phase II trains at 40% to 80% of HRR, at least 10 beats below the ischemic threshold.
  • A fall in systolic pressure of more than 10 mmHg with increasing work is abnormal everywhere.
  • Obstruction lowers FEV1/FVC and traps air; restriction lowers all volumes and causes exertional desaturation; COPD oxygen targets are about 88% to 92%.
  • Pursed lip breathing, forward lean positions and interval training ease dyspnea; airway clearance techniques each carry contraindications.
  • ABI is higher ankle over higher brachial pressure: 0.90 or less is PAD, below 0.50 avoids sustained compression, above 1.40 is unreliable; claudication walking to moderate pain for 12 weeks is first line care.
  • Lymphedema is staged 0 to III and treated with complete decongestive therapy; MLD clears proximal territories first, and cellulitis, acute DVT and decompensated heart failure stop treatment.

Words worth knowing

TermWhat it means
Acute coronary syndromeUnstable angina, NSTEMI or STEMI: an acute plaque event with partial or complete coronary occlusion that needs emergency care.
Ischemic thresholdThe heart rate or rate pressure product at which angina or ST depression appears; training stays at least 10 beats below it.
TroponinA cardiac muscle protein released when myocytes die; its rise and fall confirms myocardial infarction.
Ejection fractionThe percentage of blood in the left ventricle pumped out with each beat, normally about 55% to 70%.
HFrEFHeart failure with reduced ejection fraction (40% or less), caused by weak contraction.
OrthopneaShortness of breath when lying flat, relieved by sitting up; a sign of left heart failure.
Sternal precautionsRestrictions on lifting, pushing and arm use that protect a healing median sternotomy for about 6 to 8 weeks.
Implantable cardioverter defibrillatorAn implanted device that detects ventricular tachycardia or fibrillation and paces or shocks it.
Left ventricular assist deviceA mechanical pump that moves blood from the left ventricle to the aorta, often with continuous flow and no palpable pulse.
Denervated heartA transplanted heart without autonomic nerve supply; resting rate is high and the exercise response is delayed.
Heart rate reserveMaximal heart rate minus resting heart rate; the base of the Karvonen training formula.
METMetabolic equivalent: resting oxygen uptake of about 3.5 mL per kg per minute, used to express activity intensity.
Rating of perceived exertionThe patient's rating of effort, on the 6 to 20 Borg scale or a 0 to 10 scale; used when heart rate is unreliable.
FEV1/FVC ratioThe fraction of forced vital capacity exhaled in the first second; below 0.70 indicates obstruction.
Dynamic hyperinflationProgressive air trapping during rapid breathing in COPD that raises end expiratory volume and dyspnea.
Pursed lip breathingSlow exhalation through pursed lips that splints small airways open and slows the breathing rate.
Postural drainagePositioning so gravity drains a specific lung segment toward the central airways.
Active cycle of breathingAn independent airway clearance cycle of breathing control, thoracic expansion and huffing.
Intermittent claudicationReproducible exertional muscle pain from arterial insufficiency, relieved within minutes by rest.
Ankle brachial indexAnkle systolic pressure divided by brachial systolic pressure; 0.90 or less indicates peripheral artery disease.
Virchow triadStasis, endothelial injury and hypercoagulability: the three conditions that promote venous thrombosis.
Wells criteriaA clinical score that estimates the probability of DVT before testing.
Stemmer signInability to pinch a skin fold at the base of the second toe or middle finger; supports lymphedema.
Complete decongestive therapyTwo phase lymphedema treatment of MLD, short stretch bandaging, exercise and skin care, then self management in garments.
LipedemaSymmetric abnormal fat deposition in the legs, usually in women, sparing the feet with a negative Stemmer sign.

Check yourself

A patient with a resting HR of 64 reached a peak HR of 144 on a treadmill test taken on his usual medications. What is the target HR at 60% of heart rate reserve?
Answer. 112. Heart rate reserve is 144 minus 64 = 80; 80 times 0.6 = 48; 48 plus 64 = 112. Use the measured peak rather than an age formula when a test is available.
During inpatient ambulation after an MI, a patient's systolic pressure falls from 132 to 116 mmHg as walking speed increases. What should the therapist do?
Answer. Stop the activity, have the patient sit or lie down, monitor and report. A systolic drop of more than 10 mmHg with increasing workload suggests the left ventricle cannot raise output and is an abnormal response.
Which heart failure finding points to right sided rather than left sided failure: orthopnea, bibasilar crackles, jugular venous distension, or an S3?
Answer. Jugular venous distension. Right sided failure backs blood into the systemic veins (JVD, dependent edema, liver congestion), while orthopnea, crackles and S3 reflect left sided failure with pulmonary congestion.
A patient is 2 weeks after CABG. Which activity violates traditional sternal precautions: walking 10 minutes, rising from a chair by pushing with both arms, or splinting a cough with a pillow?
Answer. Rising by pushing with both arms. Pushing through the arms loads the healing sternum; walking is encouraged and splinted coughing is part of the precautions.
Why is RPE preferred over a target heart rate for a patient 6 months after heart transplant?
Answer. The transplanted heart is denervated, so resting rate is high and heart rate rises slowly through circulating catecholamines during exercise and stays elevated afterward. Heart rate does not track effort, so RPE with long warm up and cool down is used.
Spirometry shows FEV1 55% predicted, FVC 85% predicted and FEV1/FVC 0.52 after bronchodilator. Name the pattern and severity.
Answer. Obstructive pattern (ratio below 0.70) with moderate airflow limitation (FEV1 50% to 79% predicted), consistent with grade 2 COPD.
A patient with cystic fibrosis also has active hemoptysis and severe reflux. Which airway clearance positions should be avoided?
Answer. Head down (Trendelenburg) positions. Hemoptysis and reflux with aspiration risk are contraindications; use modified positions without tilt and independent techniques such as ACBT or oscillating PEP, while reporting the hemoptysis.
A man with diabetes has an ABI of 1.6 on the left. A venous wound is present. Is full compression safe?
Answer. Not yet known. An ABI above 1.40 means calcified, noncompressible arteries and the value is unreliable. Obtain a toe brachial index or other arterial study before applying sustained compression.
What is the correct intensity end point for a supervised claudication walking bout?
Answer. Walk until claudication reaches moderate to moderately severe pain (about 3 to 4 on a 0 to 4 scale), then rest until pain fully resolves and repeat, accumulating 30 to 45 minutes at least 3 times weekly for 12 weeks.
After a left axillary node dissection, where does manual lymph drainage begin for left arm lymphedema?
Answer. Proximally, at the neck terminus and the healthy right axillary and left inguinal nodes, then across the trunk watersheds toward those nodes, and only then on the arm from proximal to distal with strokes directed proximally.
Chapter 10 · Integumentary

Integumentary: Wounds, Burns and Skin

Skin is the organ a physical therapist sees first and touches most, and wound and burn care sits squarely inside physical therapist practice: debridement, dressings, offloading, positioning and scar control. Exam questions in this area test whether you can name a wound from its location and appearance, stage it correctly, match a dressing to the wound bed, and protect a burned patient from contracture. Get these patterns right and you will also prevent the pressure injuries that start in every hospital bed.

By the end of this chapter you can

  • Describe the epidermis, dermis and hypodermis and explain how depth of injury predicts healing.
  • Outline the inflammatory, proliferative and remodeling phases of healing and list factors that delay them.
  • Document a wound: size, undermining and tunneling, tissue type, exudate, edges and periwound skin.
  • Stage a pressure injury with current terminology and use the Braden scale to target prevention.
  • Differentiate arterial, venous and neuropathic wounds by location, appearance and treatment.
  • Choose between selective and nonselective debridement and match dressings to moisture balance.
  • Classify burn depth, estimate size with the rule of nines, and position to prevent contracture.
  • Recognize the ABCDE warning signs of melanoma and common skin infections that require referral.

Section 1Skin structure and wound healing

The layers of the skin

The epidermis is avascular stratified squamous epithelium, about 0.05 to 1.5 mm thick, nourished by diffusion from the dermis. From deep to superficial its layers are the stratum basale (dividing keratinocytes, melanocytes and Merkel cells), stratum spinosum (with Langerhans immune cells), stratum granulosum, stratum lucidum (only in thick skin of the palms and soles) and stratum corneum, dead keratinized cells that form the main water barrier. Keratinocytes move from basale to corneum in about 4 weeks.

The dermis is the vascular, innervated connective tissue layer. The thin papillary dermis interlocks with the epidermis through rete ridges, which resist shear; it holds capillary loops and touch receptors (Meissner corpuscles). The thick reticular dermis is dense type I collagen and elastin with deeper vessels, Pacinian corpuscles, sweat glands and hair follicles. Hair follicles and sweat glands are lined with epithelial cells, so when the epidermis is lost but these appendages survive, new epithelium grows up from them as well as in from the edges. That is why partial thickness wounds heal by regeneration and full thickness wounds heal by scar. The hypodermis (subcutaneous tissue) is fat and loose connective tissue that insulates and cushions.

Skin functions are protection, thermoregulation (sweating and vasomotor control), sensation, vitamin D synthesis, immune surveillance and fluid retention. Aging thins the epidermis, flattens the rete ridges (so the layers shear apart easily, causing skin tears), and reduces collagen, blood flow and sensation.

EpidermisPapillary dermisReticular dermisHypodermis (fat)blood vesselssweat glandhair follicle Burn depth reached S superficial SPT superficial partial DPT deep partial FT full thickness SSPTDPTFT
Figure 10.1 Skin layers and depth of injury. The bars on the left show how far each burn depth reaches. Partial thickness wounds spare the deeper hair follicles and sweat glands, whose epithelial linings regrow skin; full thickness wounds destroy them and must close by contraction, scar or graft.

Phases of wound healing

Healing proceeds through overlapping phases.

PhaseTypical timing in an acute woundKey cells and eventsWhat you see
Hemostasis and inflammationImmediately to about day 4 to 6Platelets form a clot and release growth factors; neutrophils clean bacteria; macrophages (the key cell) remove debris and signal repairRedness, heat, swelling, pain; serous drainage
ProliferationAbout day 3 to week 3Fibroblasts lay down type III collagen; angiogenesis forms granulation tissue; myofibroblasts pull the edges in (contraction); keratinocytes migrate across (epithelialization)Beefy red, moist, bumpy granulation; pink new epithelium at the edges
Maturation (remodeling)About day 21 to 2 yearsType III collagen replaced by stronger type I, fibers realign along stress linesScar flattens and pales; reaches only about 80% of original tensile strength

Wounds close by three routes. Primary intention: edges are approximated (sutures, staples), so healing is fast with minimal scar. Secondary intention: the wound is left open and fills with granulation tissue, contracts and epithelializes; this is how most chronic wounds heal. Delayed primary (tertiary) intention: a contaminated wound is left open for several days, then closed. A chronic wound is one that fails to progress through the phases in an orderly way, often stuck in inflammation, and has not reduced meaningfully in size after about 4 weeks of good care.

Factors that delay healing

  • Local: inadequate perfusion and oxygen, infection and biofilm, necrotic tissue, too much or too little moisture, unrelieved pressure or shear, edema, foreign bodies, repeated trauma, and a cold wound bed (dressing changes that cool the wound slow cell activity).
  • Systemic: older age, diabetes (impaired neutrophil function and microvascular disease), poor nutrition (protein in particular), anemia, smoking (vasoconstriction and carbon monoxide), obesity, immunosuppression, corticosteroids (suppress inflammation and collagen synthesis), chemotherapy and radiation, and renal or hepatic failure.
  • Nutrition markers: commonly cited low values are serum albumin below 3.5 g/dL and prealbumin below about 15 mg/dL; prealbumin, with a half life of 2 to 3 days, reflects recent intake better, though both fall with inflammation. Protein, calories, vitamin C, zinc and hydration all matter, so refer to a dietitian.

Documenting a wound

Good documentation lets anyone see whether a wound is improving.

  • Location using anatomic landmarks.
  • Size: length is measured head to toe and width perpendicular to it at the widest points; depth with a sterile cotton tipped applicator at the deepest point, all in centimeters.
  • Undermining (tissue loss under intact skin along the edge, a shelf) and tunneling (a narrow channel extending in one direction) are recorded with the clock method, where 12 o'clock points toward the patient's head: for example, "undermining 1.5 cm from 2 to 5 o'clock; tunnel 3 cm at 9 o'clock".
  • Wound bed tissue as percentages: granulation (red), epithelial (pink), slough (yellow, tan or gray, stringy or soft), eschar (black or brown, leathery necrotic tissue).
  • Exudate: amount (none, scant, small, moderate, large) and type.
  • Wound edges: attached, unattached, or rolled (epibole, which halts epithelial migration and needs to be opened); periwound skin: maceration (white, soggy from moisture), erythema, induration, callus.
  • Odor (assessed after cleansing), pain, and signs of infection. Standardized tools such as the PUSH tool track healing over time.
Exudate typeAppearanceMeaning
SerousClear, thin, watery, light yellowNormal in inflammatory phase
SerosanguineousThin, pink to light redNormal in early healing
SanguineousThin, bright redFresh bleeding, trauma to granulation tissue
Purulent (seropurulent)Thick, opaque, yellow, tan or green, often odorousInfection; report
Board tip. Granulation tissue that is red and moist means the wound is healthy and in the proliferative phase. Granulation that is pale or dusky suggests poor perfusion; bright, friable granulation that bleeds easily or rises above the skin (hypergranulation) suggests infection or excess moisture. Epibole is rolled, closed edges that stop epithelial migration.
Case. A 79 year old man has a sacral wound measuring 4 cm head to toe and 3 cm side to side, with a 2 cm deep shelf of tissue loss under the skin from 1 to 4 o'clock and a 4 cm narrow channel at 7 o'clock. He takes prednisone for COPD and his prealbumin is 11 mg/dL.
Reasoning: Document the shelf as undermining from 1 to 4 o'clock and the channel as a tunnel at 7 o'clock, with 12 o'clock toward the head. Corticosteroids and low prealbumin both slow healing, so the best plan includes a dietitian referral and communication with the physician, not only local care. A tempting choice is to call the channel "undermining"; undermining runs along the edge across a span of clock hours, while a tunnel is a narrow track in one direction. Safety point: tunnels must be filled loosely, never packed tight, and probed gently to avoid creating false tracts.
Key point

The avascular epidermis sits on the vascular dermis, whose surviving hair follicles and sweat glands let partial thickness wounds regenerate. Healing runs through inflammation, proliferation (granulation, contraction, epithelialization) and years of remodeling, and scar never regains full strength. Local factors (perfusion, infection, moisture, pressure) and systemic factors (diabetes, steroids, nutrition, smoking) decide whether a wound moves forward. Document size head to toe, undermining and tunneling by the clock, tissue percentages, exudate, edges and periwound skin.

Section 2Wound types and their features

Pressure injuries

A pressure injury is localized damage to skin and underlying tissue, usually over a bony prominence or under a medical device, from intense or prolonged pressure, often combined with shear. Pressure above capillary closing pressure (classically about 32 mmHg) for long enough causes ischemia; muscle and fat are more vulnerable than skin, so damage can begin deep and work outward. Shear (skin held by friction while the skeleton slides, as when the head of the bed is raised and the patient slides down) kinks deep vessels and is typical of sacral and coccygeal injuries. Moisture from incontinence or sweat macerates skin and raises friction. Common sites: sacrum and coccyx, heels, ischial tuberosities (sitting), greater trochanters (sidelying), occiput (infants and supine patients), elbows, scapulae and malleoli.

Staging uses the system of the National Pressure Injury Advisory Panel. Stage describes the deepest tissue layer exposed.

CategoryDefinitionNotes
Stage 1Intact skin with nonblanchable erythemaHarder to see in darkly pigmented skin; look for warmth, coolness, firmness or color change
Stage 2Partial thickness loss with exposed dermis; pink or red moist bed, or an intact or ruptured serum filled blisterNo fat, slough or eschar visible; not used for moisture damage, skin tears or burns
Stage 3Full thickness skin loss; fat visible, granulation and epibole often presentSlough or eschar may be present; undermining and tunneling possible; no fascia, muscle, tendon, ligament, cartilage or bone exposed
Stage 4Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or boneUndermining, tunneling and osteomyelitis risk
UnstageableFull thickness loss obscured by slough or eschar so depth cannot be confirmedWill be stage 3 or 4 once the base is seen; leave stable dry eschar on heels or ischemic limbs
Deep tissue pressure injuryIntact or nonintact skin with persistent nonblanchable deep red, maroon or purple discoloration, or a blood filled blisterDamage at the bone muscle interface; may evolve rapidly into a full thickness wound

Two further labels: medical device related pressure injury (shaped like the device, such as a splint, tubing or oxygen mask, and staged with the same system) and mucosal membrane pressure injury (on mucosa, not staged). Pressure injuries are never reverse staged: a stage 4 that is filling with granulation is documented as a healing stage 4, because granulation and scar are not the muscle and fat that were lost.

epidermisdermisfatmusclebone Stage 1Stage 2Stage 3Stage 4 intact skin,nonblanchable red partial thickness,dermis exposed full thickness,fat visible muscle, tendonor bone exposed Unstageable: base hidden by slough or eschar. Deep tissue injury: purple or maroon, deep damage first.
Figure 10.2 Pressure injury stages by the deepest tissue exposed. A stage 1 has intact skin; stage 2 stops in the dermis; stage 3 reaches fat; stage 4 exposes fascia, muscle, tendon or bone. Stages are never reversed as the wound fills in.

Risk assessment and prevention

The Braden scale scores six areas: sensory perception, moisture, activity, mobility (each 1 to 4), nutrition (1 to 4) and friction and shear (1 to 3). Totals range from 6 to 23, and lower scores mean higher risk. A score of 18 or less is generally considered at risk (15 to 18 mild, 13 to 14 moderate, 10 to 12 high, 9 or less very high). Prevention follows from the subscales:

  • Reposition bed bound patients at regular intervals (every 2 hours is the traditional standard; frequency is individualized to the surface and the patient's skin response).
  • Use a 30 degree tilted sidelying position rather than full sidelying over the trochanter, and keep the head of the bed at 30 degrees or less when safe to reduce shear.
  • Float the heels with a pillow under the calves or a heel boot so the heel bears no weight.
  • In sitting, teach pressure relief every 15 to 30 minutes (forward lean, side lean or push up held long enough to reperfuse, often cited as 1 to 2 minutes) and reposition at least hourly; use a pressure redistributing cushion; avoid donut cushions.
  • Manage moisture with barrier products and incontinence care, maximize nutrition and hydration, and use lift sheets so skin is not dragged.

Vascular and neuropathic wounds

The three other classic chronic wounds are recognized by location and appearance. Chapter 9 covers the circulation problems behind arterial and venous wounds.

FeatureArterialVenousNeuropathic (diabetic)
LocationToes, between toes, lateral malleolus, dorsum of foot, sites of traumaMedial lower leg above the medial malleolus (gaiter area)Plantar surface under metatarsal heads, great toe, heel, sites of shoe pressure
AppearanceRound, punched out, deep, pale or necrotic base, smooth well defined edgesShallow, irregular edges, red granular base, may be largeRound, surrounded by thick callus, often deep, may probe to bone
ExudateMinimalModerate to heavyVariable
PainSevere, worse with elevationAching, better with elevationLittle or none because of sensory loss
Surrounding signsAbsent pulses, thin hairless shiny skin, cool, dependent ruborEdema, hemosiderin staining, lipodermatosclerosis, dermatitisLoss of protective sensation, dry cracked skin, foot deformity, Charcot changes
Core treatmentRestore blood flow (vascular referral); keep dry eschar dry; protectCompression (after ABI check), elevation, exerciseOffloading (total contact cast), glucose control, debridement of callus

The diabetic foot develops wounds through neuropathy (sensory loss removes the warning of pain; motor loss causes intrinsic weakness and claw toes that raise metatarsal head pressure; autonomic loss dries and cracks the skin), vascular disease and impaired immunity. Protective sensation is screened with the 5.07 (10 gram) Semmes Weinstein monofilament: inability to feel it at tested plantar sites means loss of protective sensation. The Wagner classification grades diabetic foot ulcers from 0 (intact skin, at risk) through 1 (superficial ulcer), 2 (deep to tendon, capsule or bone without abscess or osteomyelitis), 3 (deep with abscess or osteomyelitis), 4 (forefoot gangrene) and 5 (whole foot gangrene). A wound that probes to bone strongly suggests osteomyelitis. A hot, swollen, red foot with intact skin and minimal pain in a patient with neuropathy may be acute Charcot neuroarthropathy; it needs immediate immobilization and offloading, and it is often mistaken for cellulitis or DVT.

Wounds that are not pressure injuries must not be staged as such: skin tears (traumatic separation of epidermis from dermis in fragile skin), moisture associated skin damage such as incontinence associated dermatitis (diffuse, shiny, irregular, superficial, in skin folds and the perineum, without a bony prominence), and surgical wound dehiscence.

Board tip. Location answers most wound identification questions. Medial malleolus with edema and staining: venous. Lateral malleolus or toes with absent pulses and pain on elevation: arterial. Plantar first metatarsal head with callus and no pain: neuropathic. Over the sacrum, heel or ischium in an immobile patient: pressure.
Case. A 58 year old woman with type 2 diabetes has a painless wound under the right second metatarsal head with a thick ring of callus. She cannot feel the 10 gram monofilament on either foot. Pedal pulses are palpable and ABI is 1.05.
Reasoning: Plantar location, callus, and loss of protective sensation with adequate perfusion make this a neuropathic ulcer. The highest priority intervention is offloading, ideally with a total contact cast if there is no infection, plus callus debridement and glucose control. Compression wraps (a venous treatment) and leg elevation or limiting walking alone are wrong. Safety point: check for probing to bone, spreading cellulitis and a hot red foot that could be Charcot before casting.
Case. An 82 year old woman admitted after a stroke has a purple, intact area of skin over her right heel that does not blanch, and the tissue feels boggy. Her Braden score is 11.
Reasoning: Persistent nonblanchable purple or maroon discoloration of intact skin is a deep tissue pressure injury, not a stage 1 (which is red) and not a bruise to ignore. A Braden of 11 means high risk. The best actions are to float the heels completely, use a pressure redistributing surface, reposition on a schedule, and document and report. Applying a heating pad or massaging the area would harm compromised tissue. Safety point: deep tissue injuries can open rapidly into stage 3 or 4 wounds, so offloading starts at once.
Key point

Pressure injuries are staged by the deepest tissue visible: stage 1 intact and red, stage 2 dermis, stage 3 fat, stage 4 muscle, tendon or bone, with unstageable and deep tissue injury categories and no reverse staging. The Braden scale (6 to 23, at risk at 18 or less) directs prevention: turning, heel floating, 30 degree positioning and seated pressure relief. Arterial, venous and neuropathic wounds are recognized by location, appearance and pain, and each has a different core treatment: blood flow, compression or offloading.

Section 3Wound management

Wound bed preparation

Local care follows a simple sequence often summarized by the letters TIME: remove nonviable Tissue, control Infection and inflammation, restore Moisture balance, and advance the Edge (address epibole, undermining and stalled epithelium). All of it rests on treating the cause: pressure off a pressure injury, compression on a venous wound, blood flow to an arterial wound, and offloading for a neuropathic foot. Cleanse wounds with normal saline or a noncytotoxic cleanser at a pressure of about 4 to 15 psi, enough to remove debris without driving bacteria into tissue; antiseptics such as povidone iodine, hydrogen peroxide and full strength Dakin solution damage fibroblasts and are reserved for short term use in heavily contaminated wounds.

Debridement

Debridement removes necrotic tissue, slough, foreign material and biofilm, which feed bacteria and block healing. Methods are grouped as selective (remove only nonviable tissue) or nonselective (remove viable and nonviable tissue alike).

MethodTypeHow it worksBest use and cautions
Sharp (conservative sharp)SelectiveScalpel, scissors and forceps remove loose necrotic tissue above viable tissueFastest; check state practice act and competence; caution with anticoagulation and low platelets; stop at bleeding or pain; not on ischemic wounds with stable eschar
EnzymaticSelectiveTopical collagenase digests necrotic tissueWhen sharp debridement is not possible; slower; some products are inactivated by silver or iodine
AutolyticSelectiveThe body's own enzymes liquefy necrotic tissue under a moisture retentive dressingPainless, slow; avoid in infected wounds and immunocompromised patients; expect odor and exudate under the dressing
Biological (larval)SelectiveSterile maggots digest necrotic tissue and bacteriaEffective in resistant wounds; patient acceptance varies
Mechanical: wet to dry gauzeNonselectiveMoist gauze dries and tears tissue off when removedPainful, damages granulation and cools the wound; largely outdated
Mechanical: pulsed lavage with suctionNonselective (low pressure)Pressurized irrigation (about 4 to 15 psi) with suctionGood for tunnels and large necrotic wounds; use protective gear because of aerosolized spray; caution near exposed vessels, grafts and body cavities
Mechanical: whirlpoolNonselectiveAgitated water softens and loosens debrisNow rarely used; risks cross contamination, maceration and edema in dependent limbs; avoid in venous disease and clean granulating wounds

Do not debride a stable, dry, adherent eschar without erythema, drainage or fluctuance on the heel or on an ischemic limb; it acts as a natural cover. If the eschar becomes boggy, draining or surrounded by redness, it needs medical evaluation and debridement. Ischemic wounds should not be sharply debrided until perfusion has been assessed and, ideally, restored.

Case. A 76 year old man with peripheral artery disease (ABI 0.42) has a dry, black, firmly attached eschar on the tip of the left great toe with no surrounding redness, drainage or odor. The nurse asks you to "clean it up".
Reasoning: A stable dry eschar on a poorly perfused limb should be left intact, kept dry and protected, and the patient referred to the vascular team. Sharp debridement would open a wound that cannot heal and invite infection, and autolytic debridement under an occlusive dressing would soften the eschar and risk wet gangrene. The best answer is protection, offloading and vascular referral. Safety point: watch daily for new redness, fluctuance or drainage, which would change the plan to urgent medical care.

Moisture balance and dressing selection

A moist (not wet) wound environment speeds epithelial migration, supports autolysis and reduces pain. Dressings are chosen to add moisture to a dry wound, absorb from a wet one, and protect the periwound skin from maceration. Fill dead space loosely (packing tunnels and undermining with gauze, alginate or other filler), and keep the wound warm.

Dry Heavy exudate absorptive capacity needed increases HydrogelFilm orhydrocolloidFoamAlginate orhydrofiber donates waterdry wounds,dry eschar toautolyze minimal drainagefilm: no absorptionhydrocolloid:occlusive, low moderate toheavy drainagecushions,nonadherent heavy drainage,fills cavities,gels in wound;needs secondary Infected or heavily colonized wound add an antimicrobial (silver, cadexomer iodine, honey, PHMB); avoid occlusive film and hydrocolloid
Figure 10.3 Matching the dressing to the wound's moisture. Dry wounds need moisture added (hydrogel); wetter wounds need more absorption, from film and hydrocolloid through foam to alginate and hydrofiber. Infection adds an antimicrobial and rules out occlusion.
DressingAbsorbencyIndicationsAvoid or caution
Transparent filmNoneSuperficial wounds, stage 1 and shallow stage 2, protection, securing other dressings; allows inspectionDraining or infected wounds; fragile skin (can tear on removal)
HydrocolloidLow to moderateClean partial thickness wounds with light drainage; promotes autolysis; can stay several daysInfected wounds, heavy drainage, fragile periwound skin; residue and odor are normal
HydrogelVery low (donates moisture)Dry wounds, painful wounds, radiation burns, softening dry sloughHeavily draining wounds (macerates periwound skin)
FoamModerate to highModerate to heavy drainage, cushioning over prominences, under compressionDry wounds
Calcium alginateHighHeavy drainage, cavities and tunnels; mildly hemostatic; forms a gelDry wounds or dry eschar (dries and sticks); needs a secondary dressing
Hydrofiber (gelling fiber)HighHeavy drainage; gels vertically so it protects the periwoundDry wounds
GauzeVariablePacking, cover dressing, inexpensiveDries out and adheres; frequent changes cool the wound
Antimicrobials (silver, cadexomer iodine, honey, PHMB)Varies with baseHeavy bioburden or local infection, used for a limited trial (often about 2 weeks)Iodine with thyroid disease, large wounds, pregnancy; silver can stain; reassess often

Infection

All chronic wounds carry bacteria. The levels are contamination (bacteria present, not multiplying), colonization (multiplying without harm), local or covert infection (bioburden impairs healing: stalled healing, friable bright red granulation, new odor, increased exudate, new pain, pocketing), and spreading infection (cellulitis, warmth, induration, lymphangitis, fever). Biofilm, a protected community of bacteria in a slimy matrix, is present in most chronic wounds and is removed mainly by repeated debridement and cleansing. Deep or spreading infection requires systemic antibiotics, so report it promptly. When cultures are ordered, the Levine technique swabs clean, viable tissue after cleansing (rotate the swab over a 1 cm area with enough pressure to express fluid); a tissue biopsy is the most accurate method.

Offloading and compression

For plantar neuropathic ulcers, the total contact cast is the reference standard: a well molded, minimally padded cast that spreads load across the whole plantar surface and enforces adherence. It is changed often at first (within days, then weekly). Contraindications include active infection or osteomyelitis, significant arterial insufficiency, a wound deeper than its width, excessive edema that will fluctuate, and inability to walk safely or follow precautions. Alternatives are a removable cast walker (made irremovable when possible), healing sandals, wedge shoes and felt padding. After healing, protective footwear with custom insoles prevents recurrence.

For venous wounds, compression is the core treatment once arterial disease has been excluded. Full compression (about 40 mmHg at the ankle with multilayer or short stretch systems) is commonly used when the ABI is 0.8 or higher; reduced compression is considered between about 0.5 and 0.8 with medical oversight, and sustained compression is avoided below about 0.5. Combine with elevation above heart level for periods during the day, ankle pumping and walking to activate the calf muscle pump, and lifelong stockings after healing.

Adjunct modalities

AdjunctCommon parameters or useContraindications and cautions
Electrical stimulation (high voltage pulsed current)Electrode on the wound over saline moistened gauze; commonly about 100 to 150 pulses per second, sensory level, 45 to 60 minutes, 5 to 7 days a week; negative pole often taught for infected or inflammatory phase wounds and positive pole to promote epithelializationMalignancy in the area, untreated osteomyelitis, over a pacemaker or the heart, topical metal ions (silver, iodine) left in the wound, over the carotid sinus
Negative pressure wound therapyFoam or gauze under a seal with suction, typically about 125 mmHg continuous (lower or intermittent options exist); removes exudate, reduces edema, draws edges together, stimulates granulationMalignancy in the wound, untreated osteomyelitis, unexplored or nonenteric fistula, necrotic tissue with eschar, exposed vessels, nerves or organs; caution with anticoagulation and active bleeding
Noncontact low frequency ultrasoundKilohertz range mist delivered through saline, used for debridement and stimulationOver malignancy, pacemaker, active bleeding
Hyperbaric oxygenBreathing 100% oxygen at increased atmospheric pressure in a chamber; used for selected diabetic foot ulcers (Wagner 3 or higher), radiation injury, refractory osteomyelitisUntreated pneumothorax; caution with seizures, COPD with CO2 retention, claustrophobia
Board tip. When a question asks for the best dressing, look first at the drainage and the presence of infection. Dry: hydrogel. Minimal: film or hydrocolloid. Moderate to heavy: foam. Heavy or cavity: alginate or hydrofiber. Infected: antimicrobial and never occlusive. And wet to dry gauze is almost never the best answer, because it is nonselective and painful.
Case. A 64 year old woman with chronic venous insufficiency has a 6 by 4 cm shallow wound above the left medial malleolus with heavy exudate, red granulation, and macerated periwound skin. ABI is 0.95. A hydrogel sheet and gauze are currently in use.
Reasoning: Heavy exudate plus maceration means the current hydrogel is adding moisture to an already wet wound. Switch to a highly absorptive dressing (alginate or hydrofiber with a foam cover), protect the periwound with a skin barrier, and apply multilayer compression, which is safe with an ABI of 0.95. Elevation and calf pumping complete the plan. Choosing a transparent film or hydrocolloid would trap exudate; choosing compression without checking the ABI would be unsafe in another patient. Safety point: compression treats the cause of a venous wound, and the dressing only manages its drainage.
Key point

Treat the cause first, then prepare the bed: remove nonviable tissue, control bioburden, balance moisture and advance the edge. Sharp, enzymatic, autolytic and larval debridement are selective; wet to dry, whirlpool and pulsed lavage are not. Leave stable dry eschar on heels and ischemic limbs. Choose dressings by drainage (hydrogel to film and hydrocolloid to foam to alginate and hydrofiber) and add antimicrobials for infection. Offload neuropathic feet with a total contact cast, compress venous legs after checking ABI, and know the contraindications for electrical stimulation and negative pressure therapy.

Section 4Burns

Burn depth

Burns are caused by heat (thermal), chemicals, electricity and radiation. Depth depends on temperature and duration of contact and on skin thickness: thin skin of children, older adults and the inner arm burns deeper. The central area of a burn, the zone of coagulation, is irreversibly destroyed; around it the zone of stasis has reduced blood flow and can survive or die depending on resuscitation, infection and edema; the outer zone of hyperemia recovers. Depth is often hard to judge on day one and declares itself over several days.

DepthLayers involvedAppearanceSensationHealing
Superficial (first degree)Epidermis onlyRed, dry, no blisters, blanches (sunburn)Painful3 to 7 days, no scar
Superficial partial thicknessEpidermis and papillary dermisBlisters, moist, bright red, blanches with brisk refillVery painful, sensitive to air and touchAbout 1 to 3 weeks, minimal scar, possible pigment change
Deep partial thicknessEpidermis and into reticular dermisMottled red and waxy white, drier, blisters often broken, slow or absent blanchingDecreased light touch and pain; pressure sense often preserved3 to 5 weeks or longer; hypertrophic scar likely; often grafted
Full thickness (third degree)Entire epidermis and dermis, into subcutaneous tissueWhite, tan, brown or black, leathery, dry, no blanching, thrombosed vessels visibleInsensate (nerve endings destroyed), though edges hurtWill not heal except from the edges; needs grafting
Subdermal (fourth degree)Through fat into muscle, tendon or boneCharredInsensateGrafts, flaps, often amputation; electrical injuries

Burn size: the rule of nines

Burn size is expressed as percent of total body surface area (TBSA), counting partial and full thickness burns only (not superficial). The adult rule of nines assigns 9% to the head and neck, 9% to each arm, 18% to the front of the trunk, 18% to the back of the trunk, 18% to each leg and 1% to the perineum. Children have proportionally larger heads and smaller legs (in an infant, the head is about 18% and each leg about 14%), so the Lund and Browder chart, which adjusts for age, is more accurate. For scattered or small burns, the patient's palm including the fingers is roughly 1% TBSA.

4.5184.54.599 4.5184.54.599 perineum 1 AnteriorPosterior patient Rpatient Lpatient Lpatient R Adult totalshead, neck 9each arm 9trunk front 18trunk back 18each leg 18perineum 1sum 100 Infanthead about 18each leg about 14use Lund andBrowder chart
Figure 10.4 The adult rule of nines, split front and back. Each arm is 9% (4.5 on each side), each leg 18%, and the trunk 36%. In infants the head is larger and the legs smaller, so an age adjusted chart is used.

Acute care

Major burns cause massive capillary leak and fluid shifts in the first 24 to 48 hours. Fluid resuscitation is commonly estimated with the Parkland formula: 4 mL of lactated Ringer solution times body weight in kg times %TBSA over 24 hours, half in the first 8 hours from the time of injury; urine output guides adjustment. Other priorities:

  • Inhalation injury: suspect with facial burns, singed nasal hair, soot in the mouth or sputum, hoarseness, stridor, or a fire in an enclosed space. Carbon monoxide poisoning makes SpO2 falsely normal.
  • Circumferential full thickness burns form an inelastic eschar that, as edema builds, can cut off circulation in a limb or restrict chest expansion. An escharotomy (incision through the eschar) relieves it; monitor distal pulses, capillary refill and sensation.
  • Electrical injuries look small on the skin (entry and exit wounds) but damage deep tissue along the current path: risk of arrhythmia, compartment syndrome, rhabdomyolysis with kidney injury, and delayed neurologic deficits and cataracts.
  • Hypermetabolism raises energy needs dramatically and causes muscle wasting; infection is the leading cause of death after the first days.

Grafts and skin substitutes

Excision of deep burns and early grafting shortens healing and reduces scarring. Grafts are classified by source and thickness.

  • Autograft: the patient's own skin, the only permanent graft. A split thickness skin graft takes epidermis and part of the dermis; the donor site heals like a superficial partial thickness wound in about 1 to 2 weeks and is often more painful than the graft site. A full thickness graft takes the entire dermis, contracts less and looks better, so it is used on the face and hands, but the donor site must be closed.
  • Sheet graft (unmeshed) gives the best appearance; mesh graft is cut in a pattern and expanded to cover more area and let fluid escape, but heals with a mesh pattern and more scarring.
  • Allograft (human cadaver skin), xenograft (usually pig skin) and synthetic or biosynthetic substitutes provide temporary cover; cultured epidermal autografts and dermal substitutes are used in very large burns.

After grafting, the area is immobilized, typically for about 3 to 5 days (per surgeon protocol), to let the graft adhere and vascularize; shear and range of motion of that area are avoided, while uninvolved joints keep moving. Ambulation after a leg graft waits for surgeon clearance and requires compressive wrapping to prevent venous pooling under the graft. Once cleared, range of motion resumes with careful observation of the graft.

Positioning and contracture prevention

Burned tissue contracts as it heals, and the position of comfort, usually flexion and adduction, is the position of contracture. Splints and positioning hold the opposite position from the start, combined with frequent active range of motion.

Area burnedContracture tendencyAntideformity position
Anterior neckFlexionNeck in slight extension; no pillow under the head (a towel roll under the shoulders), neck conformer
Axilla and shoulderAdduction, internal rotationShoulder abduction about 90 degrees (up to about 110), slight horizontal adduction to protect the brachial plexus, neutral rotation
Anterior elbowFlexion, pronationElbow extension, forearm supination
Wrist and dorsal handWrist flexion, MCP hyperextension, IP flexion, thumb adduction (claw)Wrist extension about 15 to 30 degrees, MCP flexion about 60 to 90, IP extension, thumb abducted (intrinsic plus position)
PalmFinger flexion, cuppingFingers and thumb extended and abducted (palmar extension splint)
Hip and groinFlexion, adductionHip extension, abduction about 10 to 20 degrees, neutral rotation; prone lying
KneeFlexionKnee extension
AnklePlantarflexionAnkle neutral (90 degrees), splint or boot

Scar management

A hypertrophic scar is raised, red and firm but stays within the boundary of the original wound, and often improves over 1 to 2 years. A keloid grows beyond the boundary of the wound, rarely regresses, and is more common in darker skin. Hypertrophic scarring is most likely when a burn takes longer than about 2 to 3 weeks to heal. Management:

  • Pressure garments: custom fitted, providing about 25 mmHg, worn about 23 hours a day until the scar matures (often 12 to 18 months or more), removed only for bathing. Interim wraps or tubular sleeves start once wounds are mostly closed.
  • Silicone gel sheets to hydrate and flatten scar, scar massage once the skin tolerates it, stretching and serial splinting or casting for developing contractures.
  • Skin care: moisturize (grafted and healed skin lacks oil and sweat glands), protect from sun for at least a year to prevent hyperpigmentation, and expect itching (pruritus) and heat intolerance.
  • A scar is mature when it is pale, flat, soft and pliable. Scar is measured with tools such as the Vancouver Scar Scale (pigmentation, vascularity, pliability, height).
Board tip. A burn that blisters and is exquisitely painful is superficial partial thickness; a burn that is leathery, white and painless is full thickness. For positioning, remember that the comfortable position is the contracture position: anterior neck goes into extension, axilla into abduction, and the hand into the intrinsic plus position (MCP flexion with IP extension).
Case. A 34 year old man has burns of the entire right arm (front and back), the anterior trunk and the anterior surface of the right leg. The arm and trunk burns are mottled red and white with decreased sensation and slow capillary refill; the leg is red with intact blisters. On day 2 he is lying with the right shoulder adducted and a pillow under his head.
Reasoning: TBSA: right arm 9% plus anterior trunk 18% plus anterior right leg 9% equals 36%. The arm and trunk are deep partial thickness; the leg is superficial partial thickness. Because axillary and anterior trunk burns tend toward adduction and flexion, position the right shoulder in about 90 degrees of abduction with slight horizontal adduction, and remove the pillow from under his head if the anterior neck or upper chest is involved. A tempting error is to count superficial burns or to estimate the whole leg as 9%: each full leg is 18%. Safety point: watch the circumferential arm burn for loss of distal pulses, capillary refill or sensation, which calls for urgent escharotomy evaluation.
Key point

Burn depth is read from blisters, color, blanching and sensation: superficial partial thickness burns blister and hurt and heal in under 3 weeks; deep partial thickness burns are mottled and slow; full thickness burns are leathery, insensate and need grafting. Size burns with the rule of nines in adults and an age adjusted chart in children. Protect grafts for about 3 to 5 days, splint and position against the contracture pattern from day one, and manage hypertrophic scar with pressure garments worn about 23 hours a day for a year or more, silicone and stretching.

Section 5Skin conditions and integumentary screening

Why physical therapists screen the skin

Therapists see skin that physicians may not: the back during a lumbar exam, the feet during gait training, the whole body during aquatic or wound care. Every examination includes inspection of the areas you treat, and every thermal agent, electrode or compression wrap begins with a skin check. Note color, temperature, texture, moisture, turgor, edema, lesions, scars, hair and nails, and ask how long any lesion has been present and whether it has changed.

Skin cancer warning signs

The three common skin cancers differ in behavior.

CancerTypical appearance and siteBehavior
Basal cell carcinomaPearly or waxy papule with rolled edges and fine surface vessels (telangiectasia), may ulcerate centrally; face, ears, neckMost common; grows slowly and invades locally; rarely metastasizes
Squamous cell carcinomaFirm, scaly, crusted or ulcerated red lesion on sun exposed skin, lips, old scars; actinic keratosis (rough scaly patch) is the precursorSecond most common; can metastasize, especially on lips and ears and in immunosuppressed patients
MelanomaNew or changing pigmented lesion meeting ABCDE criteria; anywhere, including soles, nails and the backLeast common of the three but causes most skin cancer deaths; prognosis depends on depth

The ABCDE rule flags pigmented lesions for referral: Asymmetry, Border irregularity (notched, ragged or blurred), Color variation (shades of brown, black, red, white or blue), Diameter greater than about 6 mm (the size of a pencil eraser), and Evolving (changing in size, shape, color or elevation, or new itching or bleeding). Evolution is the most important single sign. The "ugly duckling" sign, a mole that looks different from the patient's other moles, adds sensitivity. Risk factors include fair skin, blistering sunburns in childhood, many or atypical moles, family history, tanning bed use and immunosuppression.

ABCDE AsymmetryBorderColorDiameterEvolving benignbenignbenignbenignbenign concernconcernconcernconcernconcern over 6 mm changing halves differ ragged, notched many shades
Figure 10.5 The ABCDE warning signs of melanoma. The top row shows a benign mole for each feature; the bottom row shows the worrisome version. Any lesion that is new, changing or unlike the patient's other moles warrants referral.

Skin infections and infestations

ConditionKey featuresPT action
CellulitisSpreading, poorly demarcated redness, warmth, swelling and tenderness, often on a leg; fever, red streaks (lymphangitis)Refer for antibiotics; mark the border; hold compression and massage on that limb
Necrotizing fasciitisPain out of proportion to findings, rapid spread, tense swelling, dusky or purple skin, bullae, crepitus, systemic toxicityEmergency surgical referral
ImpetigoHoney colored crusts, often around nose and mouth in children; staphylococcal or streptococcalContagious; refer; contact precautions
Abscess, MRSAPainful fluctuant red nodule, may drain pus; often mistaken for a spider biteRefer for drainage; contact precautions; clean equipment
Herpes zoster (shingles)Burning or tingling pain in one dermatome followed by clustered vesicles that do not cross the midlineRefer early for antivirals; lesions are contagious to people without immunity until crusted; postherpetic neuralgia may follow
Fungal (tinea, candidiasis)Tinea: ring shaped scaly plaques, athlete's foot between toes; candida: red moist rash with satellite lesions in skin foldsKeep skin dry; refer for antifungal; tinea pedis cracks are an entry point for cellulitis in diabetes
ScabiesIntense itching worse at night, burrows in finger webs, wrists, waistlineContact precautions; refer; treat close contacts

Inflammatory and systemic skin signs

  • Psoriasis: well demarcated red plaques with silvery scale on extensor surfaces (elbows, knees), scalp and lumbosacral area; nail pitting; about a quarter to a third develop psoriatic arthritis (DIP involvement, dactylitis, sacroiliitis).
  • Atopic dermatitis (eczema): itchy, dry, lichenified patches in flexural creases; associated with asthma and allergies.
  • Systemic lupus erythematosus: butterfly (malar) rash sparing the nasolabial folds, photosensitivity. Dermatomyositis: heliotrope (violet) eyelid rash and Gottron papules over the knuckles with proximal weakness. Scleroderma: tight, thickened skin, Raynaud phenomenon, finger ulcers.
  • Systemic clues: cyanosis (central in lips and tongue suggests hypoxemia), jaundice (liver disease), pallor (anemia), petechiae and easy bruising (low platelets, anticoagulation, steroid use), clubbing (chronic hypoxia, lung cancer, cystic fibrosis), spider angiomas and palmar erythema (liver disease), café au lait spots (neurofibromatosis), and a dermatomal rash.
  • Drug reactions range from mild rashes to emergencies: a widespread rash with blistering, mucosal sores and fever suggests Stevens Johnson syndrome and needs emergency care.

Edema assessment

Edema is graded by pitting depth and rebound time. Scales differ between sources; a commonly used version:

GradePit depthRebound
1+ (trace)About 2 mmDisappears almost immediately
2+ (mild)About 4 mmWithin about 15 seconds
3+ (moderate)About 6 mmUp to about 1 minute
4+ (severe)About 8 mm2 to 5 minutes

Also note the distribution. Bilateral dependent pitting edema points to systemic causes (heart failure, kidney or liver disease, low albumin, medications such as calcium channel blockers). Unilateral edema points to a local cause (DVT, cellulitis, lymphedema, venous insufficiency, injury, or a mass obstructing outflow). Sudden unilateral swelling with warmth and calf pain needs same day DVT evaluation. Girth and figure of eight measurements (for the ankle and hand) or volumetry track change.

Prevention education

  • Diabetic foot care: inspect the feet every day (use a mirror or a helper), wash and dry carefully between the toes, moisturize but not between the toes, never walk barefoot, check shoes for objects before wearing, choose well fitting protective footwear, have nails and callus treated by a professional, and report any break, color change or swelling at once.
  • Pressure injury prevention for wheelchair users and those with sensory loss: daily skin checks, scheduled pressure relief, cushion maintenance, moisture management and nutrition.
  • Sun protection: broad spectrum sunscreen of SPF 30 or higher, reapplied every 2 hours outdoors and after swimming, protective clothing and hats, shade during peak sun hours, no tanning beds, and regular skin self checks. Healed burns and grafts burn easily.
  • Modality safety: before heat, cold or electrical stimulation, check sensation and skin integrity, and recheck the skin during and after treatment. Patients with impaired sensation, poor circulation, or new or thin scar are at higher risk of burns.
  • Skin tear prevention in older adults: lift rather than drag, pad bed rails and wheelchair parts, use long sleeves, avoid adhesive tape on fragile skin, and moisturize.
Board tip. Two skin findings demand immediate action: pain far out of proportion to a red, swollen area that is spreading quickly (necrotizing fasciitis) and a widespread blistering rash with mucosal involvement after a new drug (Stevens Johnson syndrome). For cellulitis, refer the same day and hold compression and manual lymph drainage on that limb.
Case. During a lumbar spine treatment, you notice an 8 mm mole on the right posterior shoulder of a 61 year old man. It has two shades of brown and a black area, and one edge is notched. He says his wife noticed it "looked different" a few months ago.
Reasoning: The lesion meets several ABCDE criteria (color variation, irregular border, diameter greater than 6 mm, and evolution), so it is suspicious for melanoma. The best action is to document it and recommend prompt evaluation by his physician or a dermatologist, explaining why without diagnosing. Ignoring it because it is outside the plan of care, or telling him it is cancer, are both wrong. Safety point: screening for conditions outside the referral diagnosis is part of physical therapist practice, and evolution of a lesion is the most important warning sign.
Key point

Inspect the skin in every patient you treat. Use ABCDE and the ugly duckling sign to refer suspicious moles, and remember basal cell is most common while melanoma is most deadly. Spreading redness and fever mean cellulitis (refer, hold compression); pain out of proportion means possible necrotizing fasciitis (emergency). Grade edema by pitting and rebound, and let its distribution guide you toward systemic or local causes. Teach daily foot inspection in diabetes, pressure relief in sensory loss and sun protection for everyone, especially after burns.

The chapter in one breath

  • The avascular epidermis rests on the vascular dermis; surviving hair follicles and sweat glands let partial thickness wounds regenerate.
  • Healing moves through inflammation, proliferation (granulation, contraction, epithelialization) and remodeling; scar regains only about 80% of strength.
  • Document size head to toe, undermining and tunneling by the clock (12 toward the head), tissue type, exudate, edges and periwound.
  • Pressure injury stages 1 to 4 follow the deepest tissue visible, plus unstageable and deep tissue injury, and are never reverse staged.
  • The Braden scale runs 6 to 23, and 18 or less means risk: turn, float heels, use 30 degree positions and teach seated pressure relief.
  • Arterial wounds are distal, punched out and painful; venous wounds are medial, shallow and wet; neuropathic wounds are plantar, callused and painless.
  • Debridement is selective (sharp, enzymatic, autolytic, larval) or nonselective (wet to dry, whirlpool, lavage); leave stable dry eschar on heels and ischemic limbs.
  • Match dressings to moisture: hydrogel for dry, film and hydrocolloid for minimal, foam for moderate, alginate and hydrofiber for heavy; no occlusion over infection.
  • Offload neuropathic ulcers with a total contact cast; compress venous wounds after an ABI check.
  • Burn depth: blisters and pain mean superficial partial thickness; mottled and slow means deep partial; leathery and insensate means full thickness. Size with the rule of nines.
  • Position against contracture, protect grafts for about 3 to 5 days, and use pressure garments about 23 hours a day until scar matures.
  • Refer ABCDE lesions, cellulitis and shingles; treat suspected necrotizing fasciitis as an emergency.

Words worth knowing

TermWhat it means
EpidermisThe outer, avascular layer of skin made of keratinocytes, renewed from the stratum basale.
DermisThe vascular connective tissue layer beneath the epidermis containing collagen, nerves, hair follicles and glands.
Granulation tissueMoist, red, bumpy new tissue of capillaries and collagen that fills a wound during proliferation.
EpithelializationMigration of keratinocytes across the wound surface to close it.
Wound contractionInward pulling of wound edges by myofibroblasts, which reduces the area to be closed.
Secondary intentionHealing of an open wound by granulation, contraction and epithelialization.
UnderminingTissue destruction under intact skin along the wound edge, spanning part of the perimeter.
TunnelingA narrow channel extending from the wound into deeper tissue in one direction.
SloughSoft, moist, yellow, tan or gray nonviable tissue in the wound bed.
EscharThick, dry, black or brown leathery necrotic tissue.
EpiboleRolled, curled wound edges that stop epithelial migration.
MacerationSoftened, white, waterlogged skin from prolonged moisture.
Deep tissue pressure injuryPersistent nonblanchable maroon or purple discoloration from pressure damage at the bone muscle interface.
Unstageable pressure injuryA full thickness pressure injury whose base is hidden by slough or eschar.
Braden scaleA six item pressure injury risk tool scored 6 to 23, with lower scores meaning higher risk.
ShearForce from the skeleton sliding while the skin is held in place, which kinks deep vessels.
Loss of protective sensationInability to feel the 10 gram monofilament, which puts the foot at high risk of ulceration.
Total contact castA closely molded walking cast that redistributes plantar pressure to heal neuropathic ulcers.
Selective debridementRemoval of only nonviable tissue, by sharp, enzymatic, autolytic or larval methods.
Autolytic debridementBreakdown of necrotic tissue by the body's own enzymes under a moisture retentive dressing.
BiofilmA protected community of bacteria within a matrix on the wound surface that resists antibiotics.
AlginateA highly absorbent seaweed derived dressing that forms a gel and fills cavities.
Negative pressure wound therapySuction applied through a sealed foam dressing to remove exudate and promote granulation.
Zone of stasisThe area around a burn's dead center with reduced blood flow that can survive or die.
EscharotomySurgical incision through a circumferential burn eschar to restore circulation or breathing.
Split thickness skin graftAn autograft of epidermis and part of the dermis taken from a donor site that heals on its own.
Mesh graftA graft cut in a pattern and expanded to cover a larger area and allow drainage.
Hypertrophic scarA raised, red, firm scar that stays within the original wound boundary.
KeloidA scar that grows beyond the boundary of the original wound and rarely regresses.
ABCDE ruleAsymmetry, border, color, diameter and evolution: warning signs of melanoma.

Check yourself

A wound has a 3 cm channel extending at 10 o'clock and a 1 cm shelf under the skin from 3 to 6 o'clock. How are these documented?
Answer. A 3 cm tunnel at 10 o'clock and 1 cm of undermining from 3 to 6 o'clock, with 12 o'clock toward the patient's head. A tunnel is a narrow track in one direction; undermining spans part of the edge.
A sacral wound shows exposed subcutaneous fat but no muscle, tendon or bone. What stage is it?
Answer. Stage 3. Full thickness skin loss with visible fat is stage 3; stage 4 requires exposed or palpable fascia, muscle, tendon, ligament, cartilage or bone.
Six weeks later the stage 4 ischial wound is filled with granulation tissue. How should it be documented?
Answer. As a healing stage 4 pressure injury. Pressure injuries are not reverse staged, because granulation tissue does not replace the lost muscle and fat.
What does a Braden score of 12 indicate?
Answer. High risk (10 to 12) for pressure injury. Lower Braden scores mean higher risk; 18 or less is generally at risk.
A painful, round, punched out wound with a pale base is located on the lateral malleolus of a smoker with absent pedal pulses. What type of wound is it and what is the priority?
Answer. Arterial insufficiency wound. The priority is vascular referral to restore blood flow; compression is contraindicated in significant arterial disease, and dry stable necrotic tissue should not be debrided.
Which debridement method is nonselective: collagenase ointment, conservative sharp debridement, wet to dry gauze, or a hydrocolloid dressing?
Answer. Wet to dry gauze. It removes viable and nonviable tissue together when the dried gauze is pulled off; the others are selective (enzymatic, sharp, autolytic).
A wound has heavy drainage and a 2 cm deep cavity without infection. Which primary dressing fits best?
Answer. A calcium alginate or hydrofiber placed loosely in the cavity, covered by a secondary dressing such as foam. Both absorb heavy exudate and conform to dead space.
A burn is blistered, moist, bright red, blanches quickly and is extremely painful. Classify the depth and expected healing.
Answer. Superficial partial thickness. It involves the epidermis and papillary dermis and usually heals in about 1 to 3 weeks with minimal scarring.
Using the adult rule of nines, what is the TBSA of burns to the entire head and neck and the entire left arm, both deep partial thickness?
Answer. 18%: 9% for the head and neck plus 9% for the arm.
A patient with an anterior neck burn prefers to rest with two pillows under his head. What should the therapist do?
Answer. Remove the pillows and position the neck in slight extension (a towel roll under the shoulders, possibly a neck conformer). The position of comfort, neck flexion, is the position of contracture.
Chapter 11 · Other Systems

Other Systems and System Interactions

Most patients who walk into a physical therapy clinic bring more than a sore knee or a weak hip: they bring diabetes, thyroid disease, a cancer history, a pregnancy, a pelvic floor problem or a medication list that changes how they respond to exercise. The exam rewards the therapist who notices these other systems, adjusts the plan safely and recognizes when pain is coming from an organ rather than a joint. This chapter covers the metabolic, endocrine, gastrointestinal, genitourinary, oncologic and immune content of the outline, then ties it together with medical screening and the drugs that matter most for exercise, falls and healing.

By the end of this chapter you can

  • Apply blood glucose thresholds before, during and after exercise and recognize hypoglycemia and diabetic ketoacidosis.
  • Describe the musculoskeletal and exercise effects of thyroid and adrenal disease, and prescribe safe exercise for osteoporosis and obesity.
  • Classify urinary incontinence by type, outline pelvic floor training, and apply exercise guidance and warning signs for pregnancy and the postpartum period.
  • Use platelet, hemoglobin and neutrophil values to adjust exercise in patients receiving cancer treatment, and identify lymphedema risk and staging.
  • Compare rheumatoid arthritis, osteoarthritis and other rheumatologic diseases, and adapt care for patients with HIV.
  • Recognize viscerogenic pain patterns and red flags, and decide between continuing care, routine referral and emergency referral.
  • Predict how beta blockers, anticoagulants, corticosteroids, opioids and other drug classes change exercise response, fall risk and tissue healing.

Section 1Metabolic and endocrine disorders

Diabetes mellitus

Type 1 diabetes is autoimmune destruction of pancreatic beta cells, producing absolute insulin deficiency; onset is usually in youth, and the patient depends on insulin for life. Type 2 diabetes combines insulin resistance in muscle, liver and fat with a gradual failure of insulin secretion; it is strongly linked to obesity and inactivity and is treated with activity, diet, oral or injectable agents and, later, insulin. Gestational diabetes appears during pregnancy and raises the mother's later risk of type 2 disease. The usual diagnostic values are a fasting plasma glucose of 126 mg/dL or higher, a 2 hour oral glucose tolerance value of 200 mg/dL or higher, a random glucose of 200 or higher with symptoms, or an HbA1c of 6.5% or higher. Prediabetes is a fasting glucose of 100 to 125 mg/dL or an HbA1c of 5.7 to 6.4%. A normal fasting glucose is roughly 70 to 99 mg/dL.

Exercise is a cornerstone of diabetes care. A single bout increases glucose uptake by contracting muscle through an insulin independent pathway (translocation of GLUT4 transporters to the cell membrane), and regular training improves insulin sensitivity for 24 to 72 hours after each session. The general recommendation is at least 150 minutes per week of moderate aerobic activity spread over at least 3 days, with no more than 2 consecutive days off, plus resistance training 2 to 3 days per week and flexibility and balance work, especially in older adults.

Glucose safety around exercise

The therapist checks glucose before exercise in any patient who uses insulin or an insulin secretagogue (a sulfonylurea such as glipizide or glyburide, or a meglitinide), because these drugs can drive glucose too low once muscle uptake is added. Metformin, the DPP-4 inhibitors, GLP-1 receptor agonists and SGLT2 inhibitors rarely cause hypoglycemia on their own. Commonly taught thresholds appear below and in Figure 11.1.

Pre-exercise glucoseActionReason
Below 70 mg/dLDo not start; treat with 15 g of fast carbohydrate (4 oz juice, glucose tablets), recheck in 15 minutesHypoglycemia; exercise will lower glucose further
70 to 100 mg/dL (insulin or secretagogue users)Eat 15 to 30 g of carbohydrate, then beginPrevents exercise induced hypoglycemia
100 to 250 mg/dLExercise is generally safeUsual target range for activity
Above 250 mg/dLCheck urine or blood ketones; if ketones are present, no vigorous exercise and contact the providerInsulin deficiency; exercise can raise glucose and ketones further
Above 300 mg/dL without ketonesUse caution, keep intensity light to moderate, hydrate, monitor symptomsOlder guidance set 300 as a stop point; current guidance allows light activity if the patient feels well

Sources differ slightly; for the exam, below 70 is stop and treat, below 100 is snack first for insulin users, and above 250 with ketones is stop.

Check glucose before exercise Below 70 mg/dL70 to 100 mg/dL100 to 250 mg/dLAbove 250 mg/dL Hypoglycemia:do not start.Give 15 g fastcarbohydrate,recheck in15 minutes. On insulin or asecretagogue:eat 15 to 30 gcarbohydratefirst, thenexercise. Generally safeto exercise.Watch forsymptoms andrecheck afterlong sessions. Test ketones.Ketones present:no vigorousexercise.Above 300, noketones: lightonly, hydrate. Stop and recheck at any time if shakiness, sweating, confusion or tachycardia appear. Late hypoglycemia can occur up to 24 hours after exercise.
Figure 11.1 Pre-exercise glucose decision chart using the commonly taught thresholds. The two red ranges stop or delay exercise; the amber range needs a snack first in insulin users.

Hypoglycemia, hyperglycemia and complications

Hypoglycemia (glucose below 70 mg/dL) comes on quickly. Adrenergic signs come first: shakiness, sweating, pallor, tachycardia, anxiety and hunger, followed by neuroglycopenic signs such as headache, confusion, slurred speech, poor coordination, seizure and loss of consciousness. Beta blockers can hide the tremor and tachycardia, leaving sweating as the main clue. A conscious patient receives 15 to 20 g of fast carbohydrate (the "rule of 15"); an unconscious patient receives nothing by mouth and the therapist activates emergency services (glucagon may be given by trained responders). Hyperglycemia develops over hours to days: polyuria, polydipsia, fatigue, blurred vision and, in diabetic ketoacidosis (mostly type 1), fruity breath, nausea, abdominal pain and deep rapid Kussmaul respirations. Hyperosmolar hyperglycemic state occurs mostly in older adults with type 2 disease, with extreme glucose, dehydration and confusion but little ketosis.

Avoid injecting insulin into a limb about to be exercised, avoid exercising at peak insulin action, keep fast carbohydrate at hand, and watch for delayed hypoglycemia after long sessions. Complications drive much of physical therapy care: peripheral neuropathy (loss of protective sensation on the 5.07 Semmes Weinstein monofilament, which delivers 10 g), autonomic neuropathy (orthostatic hypotension, silent ischemia, blunted heart rate response), retinopathy, nephropathy, peripheral arterial disease and poor wound healing. Proliferative retinopathy rules out heavy lifting, Valsalva and head down positions. Patients with neuropathy need daily foot checks and proper footwear; weight bearing exercise is allowed without active ulcers. Diabetes also raises rates of adhesive capsulitis, trigger finger, carpal tunnel syndrome and Charcot neuroarthropathy.

Board tip. A patient with diabetes who becomes sweaty, shaky and confused during gait training is hypoglycemic until proven otherwise. The first action is to stop the activity and give fast acting carbohydrate if the patient can swallow safely, then recheck. Do not call it a vasovagal episode or a cardiac event first. If the patient is unresponsive, call emergency services and give nothing by mouth.

Thyroid disease

Thyroid hormone sets the basal metabolic rate. Hypothyroidism (most often Hashimoto thyroiditis) causes fatigue, cold intolerance, weight gain, constipation, dry skin, bradycardia, depression and slowed relaxation of deep tendon reflexes. The musculoskeletal picture includes proximal muscle weakness and cramping, myalgia, elevated CK, carpal tunnel syndrome from soft tissue swelling, and joint stiffness that can mimic arthritis. Hyperthyroidism (most often Graves disease) causes heat intolerance, weight loss, tremor, anxiety, tachycardia and atrial fibrillation, exophthalmos in Graves disease, and a proximal myopathy affecting the hip and shoulder girdles. Long standing hyperthyroidism accelerates bone loss. A severe crisis (thyroid storm) produces fever, marked tachycardia and delirium and is a medical emergency.

Untreated hyperthyroidism raises resting heart rate and arrhythmia risk, so intensity stays low until the patient is euthyroid; untreated hypothyroidism blunts heart rate response and exercise tolerance. Once levels normalize, standard prescription applies.

Adrenal disorders

Cushing syndrome is cortisol excess, usually from long term corticosteroid medication. Features include central obesity with thin limbs, a rounded face, purple striae, fragile skin with easy bruising, hypertension, hyperglycemia, proximal steroid myopathy, osteoporosis and poor wound healing; exercise stresses proximal strengthening, weight bearing and skin protection during transfers. Adrenal insufficiency (Addison disease when primary) causes fatigue, weakness, hypotension and, in primary disease, hyperpigmentation. Stress or abrupt withdrawal of long term steroids can trigger an adrenal crisis (shock, vomiting, abdominal pain), an emergency.

Osteoporosis

The World Health Organization criteria use the dual energy x-ray absorptiometry T score: normal is −1.0 or above, osteopenia (low bone mass) is between −1.0 and −2.5, and osteoporosis is −2.5 or below. A fragility fracture of the hip or spine establishes osteoporosis clinically regardless of the T score. Risk factors include female sex, age, white or Asian ancestry, low body weight, family history, smoking, excess alcohol, inactivity, early menopause, long term glucocorticoids, hyperthyroidism, rheumatoid arthritis and some anticonvulsants. Vertebral compression fractures are the most common osteoporotic fracture; many are silent and show up as height loss and increasing thoracic kyphosis.

Exercise prescription combines progressive resistance training, weight bearing impact as tolerated, balance training to prevent falls, and posture and spinal extensor strengthening. The key precaution is to avoid loaded spinal flexion, especially flexion combined with rotation (sit ups, toe touches, golf swings without modification, lifting with a rounded back), because anterior vertebral body loading drives wedge fractures. High risk patients learn hip hinging and log rolling. Hip protectors, home hazard reduction and vision checks reduce fall related fractures.

Obesity and metabolic syndrome

Body mass index (kg/m2) classifies adults: 25 to 29.9 overweight, 30 or higher obese, and 40 or higher class III obesity. Metabolic syndrome is three or more of abdominal obesity, high triglycerides, low HDL, high blood pressure and high fasting glucose. Exercise for weight loss favors larger volumes (about 200 to 300 minutes per week) using low impact modes such as cycling and aquatic exercise. Check equipment weight limits, use an adequately sized blood pressure cuff (a small cuff falsely raises the reading), and watch for heat intolerance and sleep apnea.

Case. A 68 year old woman with a T score of −2.8 at the lumbar spine and a healed T12 compression fracture asks for a home program. The student's draft includes crunches for core strength, standing toe touches for flexibility, wall slides and single leg stance.
Reasoning: The question is really asking which exercise is contraindicated. Crunches and toe touches load the anterior vertebral bodies in flexion and are the classic wrong answers for osteoporosis; flexion with rotation is worse still. Wall slides (closed chain quadriceps strengthening) and single leg stance near a counter (balance) are appropriate. Replace the flexion exercises with prone or seated thoracic extension, abdominal bracing in neutral and hip hinge training. Safety point: also screen fall risk and the home environment, because a fall onto the hip is the fracture that most threatens independence and survival.
Key point

Exercise is medicine for every metabolic and endocrine condition, but each has a safety filter: glucose thresholds and hypoglycemia recognition in diabetes, heart rate caution in untreated thyroid disease, skin and bone protection in cortisol excess, no loaded flexion in osteoporosis, and joint friendly volume in obesity.

Section 2Gastrointestinal and genitourinary conditions

Gastrointestinal referral patterns

The viscera have sparse, poorly localized afferent supply that enters the spinal cord at the same segments as somatic structures, so organ disease can present as musculoskeletal pain (Section 4 develops this further). Gastrointestinal pain clues are a relationship to eating, bowel movements or swallowing; associated nausea, vomiting, bloating, heartburn, melena (black tarry stool from upper GI bleeding) or hematochezia (bright red blood); and pain that does not change with posture or movement.

Organ or conditionTypical referral or presentationClue that it is visceral
EsophagusSubsternal pain, may radiate to the mid back or mimic anginaPain with swallowing, heartburn, worse lying down after meals
Stomach or duodenum (peptic ulcer)Epigastric pain; posterior duodenal ulcer refers to the mid thoracic spine (T6 to T10)Pain related to meals, NSAID use, melena
GallbladderRight upper quadrant, right shoulder and right scapulaAfter fatty meals, nausea, Murphy sign
PancreasEpigastric pain boring into the mid back (around T10 to L2)Alcohol use or gallstones, relieved by leaning forward, worse supine
LiverRight upper quadrant, right shoulderJaundice, ascites, asterixis, bilateral carpal tunnel signs
Small intestinePeriumbilical pain, mid backCramping, diarrhea, bloating
AppendixPeriumbilical, then right lower quadrant; right hip or thighFever, McBurney point tenderness, psoas and obturator signs
Colon and rectumLower abdomen, sacrum, low backChange in bowel habits, blood in stool, relieved by defecation

The psoas sign is pain in the abdomen or groin with resisted hip flexion or passive hip extension, suggesting an inflamed structure (appendix, abscess) lying on the psoas. The obturator sign is pain with passive internal rotation of the flexed hip. Both can make abdominal disease look like a hip problem. Inflammatory bowel disease (Crohn disease and ulcerative colitis) is associated with enteropathic arthritis, sacroiliitis and ankylosing spondylitis, so a young adult with inflammatory back pain and chronic diarrhea deserves a question about both.

Renal and urologic referral

Kidney pain (pyelonephritis, stones) is felt in the flank and costovertebral angle; a moving ureteral stone causes colicky pain radiating from flank to groin. Bladder pain is suprapubic, and prostate disease refers to the low back, sacrum and perineum. Fever, dysuria, hematuria, frequency and pain unchanged by spinal motion are the clues; a man over 50 with new back pain and urinary hesitancy or nocturia needs prostate screening.

The pelvic floor

The pelvic floor is a muscular hammock: the levator ani (puborectalis, pubococcygeus and iliococcygeus) and the coccygeus form the pelvic diaphragm, and a superficial layer of perineal muscles lies below. It supports the pelvic organs, keeps the urethra and anal canal closed during rises in abdominal pressure, relaxes for voiding and defecation, contributes to sexual function, and works with the diaphragm, transversus abdominis and multifidus to stabilize the trunk. Innervation is mainly from S2 to S4 through the pudendal nerve and direct sacral branches. Dysfunction may be underactive (weak, poorly timed, after childbirth or with aging) or overactive (high tone, often painful, with dyspareunia, urinary urgency, constipation and pelvic pain). Overactive muscles need downtraining, relaxation, breathing and manual therapy before strengthening; strengthening a high tone pelvic floor can worsen symptoms.

Urinary incontinence

Continence requires a bladder that stores at low pressure, a urethral closure system that stays shut under load, intact neural control and the ability to reach a toilet in time. Each type of incontinence fails a different part of that system (Figure 11.2).

TypeMechanismTypical historyPhysical therapy management
StressWeak urethral support or sphincter; leakage when abdominal pressure exceeds closure pressureSmall leaks with cough, sneeze, laugh, jump or lift; common after vaginal delivery and prostatectomyPelvic floor muscle training (first line), "the knack" (contract before a cough), weight and constipation management
Urge (overactive bladder)Detrusor overactivity; involuntary bladder contractionSudden strong urge, leaks before reaching the toilet, frequency, nocturia, triggers such as running water or key in the doorBladder diary, timed voiding with gradually longer intervals, urge suppression (stop, quick pelvic floor contractions, breathe, then walk calmly), reduce caffeine and bladder irritants
MixedStress plus urgeBoth patterns; common in older womenTreat the more bothersome component first
OverflowUnderactive detrusor or outlet obstruction; bladder overfillsDribbling, weak stream, incomplete emptying; diabetes, prostate enlargement, spinal cord or cauda equina lesions, anticholinergic drugsRefer for medical evaluation; may need catheterization
FunctionalLower urinary tract is normal; mobility, dexterity, cognition or environment prevents timely toiletingPatient with dementia, severe arthritis or stroke who cannot get to or undress for the toiletMobility and transfer training, clothing changes, bedside commode, prompted voiding schedules
Urine stored at low pressure Detrusor (bladder wall) Internal sphincter Urethra Pelvic floor and external sphincter (S2 to S4) Stress: closure fails Weak pelvic floor or sphincter; leaks with cough or lifting. Pelvic floor training. Urge: detrusor overactive Bladder contracts too early. Bladder diary, timed voiding, urge suppression. Overflow: emptying fails Weak detrusor or blocked outlet; dribbling, retention. Refer for medical workup. Functional: system is normal Mobility, dexterity or cognition delays toileting. Train transfers, adapt setting.
Figure 11.2 The continence system and where each type of incontinence fails. Stress incontinence is a closure problem, urge and overflow are detrusor or outlet problems, and functional incontinence lies outside the urinary tract.

Pelvic floor muscle training is first line treatment for stress and mixed incontinence. The patient first learns to isolate the muscles (squeeze and lift without breath holding, gluteal squeezing or bearing down), aided by cues, palpation by a pelvic health therapist or surface EMG biofeedback. Training combines endurance holds (toward about 10 seconds) and quick flicks, typically 8 to 12 repetitions three times daily for at least 12 weeks, progressed from gravity minimized positions to standing and function. Men after prostatectomy benefit as well. Pelvic organ prolapse causes pressure and a bulge that worsens through the day; pelvic floor training, avoiding straining and physician pessary fitting help.

Board tip. Match the leak to the mechanism: leaking with a cough is stress, leaking on the way to the bathroom after a sudden urge is urge, constant dribbling with a sense of incomplete emptying is overflow (refer), and a cognitively impaired patient who cannot reach the toilet is functional. New incontinence with saddle anesthesia and bilateral leg symptoms is cauda equina syndrome, an emergency.

Pregnancy

Pregnancy raises blood volume about 40 to 50%, cardiac output 30 to 50% and resting heart rate 10 to 20 beats per minute, while blood pressure dips in the second trimester. The hormone relaxin, along with estrogen and progesterone, increases ligament laxity. The center of mass moves anteriorly and superiorly, lumbar lordosis and thoracic kyphosis often increase, and the base of support widens. Common musculoskeletal problems are low back pain, pelvic girdle pain (posterior pelvic pain and symphysis pubis dysfunction, provoked by single leg loading, stairs and rolling in bed), carpal tunnel syndrome from fluid retention, diastasis recti abdominis, and leg cramps. A diastasis is a separation of the rectus abdominis at the linea alba; a gap of more than about 2 cm (often described as two fingerbreadths) during a partial curl up is the usual threshold. Management stresses transversus abdominis and pelvic floor activation, splinting with the hands during curl ups, and avoiding straining and full sit ups until the gap and tension improve.

Healthy pregnant women without contraindications are encouraged to accumulate at least 150 minutes per week of moderate intensity aerobic activity, plus strength training. Because heart rate responses vary, intensity is guided by the rating of perceived exertion (about 12 to 14 on the 6 to 20 scale) or the talk test. Important modifications: avoid prolonged supine positions after the first trimester (the uterus compresses the inferior vena cava, causing supine hypotension; use left side lying or a wedge), avoid contact sports and activities with high fall risk, avoid scuba diving, avoid exercise in heat with overheating, stay hydrated, and avoid prolonged Valsalva.

Absolute contraindications to aerobic exercise in pregnancy (examples)Warning signs to stop exercise and seek care
Hemodynamically significant heart disease; restrictive lung diseaseVaginal bleeding
Incompetent cervix or cerclage; multiple gestation at risk for preterm laborRegular painful contractions
Persistent second or third trimester bleeding; placenta previa after about 26 weeksAmniotic fluid leakage
Preterm labor or ruptured membranes in the current pregnancyDyspnea before exertion, chest pain, dizziness or headache
Preeclampsia or pregnancy induced hypertension; severe anemiaCalf pain or swelling (rule out DVT); muscle weakness affecting balance

Pregnancy is a hypercoagulable state, so unilateral calf pain and swelling must be treated as possible deep vein thrombosis. Severe headache, visual changes, epigastric pain and sudden swelling of the face and hands with high blood pressure suggest preeclampsia, which needs urgent medical attention.

Postpartum care

After vaginal delivery, walking, pelvic floor contractions and gentle abdominal work can begin within days. After a cesarean delivery, the patient splints the incision when coughing, log rolls out of bed and avoids lifting more than the baby for several weeks. Return to running is usually deferred until at least about 12 weeks and until she can walk, hop and jog in place without leakage, heaviness or pain. Screen for incontinence, prolapse, diastasis, de Quervain tenosynovitis from infant care, and postpartum depression.

Case. A 31 year old woman at 28 weeks of gestation is referred for low back and posterior pelvic pain. She asks to do her usual supine bridging and abdominal curls. During the session she reports that her calf has been swollen and tender since yesterday.
Reasoning: Two issues are tested. First, after the first trimester, prolonged supine exercise risks supine hypotension from vena cava compression, so bridges and abdominal work move to side lying, standing or an inclined position, and full curl ups are avoided because of diastasis risk. Second, and more urgent, pregnancy is hypercoagulable and a new swollen, tender calf may be a deep vein thrombosis. The best action is to stop exercise and contact the physician for same day evaluation, not to massage the calf or prescribe compression first. Safety point: a DVT that embolizes can cause a fatal pulmonary embolism.
Key point

Gastrointestinal and genitourinary disease can masquerade as back, shoulder or hip pain, and the clue is a link to eating, bowel, bladder or systemic signs rather than movement. Incontinence types map to mechanisms: stress to closure, urge to detrusor overactivity, overflow to failed emptying, and functional to barriers outside the bladder. Pregnant patients exercise by perceived exertion, avoid prolonged supine positions after the first trimester, and stop for bleeding, contractions, fluid leakage or calf swelling.

Section 3Oncology and immune conditions

Cancer and its treatments

Exercise before, during and after cancer treatment reduces cancer related fatigue, preserves strength and fitness and improves quality of life. Survivors are advised to avoid inactivity and work toward about 150 minutes per week of moderate aerobic exercise plus resistance training twice weekly, adjusted to treatment phase, blood counts and symptoms. Cancer related fatigue is not relieved by rest; graded aerobic exercise is among its best supported treatments.

TreatmentEffects relevant to physical therapyImplications
SurgeryIncision pain, scar adhesion, loss of motion, lymph node removal, deconditioningFollow surgical precautions; early mobilization; lymphedema risk after node dissection
Chemotherapy (general)Bone marrow suppression (anemia, neutropenia, thrombocytopenia), nausea, fatigue, mucositisCheck blood counts before each session; infection control
Anthracyclines (doxorubicin) and trastuzumabCardiotoxicity, cardiomyopathy and heart failure, sometimes years laterMonitor heart rate, blood pressure, dyspnea and edema
Taxanes, vinca alkaloids, platinum agentsChemotherapy induced peripheral neuropathy (stocking glove sensory loss, balance impairment)Balance training, fall prevention, foot inspection
BleomycinPulmonary fibrosisMonitor oxygen saturation and dyspnea
Radiation therapySkin reactions, tissue fibrosis and contracture, fatigue, radiation pneumonitis, late plexopathy, osteoradionecrosisAvoid heat, friction and lotions on irradiated skin during treatment; stretch to prevent fibrosis
Hormonal therapy (aromatase inhibitors, androgen deprivation)Bone loss, arthralgia, muscle loss, weight gainResistance and weight bearing exercise; osteoporosis precautions
CorticosteroidsSteroid myopathy, hyperglycemia, osteoporosis, skin fragilityProximal strengthening, glucose monitoring

Laboratory values that guide exercise

Before each session with a patient on active chemotherapy or after transplant, the therapist reviews the complete blood count. Normal values and the commonly taught exercise thresholds are summarized here and in Figure 11.3. Thresholds vary among institutions and published guidelines, so the exam usually tests the direction of the decision rather than an exact cutoff; when in doubt, consult the medical team.

ValueUsual normal rangeExercise implication
HemoglobinMen about 13.5 to 17.5 g/dL; women about 12 to 16 g/dLBelow about 8 g/dL: defer or limit to essential activity and consult; 8 to 10: light, symptom guided activity; monitor dyspnea, heart rate and fatigue
Platelets150,000 to 450,000 per microliterAbove 50,000: progressive exercise as tolerated; 20,000 to 50,000: light aerobic and active ROM, no heavy resistance; below 20,000: essential ADLs and walking only, after consultation
White blood cellsAbout 4,500 to 11,000 per microliterLow counts raise infection risk; fever with a low count is an emergency
Absolute neutrophil count (ANC)About 1,500 to 8,000 per microliterBelow 1,500 neutropenia; below 500 severe: protective (neutropenic) precautions, treat in the room, masks and strict hand hygiene
INR (not on anticoagulant)About 0.8 to 1.2Therapeutic on warfarin usually 2 to 3 (2.5 to 3.5 for some mechanical valves); higher values raise bleeding and fall injury risk
Platelets (per µL)Hemoglobin (g/dL)Neutrophils, ANC (per µL) Above 50,00020,000 to 50,000Below 20,000 Above 108 to 10Below 8 Above 1,500500 to 1,500Below 500 Progressive exercise,resistance as tolerated Light aerobic, AROM;no heavy resistance Essential ADLs andwalking only; consult Usual exerciseprescription Light, symptom guided;watch HR and dyspnea Defer or limit toessentials; consult Standard precautionsand hand hygiene Neutropenic care;avoid crowded gym Protective isolation,treat in the room Cutoffs vary between facilities; fever with neutropenia is a medical emergency.
Figure 11.3 Commonly taught exercise zones for blood counts during cancer treatment. Read each column from green (proceed) to red (restrict and consult); the exam usually tests the direction of the decision.

Bone metastasis, spinal cord compression and other oncologic emergencies

Breast, prostate, lung, kidney and thyroid cancers most often spread to bone, along with multiple myeloma, which arises in the marrow. Bone metastases cause deep, constant pain that is often worse at night and with weight bearing, and they create pathologic fracture risk, especially in the proximal femur, humerus and vertebrae. Patients with known lytic lesions avoid heavy resistance, high impact and end range twisting through the affected bones; resistance is applied proximal to lesions, and weight bearing status follows the physician's orders. Malignant spinal cord compression presents with progressive back pain followed by weakness, sensory level and bowel or bladder changes and is an emergency. Hypercalcemia of malignancy causes fatigue, weakness, confusion, constipation and polyuria. Superior vena cava syndrome (facial and arm swelling, dyspnea, distended neck veins, often from lung cancer) and neutropenic fever (temperature of about 38.0 to 38.3 °C or higher with a low ANC) also require immediate referral.

Lymphedema

Lymphedema is accumulation of protein rich interstitial fluid caused by impaired lymphatic transport. Primary lymphedema results from congenital lymphatic malformation; secondary lymphedema, far more common in practice, follows lymph node dissection, radiation, trauma, infection or venous disease (worldwide, filariasis is a major cause). After breast cancer treatment, risk rises with axillary lymph node dissection (compared with sentinel node biopsy), regional radiation, obesity, infection and higher numbers of nodes removed. The International Society of Lymphology stages are: stage 0 latent (impaired transport, no visible swelling, possible heaviness), stage I pitting edema that subsides with elevation, stage II swelling that does not resolve with elevation, with fibrosis developing and pitting becoming harder to elicit, and stage III lymphostatic elephantiasis with skin changes such as papillomas and hyperkeratosis. A positive Stemmer sign (inability to pinch and lift a fold of skin at the base of the second toe or finger) supports the diagnosis.

Limb volume is measured with circumferential tape measures (a difference of about 2 cm, or about 10% volume, is a common threshold), water displacement or perometry. Complete decongestive therapy has an intensive phase (manual lymphatic drainage, multilayer short stretch bandaging, exercise, skin care) and a maintenance phase (compression garments, self drainage, exercise). Short stretch bandages give low resting and high working pressure. Gradually progressed resistance exercise does not increase lymphedema risk and is recommended. Contraindications to drainage and compression include acute cellulitis, acute DVT, decompensated heart failure and, for compression, an ankle brachial index below about 0.5.

Board tip. Cellulitis in a lymphedematous limb (redness, warmth, sudden increase in swelling, fever) is a reason to stop manual lymphatic drainage and bandaging and refer for antibiotics. Massage will not cure an infection and may spread it. Resume decongestive therapy only after the infection is treated.

HIV

HIV infects CD4 T lymphocytes; a CD4 count below 200 cells per microliter defines AIDS (normal is about 500 to 1,500). With antiretroviral therapy, therapists mainly see peripheral neuropathy, myopathy, metabolic syndrome, cardiovascular disease, neurocognitive disorder and deconditioning. Aerobic and resistance exercise are safe and do not lower CD4 counts. Standard precautions suffice unless an opportunistic infection such as active tuberculosis requires airborne precautions.

Rheumatologic disease

Autoimmune and inflammatory joint diseases share morning stiffness, systemic signs and flares, and they differ from osteoarthritis in pattern and pathology.

FeatureRheumatoid arthritisOsteoarthritis
PathologyAutoimmune synovitis with pannus that erodes cartilage and boneDegeneration of articular cartilage with osteophytes and subchondral sclerosis
Onset and ageAny adult age, peak 30s to 50s; women about 2 to 3 times more oftenUsually after 50; related to age, load and prior injury
DistributionSymmetric, small joints first: MCP, PIP, wrists, MTP; spares DIP; cervical spine (atlantoaxial instability)Asymmetric, weight bearing joints (hip, knee), DIP (Heberden nodes), PIP (Bouchard nodes), first CMC, spine
Morning stiffnessMore than 1 hourLess than about 30 minutes; pain worse with use, better with rest
Systemic signsFatigue, low grade fever, weight loss, rheumatoid nodules, anemia, lung and eye diseaseNone
DeformitiesUlnar drift, swan neck, boutonniere, volar MCP subluxationBony enlargement, genu varum
LabsRheumatoid factor, anti CCP antibodies, elevated ESR and CRPNormal

During an acute flare of rheumatoid arthritis the goals are protection and maintenance: rest of inflamed joints, resting splints, gentle active or active assisted ROM once or twice daily to prevent contracture, isometrics rather than resistance through range, energy conservation and joint protection education (use larger joints, avoid sustained grips and positions of deformity). Between flares, aerobic conditioning and progressive strengthening are encouraged; aquatic exercise in warm water is well tolerated. Because of atlantoaxial instability, cervical manipulation and end range cervical techniques are contraindicated, and new symptoms such as occipital headache, paresthesia or gait change in a patient with long standing rheumatoid arthritis need prompt medical evaluation. Long term corticosteroid use adds osteoporosis and skin fragility.

Other rheumatologic conditions: systemic lupus erythematosus (young women; malar rash, photosensitivity, nonerosive polyarthralgia, renal disease, Raynaud phenomenon); ankylosing spondylitis (young men; inflammatory back pain better with exercise, sacroiliitis, reduced chest expansion, HLA-B27; extension, posture and breathing exercise); systemic sclerosis (skin thickening and contractures); polymyalgia rheumatica (older adults; shoulder and hip girdle stiffness with high ESR, linked to giant cell arteritis, which threatens vision); gout (urate crystals, hot first MTP joint); and fibromyalgia (widespread pain and central sensitization, best managed with graded aerobic exercise and education).

Case. A 56 year old man receiving chemotherapy for lymphoma arrives for his session. His laboratory values today show hemoglobin 9.2 g/dL, platelets 18,000 per microliter and an ANC of 1,800. He wants to continue his resistance program with free weights.
Reasoning: Scan the counts against the zones. The ANC is acceptable and the hemoglobin allows light, symptom guided activity, but platelets below 20,000 carry a high risk of spontaneous bleeding, so resistance training is deferred. The best choice is to limit the session to essential functional mobility and light walking after communicating with the oncology team, while guarding against falls. Lighter weights still carry bleeding risk, and cancelling all activity without communicating is also wrong. Safety point: watch for petechiae, bruising, nosebleeds and headache, which may signal bleeding.
Key point

Exercise is recommended through and after cancer treatment, but the therapist must know each treatment's side effects, check blood counts every session, protect bones with metastases, and recognize emergencies such as cord compression and neutropenic fever. Lymphedema is staged by reversibility and treated with complete decongestive therapy unless infection, acute DVT or decompensated heart failure is present. Rheumatoid arthritis is symmetric, inflammatory and systemic, so flares call for protection and gentle motion rather than loading.

Section 4Medical screening and differential diagnosis

Why screening is a core skill

Under direct access, the physical therapist is often the first clinician a patient sees. The examination therefore includes a systems review and a review of systems (fever, chills, night sweats, unexplained weight loss, fatigue) to decide whether the problem fits physical therapy, needs referral alongside therapy, or needs immediate medical care. Screening is not diagnosing disease; it is recognizing when the pattern does not fit a neuromusculoskeletal cause.

How visceral pain behaves

Visceral afferents travel with sympathetic nerves and converge on the same dorsal horn neurons as somatic afferents from skin and muscle at the same segment. The brain, more used to signals from the body wall, projects the pain to the somatic dermatome: this is referred pain. The diaphragm, innervated by the phrenic nerve (C3 to C5), refers to the shoulder, so irritation of its undersurface by blood, bile or an inflamed organ produces shoulder pain. Visceral pain tends to be deep, aching or colicky, poorly localized, and not reproduced or changed by movement, palpation or position, although some musculoskeletal screening tests can still look positive. It often comes with systemic signs and a link to organ function (eating, voiding, breathing, exertion, menstrual cycle).

SourceCommon referral areaDistinguishing features
Heart (angina, myocardial infarction)Substernal chest, left shoulder and arm (ulnar side), jaw, neck, upper backBrought on by exertion, cold or stress; relieved by rest or nitroglycerin (angina); diaphoresis, dyspnea, nausea; women and people with diabetes more often have atypical symptoms
PericardiumChest, left shoulder, upper trapeziusSharp pain worse lying supine and with breathing, relieved by sitting forward
Lungs and pleuraChest wall, shoulder, scapula; Pancoast tumor to shoulder and medial arm (C8 to T1)Worse with breathing or coughing; dyspnea, cough, hemoptysis; Horner syndrome with Pancoast tumor
Aorta (abdominal aortic aneurysm)Low back, abdomen, flankPulsatile abdominal mass, older male smoker, throbbing pain not changed by position; rupture causes tearing pain and shock
SpleenLeft shoulder (Kehr sign), left upper quadrantAfter trauma or with mononucleosis; Kehr sign signals blood irritating the diaphragm
Gallbladder and liverRight upper quadrant, right shoulder, right scapulaFatty meals, nausea, jaundice
Kidney and ureterFlank, costovertebral angle, groinFever, dysuria, hematuria, colicky pain
PancreasEpigastrium and mid backAlcohol use, gallstones, relief leaning forward
Gynecologic (ectopic pregnancy, endometriosis, ovarian cyst)Low back, sacrum, lower abdomen, groinMissed period or abnormal bleeding, cyclic pain; ruptured ectopic pregnancy can cause shoulder pain and shock
AnteriorPosterior Patient's right is on the viewer's left in front, on the viewer's right from behind Heart: left chest,left arm, jaw Spleen (Kehr):left shoulder Gallbladder:right upperquadrant Appendix:right lowerquadrant Gallbladder:right scapula Kidneys:flank andCVA Pancreas:mid back(T10 to L2)
Figure 11.4 Common viscerogenic referral areas. Note sidedness: cardiac and splenic pain refer to the patient's left, gallbladder pain to the patient's right shoulder and scapula, and renal pain to the flank and costovertebral angle.

Red flags

Red flags raise suspicion of serious pathology, and clusters matter more than single items. The best supported single flag for spinal malignancy is a previous history of cancer. Others: age over 50 with new pain, unexplained weight loss, constant pain unrelieved by rest or position, night pain, fever and night sweats, immune suppression or IV drug use, trauma in someone with osteoporosis, long term steroids, failure to improve in about a month, and progressive neurologic deficit.

Suspected conditionKey screening findingsUrgency
Cauda equina syndromeSaddle anesthesia, urinary retention or incontinence, fecal incontinence, bilateral leg weakness or sciatica, sexual dysfunctionEmergency
Spinal malignancyHistory of cancer, age over 50, unexplained weight loss, failure to improve, night painUrgent physician referral
Spinal infection (osteomyelitis, discitis, epidural abscess)Fever, IV drug use, recent infection or procedure, immune suppression, diabetesUrgent to emergency
Vertebral fractureOlder age, osteoporosis, steroid use, trauma; focal spinous process tendernessPhysician referral, imaging
Abdominal aortic aneurysmOlder male smoker, pulsatile mass, back or abdominal pain not mechanicalEmergency if symptomatic
Myocardial infarctionChest pressure, arm or jaw pain, diaphoresis, dyspnea, nauseaEmergency (activate EMS)
Deep vein thrombosisUnilateral calf swelling, pain, warmth, recent surgery or immobility; Wells criteriaSame day medical evaluation; emergency if chest symptoms suggest pulmonary embolism
Cervical arterial dysfunctionThe 5 D's and 3 N's: dizziness, diplopia, dysarthria, dysphagia, drop attacks, nystagmus, nausea, numbness; new unusual headache or neck painEmergency if symptoms are acute
Upper cervical instabilityRheumatoid arthritis, Down syndrome, trauma; lip paresthesia, bilateral symptoms, sense of head being heavyNo manual therapy; physician referral

Deciding what to do

Screening ends in one of three decisions. Treat when the findings fit a neuromusculoskeletal problem. Treat and refer (or refer and communicate) when there is a concurrent medical issue that needs attention but the patient is stable, for example newly found hypertension or a suspicious skin lesion. Refer immediately (activate emergency services or send to the emergency department) when life, limb or neurologic function is at risk: signs of myocardial infarction, stroke, pulmonary embolism, cauda equina syndrome, acute spinal cord compression, septic shock or a symptomatic aneurysm. The exam often asks which finding most warrants referral; choose the one that signals the most serious and time sensitive condition. Documentation should record the findings, the decision and the communication with the physician.

Vital signs are part of every screen. Resting blood pressure of 180/110 mm Hg or higher is commonly given as a reason not to begin exercise and to refer; a resting heart rate above about 120 beats per minute, an oxygen saturation below about 88 to 90%, or an oral temperature at or above about 100 °F (37.8 °C) with systemic symptoms also stop or delay treatment. Blood pressure categories in adults are: normal below 120/80, elevated 120 to 129 systolic with diastolic below 80, stage 1 hypertension 130 to 139 or 80 to 89, and stage 2 hypertension 140/90 or higher; a value above 180/120 is a hypertensive crisis.

Board tip. When a question describes shoulder or back pain that is not reproduced by any movement, palpation or resisted test, it is pointing you to a visceral source. Look for the link to organ function (exertion for the heart, meals for the gallbladder, breathing for the lungs, voiding for the kidney) and the systemic signs, and pick referral over another musculoskeletal test.
Case. A 62 year old man with hypertension and a 40 pack year smoking history comes to physical therapy by direct access for left shoulder and upper arm pain that started a week ago while shoveling snow. Shoulder range of motion is full and painless, resisted tests are strong and pain free, and the pain comes on after climbing one flight of stairs and settles after a few minutes of rest.
Reasoning: A normal musculoskeletal exam plus exertional pain relieved by rest in a man with cardiac risk factors describes angina. The best action is to stop the exam and refer him for prompt medical evaluation (and activate emergency services if pain is present at rest, prolonged, or accompanied by diaphoresis, dyspnea or nausea). Treating for rotator cuff tendinopathy, ordering imaging of the shoulder or prescribing a walking program before cardiac clearance are wrong. Safety point: do not let him drive himself if symptoms are ongoing.
Key point

Screening asks whether the pattern fits the musculoskeletal system. Visceral pain is deep, diffuse, unchanged by movement and tied to organ function and systemic signs, and its referral areas follow shared spinal segments and the phrenic nerve. Weigh red flags in clusters, with history of cancer as the strongest single flag for malignancy, and choose emergency referral for threats to life, limb or neurologic function.

Section 5Pharmacology for physical therapists

What the exam expects

The exam tests consequences, not dosing. Ask of every drug: does it change heart rate or blood pressure, cause sedation or orthostasis, affect bleeding, bone, muscle, tendon or skin, or change glucose and electrolytes?

Cardiovascular drugs

Beta blockers (metoprolol, atenolol, carvedilol, propranolol) block beta 1 receptors in the heart, lowering resting and exercise heart rate, contractility and blood pressure. Cardioselective agents act mainly on beta 1; nonselective agents (propranolol) also block beta 2 receptors in the airways and can provoke bronchospasm in people with asthma. Because heart rate rises less with workload, target heart rate formulas based on age predicted maximum are invalid; use the rating of perceived exertion (about 11 to 14 on the 6 to 20 scale), the talk test, or a heart rate range from an exercise test performed on the medication. Beta blockers also mask the tachycardia of hypoglycemia, can cause fatigue and orthostatic hypotension, and are important to take consistently, since abrupt withdrawal can cause rebound tachycardia and angina.

Calcium channel blockers: dihydropyridines (amlodipine) cause peripheral edema and flushing; verapamil and diltiazem also slow heart rate. ACE inhibitors (-pril) cause dry cough, and both they and angiotensin receptor blockers (-sartan) can cause hyperkalemia and dizziness. Loop and thiazide diuretics cause hypokalemia (weakness, cramps, arrhythmia), dehydration and orthostatic hypotension. Nitroglycerin causes headache and hypotension, so the patient sits to take it; the usual teaching is one sublingual dose every 5 minutes up to three, with emergency services called if pain is not relieved after the first dose. Digoxin toxicity causes nausea, visual halos, confusion and arrhythmias, more likely with hypokalemia. Statins can cause myalgia and, rarely, rhabdomyolysis (severe pain, weakness, dark urine), which needs urgent referral.

Anticoagulants and antiplatelet drugs

Warfarin blocks the vitamin K dependent clotting factors (II, VII, IX, X) and is monitored by the INR (target usually 2 to 3). Heparin and low molecular weight heparin are injected; the direct oral anticoagulants (apixaban, rivaroxaban, dabigatran) need no INR monitoring; aspirin and clopidogrel are antiplatelet drugs. All raise bleeding risk: avoid aggressive deep tissue work and manipulation when bleeding risk is high, prevent falls (a head strike needs medical evaluation because of intracranial hemorrhage risk), and watch for bruising, hematuria, melena, hemarthrosis and unusual headache.

A patient with a new DVT may usually begin walking once therapeutic anticoagulation is established, per the physician, because early ambulation does not raise pulmonary embolism risk.

Anti-inflammatory and immune modifying drugs

NSAIDs inhibit cyclooxygenase; they cause gastrointestinal bleeding, kidney injury, fluid retention, higher blood pressure and cardiovascular risk, and may slow bone and soft tissue healing. Black stools or epigastric pain on NSAIDs warrant referral. Acetaminophen has no anti-inflammatory action, and overdose causes liver failure.

Corticosteroids used long term cause osteoporosis, steroid myopathy (proximal weakness), fragile skin, delayed healing, hyperglycemia, hypertension, infection risk, avascular necrosis of the femoral head and adrenal suppression. Repeated local injections can weaken tendons. Methotrexate and biologic agents (such as TNF inhibitors) suppress immunity and can reactivate tuberculosis.

Pain, sedation and the nervous system

Opioids cause sedation, dizziness, constipation, orthostatic hypotension and, at high doses or with other sedatives, respiratory depression; they raise fall risk and can mask pain during exercise. Sessions needing full participation can be timed near peak effect (about 30 to 60 minutes after an oral dose) if the patient is alert. Overdose shows pinpoint pupils, slow breathing and unresponsiveness: activate emergency services, and naloxone may be given.

Antispasticity drugs: baclofen (GABA-B agonist; sedation and weakness, and abrupt withdrawal, especially from an intrathecal pump, causes seizures, hallucinations and high fever), tizanidine (sedation, hypotension, liver toxicity), dantrolene (acts on muscle; generalized weakness, liver toxicity) and botulinum toxin (local effect for about 3 months; pair with stretching, casting and antagonist strengthening). Benzodiazepines and muscle relaxants for spasm cause sedation and falls in older adults.

Levodopa with carbidopa brings wearing off and peak dose dyskinesia over time; schedule therapy in the "on" period, about 45 to 90 minutes after a dose, and watch for orthostatic hypotension. Antidepressants (especially tricyclics) and antiepileptic drugs cause dizziness and falls. Fluoroquinolones (ciprofloxacin, levofloxacin) raise the risk of Achilles tendon rupture, especially in older adults taking corticosteroids.

Diabetes and other endocrine drugs

Exercise should avoid the peak of rapid acting insulin (about 1 to 2 hours after injection) and regular insulin (about 2 to 4 hours). Sulfonylureas cause hypoglycemia; SGLT2 inhibitors cause dehydration; GLP-1 receptor agonists cause nausea and weight loss that includes muscle, which resistance training helps protect. Excess levothyroxine causes hyperthyroid signs and bone loss. Oral bisphosphonates require the patient to stay upright for 30 to 60 minutes after the dose; rare effects include osteonecrosis of the jaw and atypical femoral fracture, which may present as thigh pain.

Medications, aging and falls

Older adults clear drugs more slowly and often take five or more (polypharmacy). Sedative, anticholinergic and blood pressure lowering drugs raise fall risk; the therapist checks orthostatic vitals, screens fall risk and reports new dizziness or confusion after a medication change.

Drug classMain effects that matter in therapyWhat the therapist does
Beta blockersBlunted heart rate and blood pressure response, fatigue, masked hypoglycemiaUse RPE or talk test, not age predicted heart rate
DiureticsHypokalemia, dehydration, orthostatic hypotensionCheck orthostatic vitals, watch for cramps and arrhythmia
Vasodilators, nitrates, alpha blockersHypotension, dizziness; avoid hot environments after doseGradual position changes, longer cool down
Anticoagulants and antiplateletsBleeding, bruising, hemarthrosis, intracranial bleed after fallsFall prevention, avoid aggressive manual techniques, refer any head strike
StatinsMyalgia, rarely rhabdomyolysisRefer for unexplained muscle pain with weakness or dark urine
Corticosteroids (long term)Osteoporosis, myopathy, fragile skin, poor healing, hyperglycemiaWeight bearing and proximal strengthening, skin protection
NSAIDsGI bleeding, kidney injury, fluid retention, possible slowed healingScreen for melena and epigastric pain, monitor blood pressure
OpioidsSedation, respiratory depression, constipation, fallsAssess alertness, time sessions, recognize overdose
Antispasticity drugsSedation, weakness (dantrolene), withdrawal crisis (baclofen)Balance tone reduction against functional use of tone
LevodopaWearing off, dyskinesia, orthostatic hypotensionSchedule in "on" time
Insulin and sulfonylureasHypoglycemiaCheck glucose, avoid peak action, keep carbohydrate available
FluoroquinolonesTendinopathy and tendon ruptureDelay heavy eccentric loading, report heel cord pain
60100140180 Workload (for example, treadmill stage) Heart rate (beats/min) Same work,lower HR No beta blocker On a beta blocker Age predicted targetheart rate is not valid. Guide intensity with: RPE 11 to 14 (6 to 20) Talk test HR range from a testdone on the drug Also watch for maskedhypoglycemia signs
Figure 11.5 Beta blockade flattens the heart rate response to work. Because the same workload produces a lower heart rate, intensity must be guided by perceived exertion or a heart rate range established on the medication.
Board tip. When a stem mentions a beta blocker and asks how to monitor intensity, the answer is the rating of perceived exertion (or talk test), not a percentage of age predicted maximum heart rate. When a stem mentions an anticoagulant and a fall with a head strike, the answer is immediate medical evaluation even if the patient feels fine.
Case. A 74 year old woman on warfarin, furosemide, metoprolol and oxycodone is two days after a hip fracture repair. When she stands for the first time she reports dizziness and her blood pressure falls from 128/76 supine to 104/68 standing, with her heart rate changing from 64 to 68.
Reasoning: A drop of 20 mm Hg or more systolic (or 10 or more diastolic) on standing is orthostatic hypotension. The small heart rate rise is expected with a beta blocker, which blunts the compensatory tachycardia, and the diuretic and opioid add volume depletion and vasodilation. The best response is to return her to sitting or supine, then progress slowly (ankle pumps, sitting, dangling, standing with a walker), hydrate as allowed, consider compression stockings or an abdominal binder, and report the finding. Pushing on to gait training through dizziness is wrong, and so is stopping therapy for the day without a graded retry. Safety point: a fall on warfarin carries a high risk of intracranial bleeding.
Key point

Know drugs by their consequences: beta blockers flatten heart rate response, diuretics and vasodilators cause orthostasis, anticoagulants turn falls into bleeding emergencies, long term steroids weaken bone, muscle and skin, opioids and sedatives raise fall risk and depress breathing, and insulin and sulfonylureas cause hypoglycemia. Time sessions to drug action and communicate new adverse effects.

The chapter in one breath

  • Check glucose before exercise in insulin and secretagogue users: below 70 treat first, 70 to 100 snack first, above 250 with ketones no vigorous exercise.
  • Hypoglycemia is fast (shaky, sweaty, confused); give 15 g of fast carbohydrate if the patient can swallow and recheck in 15 minutes.
  • Hypothyroidism and hyperthyroidism both cause proximal myopathy; long term cortisol excess adds osteoporosis, skin fragility and poor healing.
  • Osteoporosis (T score of −2.5 or lower) calls for resistance, impact as tolerated and balance work, and no loaded flexion or flexion with rotation.
  • Incontinence types: stress (closure), urge (detrusor overactivity), overflow (failed emptying, refer) and functional (barriers outside the bladder); pelvic floor training is first line for stress incontinence.
  • In pregnancy, use RPE, avoid prolonged supine after the first trimester, and stop for bleeding, contractions, fluid leakage, chest pain or calf swelling.
  • During cancer treatment check platelets, hemoglobin and ANC every session; platelets below 20,000 and ANC below 500 sharply restrict activity.
  • Lymphedema is staged 0 to III by reversibility and treated with complete decongestive therapy; cellulitis, acute DVT and decompensated heart failure come first.
  • Rheumatoid arthritis is symmetric, inflammatory and systemic with atlantoaxial instability; flares call for rest, splints, gentle ROM and isometrics.
  • Visceral pain is not changed by movement and is tied to organ function; know heart (left arm, jaw), gallbladder (right scapula), spleen (left shoulder) and kidney (flank) patterns.
  • A history of cancer is the strongest single red flag for spinal malignancy; cauda equina syndrome, chest pain with risk factors and signs of PE are emergencies.
  • On beta blockers use RPE; on anticoagulants prevent falls and refer head strikes; long term steroids weaken bone, muscle and skin; fluoroquinolones threaten tendons.

Words worth knowing

TermWhat it means
HypoglycemiaBlood glucose below 70 mg/dL, with shakiness, sweating, tachycardia and, if severe, confusion and loss of consciousness.
Diabetic ketoacidosisLife threatening state of insulin deficiency with hyperglycemia, ketones and metabolic acidosis, marked by fruity breath and Kussmaul breathing.
Steroid myopathyProximal muscle weakness caused by excess corticosteroid, either from medication or Cushing syndrome.
T scoreBone density compared with a healthy young adult, in standard deviations; −2.5 or below is osteoporosis.
Stress incontinenceLeakage of urine when abdominal pressure rises, as with coughing or lifting, because urethral closure is inadequate.
Urge incontinenceLeakage after a sudden strong need to void, caused by involuntary detrusor contraction.
Overflow incontinenceDribbling leakage from an overfilled bladder that does not empty because of a weak detrusor or blocked outlet.
Pelvic floor muscle trainingStructured strengthening and coordination exercise of the levator ani and related muscles, first line care for stress incontinence.
Diastasis recti abdominisSeparation of the two rectus abdominis muscles along the linea alba, common in pregnancy; more than about 2 cm is significant.
Absolute neutrophil countNumber of neutrophils per microliter; below 500 means severe neutropenia and high infection risk.
ThrombocytopeniaLow platelet count, which raises bleeding risk; below about 20,000 per microliter sharply limits exercise.
Cancer related fatiguePersistent exhaustion from cancer or its treatment that is not relieved by rest and improves with graded exercise.
LymphedemaSwelling from protein rich fluid that collects because lymphatic transport is impaired.
Stemmer signInability to lift a skin fold at the base of the second toe or finger, supporting a diagnosis of lymphedema.
Complete decongestive therapyTwo phase lymphedema treatment of manual lymphatic drainage, compression, exercise and skin care.
Atlantoaxial instabilityExcess motion between C1 and C2, seen in rheumatoid arthritis and Down syndrome, which contraindicates upper cervical manipulation.
Referred painPain felt away from its source because visceral and somatic afferents converge on the same spinal segment.
Kehr signPain at the left shoulder from blood or irritation under the left diaphragm, classically after splenic rupture.
Red flagA history or exam finding that raises suspicion of serious disease and may require referral.
Cauda equina syndromeCompression of the lumbosacral nerve roots causing saddle anesthesia and bowel or bladder dysfunction; a surgical emergency.
Orthostatic hypotensionA fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing.
INRInternational normalized ratio, a standardized clotting time used to monitor warfarin; usual target 2 to 3.
Rating of perceived exertionA patient rated effort scale (6 to 20 or 0 to 10) used when heart rate is unreliable.
RhabdomyolysisBreakdown of muscle tissue releasing myoglobin that can injure the kidneys; a rare statin effect marked by pain, weakness and dark urine.

Check yourself

A 45 year old man with type 1 diabetes checks his glucose before a treadmill session: 82 mg/dL. He injected rapid acting insulin 30 minutes ago with lunch. What should the therapist do?
Answer. Have him eat about 15 to 30 g of carbohydrate before starting and recheck, and if possible shift the session away from the insulin peak. A value under 100 mg/dL in an insulin user, close to peak insulin action, predicts exercise induced hypoglycemia.
Which exercise is the poorest choice for a patient with osteoporosis and a history of a vertebral compression fracture: prone thoracic extension, mini squats, sit ups, or tandem standing?
Answer. Sit ups. Loaded spinal flexion increases anterior vertebral body compression and the risk of wedge fracture. The other choices strengthen extensors and legs or train balance.
A 70 year old woman reports frequent, sudden, intense urges to urinate and leakage before she reaches the bathroom, especially when she arrives home and unlocks the door. Name the incontinence type and two interventions.
Answer. Urge incontinence (overactive bladder). Interventions include a bladder diary, urge suppression with quick pelvic floor contractions and calm breathing, timed voiding with gradually lengthening intervals, and reducing caffeine and other bladder irritants.
A woman at 24 weeks of gestation asks which position to avoid during her exercise program and why.
Answer. Prolonged supine positions, because after the first trimester the enlarged uterus can compress the inferior vena cava, reducing venous return and causing supine hypotension. Use left side lying, inclined or standing positions.
A patient on chemotherapy has a platelet count of 35,000 per microliter. Which activities are appropriate?
Answer. Light aerobic activity and active range of motion with functional mobility, but no heavy resistance training or high fall risk activities. Between 20,000 and 50,000 bleeding risk is moderate; above 50,000 progressive exercise is usually allowed.
During complete decongestive therapy for arm lymphedema, the patient's arm becomes red, hot and more swollen, and she has a temperature of 38.4 °C. What is the next step?
Answer. Stop manual lymphatic drainage and compression bandaging and refer promptly for medical treatment of probable cellulitis. Decongestive therapy resumes after the infection is treated.
A patient with long standing rheumatoid arthritis has new occipital headache and tingling in both hands when looking down. Which intervention is contraindicated and what should the therapist do?
Answer. Upper cervical manipulation and end range cervical flexion techniques are contraindicated because the symptoms suggest atlantoaxial instability. Stop cervical treatment and refer for medical evaluation and imaging.
A 48 year old woman has right shoulder and right scapular pain that worsens about an hour after fatty meals, with nausea. Shoulder motion and strength are normal. What is the likely source?
Answer. The gallbladder (biliary colic or cholecystitis), which refers to the right upper quadrant, right shoulder and right scapula. Normal shoulder findings and a link to meals point to a visceral source and referral.
Which single history item is the strongest red flag for spinal malignancy in a patient with low back pain?
Answer. A previous history of cancer. Age over 50, unexplained weight loss and failure to improve with conservative care add suspicion, especially in combination.
A patient taking metoprolol is beginning cardiac rehabilitation. How should exercise intensity be prescribed?
Answer. With the rating of perceived exertion (about 11 to 14 on the 6 to 20 scale), the talk test, or a heart rate range taken from an exercise test performed while on the drug. Age predicted heart rate targets are invalid because the beta blocker blunts the heart rate response.
Chapter 12 · Non Systems

Therapeutic Modalities, Equipment and Devices

Modalities, devices and equipment are where physics meets the patient: a setting that is too intense burns skin, a cane on the wrong side worsens a limp, and a prosthetic socket that is a few millimeters off produces a gait deviation the exam expects you to trace to its cause. Questions in this area are highly predictable because they test parameters, indications, contraindications and fitting rules. This chapter organizes those numbers and the reasoning behind them so you can choose the safest effective option for each patient.

By the end of this chapter you can

  • Explain how superficial heat, cryotherapy, therapeutic ultrasound and diathermy transfer energy, and select parameters by tissue depth and goal.
  • List the contraindications and precautions for each thermal agent and for electrical stimulation.
  • Describe waveforms and stimulation parameters, and set up TENS, NMES, iontophoresis and EMG biofeedback for common goals.
  • Choose traction position and force, compression pressures, CPM use and hydrotherapy properties for specific conditions.
  • Fit canes, crutches and walkers, teach gait patterns and stair sequences, and guard safely.
  • Measure for a wheelchair, choose seating features, and apply accessibility standards for ramps and doorways.
  • Match prosthetic components to function level and trace prosthetic gait deviations to their causes.
  • Select orthoses for common neurologic and orthopedic conditions.

Section 1Thermal agents and ultrasound

How heat moves

Heat transfers by four mechanisms. Conduction is transfer by direct contact between two materials at different temperatures (hot packs, paraffin, ice packs). Convection is transfer by a moving medium (whirlpool, fluidized therapy with heated cellulose particles). Radiation is transfer of electromagnetic energy without a medium (infrared lamps). Conversion changes another form of energy into heat within the tissue (ultrasound, diathermy). The amount of heating depends on the temperature difference, the duration of contact, the area treated and the thermal conductivity of the tissue. Fat is a poor conductor and insulates deeper tissue, so superficial agents heat only about 1 to 2 cm deep and mostly heat skin and subcutaneous tissue.

Superficial heat

Physiologic effects of heat include vasodilation and increased blood flow, increased metabolic rate (about 2 to 3 times for each 10 °C rise), increased nerve conduction velocity, reduced pain through the gate mechanism and reduced muscle guarding, and increased collagen extensibility when tissue is heated and then stretched. Heat is used for subacute and chronic pain, muscle guarding, joint stiffness and before stretching or mobilization.

AgentMechanismCommonly taught parametersNotes
Moist hot packConductionStored in water at about 70 to 75 °C (158 to 167 °F); 6 to 8 layers of toweling; 15 to 20 minutesCheck skin at 5 minutes; do not let patient lie on the pack
ParaffinConductionAbout 52 to 54 °C (126 to 130 °F); dip and wrap (6 to 10 dips, then wrap for 15 to 20 minutes) or dip and immerseGood for hands and feet with irregular surfaces, as in rheumatoid or osteoarthritis outside a flare; not over open wounds
Fluidized therapyConvectionAbout 38.9 to 47.8 °C (102 to 118 °F), 15 to 20 minutesPatient can move the part during treatment; desensitization
Infrared lampRadiation15 to 20 minutes; intensity follows the inverse square law and the cosine lawLittle used today; no contact pressure
Warm whirlpoolConvectionLimb about 37 to 40 °C (99 to 104 °F); full body no higher than about 38 °C (100 to 102 °F)See hydrotherapy in Section 3

Contraindications to heat: acute injury or inflammation, recent or potential hemorrhage, thrombophlebitis or DVT, malignancy in the area, impaired sensation or impaired mentation (cannot report burning), impaired circulation (tissue cannot dissipate heat), over the eyes, and over areas recently treated with topical counterirritants. Precautions: pregnancy (avoid raising core temperature, avoid heat over the abdomen and low back), cardiac insufficiency, edema, open wounds, metal in the area and poor thermal regulation in very young or very old patients.

Cryotherapy

Cold causes immediate vasoconstriction, slows metabolism and nerve conduction velocity, raises the pain threshold, reduces muscle spindle activity (temporarily reducing spasticity and spasm) and limits secondary hypoxic injury after acute trauma. Patients typically feel a predictable sequence: cold, burning or aching, then numbness; numbness usually arrives in about 5 to 10 minutes. Cold packs and ice packs are applied for about 10 to 20 minutes; ice massage for about 5 to 10 minutes over a small area; cold whirlpool water at about 0 to 27 °C (32 to 80 °F); vapocoolant spray is used with stretch for trigger points. A brief reflex vasodilation can follow prolonged intense cold (the hunting response), but its clinical importance is debated. Cold is used for acute injury, pain, edema control as part of rest, compression and elevation, postoperative pain, and temporary reduction of spasticity before functional training.

Contraindications to cold: cold hypersensitivity (cold urticaria), cryoglobulinemia, paroxysmal cold hemoglobinuria, Raynaud phenomenon, over regenerating peripheral nerves, over areas of compromised circulation or peripheral vascular disease. Precautions: over superficial nerves (the common fibular nerve at the fibular head and the ulnar nerve at the elbow can develop a cold induced palsy), hypertension (cold can raise blood pressure), impaired sensation or cognition, open wounds, and the very young or old.

Board tip. The classic cold contraindication list is "the four C's and an R": cold urticaria, cryoglobulinemia, cold hemoglobinuria (paroxysmal), compromised circulation, and Raynaud phenomenon. For heat the key ideas are "no heat on acute, bleeding, clotting, cancer, or insensate tissue."

Therapeutic ultrasound

Therapeutic ultrasound uses a piezoelectric crystal that vibrates at high frequency (the reverse piezoelectric effect) to produce acoustic waves that are absorbed in tissue and converted to heat. Absorption is highest in tissues with high collagen content (tendon, ligament, joint capsule, fascia) and lowest in fat, which makes ultrasound well suited to heating dense connective tissue. A coupling medium (gel or water) is required because air reflects nearly all ultrasound. Large reflections at bone and metal interfaces create "hot spots," including periosteal pain if intensity is too high.

ParameterOptions and valuesHow to choose
Frequency1 MHz penetrates about 2 to 5 cm; 3 MHz about 1 to 2 cm and heats about three times fasterDeep target (hip capsule, piriformis) 1 MHz; superficial target (lateral epicondyle, patellar tendon) 3 MHz
Duty cycleContinuous (100%) for thermal effects; pulsed (often 20% or less) for nonthermal effectsThermal for chronic stiffness and extensibility; pulsed for acute or subacute healing goals
Intensity (spatial average)Thermal: about 1.0 to 2.0 W/cm2 at 1 MHz, about 0.5 W/cm2 or more at 3 MHz; nonthermal: about 0.5 to 1.0 W/cm2 pulsedAdjust to patient report: mild warmth, never pain
Treatment areaTwo to four times the effective radiating area (ERA) of the sound headLarger areas need a different modality or a larger head
DurationUsually 5 to 10 minutes; longer for larger areas or vigorous heatingTime depends on intensity, frequency, area and goal
Beam nonuniformity ratio (BNR)Ratio of peak to average intensity; ideally under about 5 to 6Lower BNR is more uniform; keep the head moving at about 4 cm per second

Tissue temperature goals are described as mild (about 1 °C, increases metabolism and healing), moderate (about 2 to 3 °C, reduces pain and muscle spasm) and vigorous (about 3 to 4 °C, increases extensibility of collagen for stretching). Stretch during or immediately after vigorous heating, because the window of increased extensibility is short. Nonthermal effects (cavitation and acoustic streaming) alter cell membrane permeability and may support healing in the inflammatory and proliferative phases, though evidence for clinical benefit is mixed. Phonophoresis uses ultrasound to enhance transdermal delivery of a medication such as a corticosteroid; evidence for added benefit over ultrasound alone is limited.

Contraindications to ultrasound: malignancy in the area, pregnancy (over the abdomen, low back and pelvis), over the eyes, over reproductive organs, over a cardiac pacemaker or the heart, over the spinal cord after laminectomy, over areas of active bleeding or DVT, over infection, and thermal ultrasound in areas of impaired sensation or circulation. Precautions: open epiphyses in children, acute inflammation (use pulsed or avoid thermal), fractures, breast implants, and plastic or cemented joint components (methyl methacrylate and plastic heat rapidly). Metal implants are a precaution rather than an absolute contraindication because metal conducts heat away quickly, but the beam reflects strongly.

SkinFatMuscle anddeep capsuleBone 2 cm5 cm Hot packUS 3 MHzUS 1 MHz Heats skin andfat, about1 to 2 cm 1 to 2 cm, heatsabout 3 timesfaster 2 to 5 cm,deep capsuleand muscle Inductive shortwave diathermy also heats deep muscle (about 3 to 5 cm) over a larger area.
Figure 12.1 Depth of heating by agent. Superficial agents and 3 MHz ultrasound stop within about 2 cm, while 1 MHz ultrasound reaches deep capsule and muscle. Fat absorbs little ultrasound but insulates against conductive heat.

Diathermy and other electromagnetic agents

Shortwave diathermy (usually 27.12 MHz) heats by electromagnetic energy. Inductive applicators (drum or coil) induce eddy currents that heat conductive, well perfused muscle over a larger, deeper area than ultrasound; capacitive applicators (plates) preferentially heat low conductivity fat and skin. A towel absorbs perspiration, which would otherwise concentrate heat. Contraindications are broader than for ultrasound: any implanted metal or electronic device, metal jewelry, pregnancy, malignancy, eyes, open epiphyses, hemorrhage, ischemic tissue and impaired sensation. Low level laser (photobiomodulation) requires protective eyewear and is avoided over the eyes, malignancy and the pregnant abdomen.

Case. A 52 year old man has chronic adhesive capsulitis with limited glenohumeral external rotation and abduction. The therapist wants to heat the anterior and inferior capsule before joint mobilization. Options: hot pack, 3 MHz continuous ultrasound, 1 MHz continuous ultrasound, or ice massage.
Reasoning: The target is deep (the inferior and anterior glenohumeral capsule lies several centimeters below the skin) and the goal is vigorous heating of collagen to increase extensibility. A hot pack heats only 1 to 2 cm, 3 MHz is for superficial targets, and ice reduces extensibility. The best choice is 1 MHz continuous ultrasound at a thermal intensity over an area two to four times the ERA, followed immediately by mobilization and stretching while tissue is warm. Safety point: confirm intact sensation, and stop if the patient reports deep aching that suggests periosteal overheating.
Key point

Choose thermal agents by depth and goal: superficial heat and cold for skin, fat and superficial muscle, 3 MHz ultrasound for superficial dense tissue, and 1 MHz ultrasound or inductive diathermy for deep tissue. Continuous ultrasound heats; pulsed ultrasound is used for nonthermal effects. Avoid heat on acute, bleeding, clotting, malignant or insensate tissue, and avoid cold in cold sensitivity disorders, Raynaud phenomenon and compromised circulation.

Section 2Electrical stimulation

Currents and waveforms

Clinical electrical stimulation uses three broad current types. Direct current (DC) flows continuously in one direction for at least about 1 second; it produces chemical effects at the electrodes and is used for iontophoresis and for stimulating denervated muscle. Alternating current (AC) changes direction continuously; clinically it is delivered as medium frequency carrier waves such as interferential current and Russian current. Pulsed current (also called pulsatile current) delivers brief pulses separated by intervals of no current; pulses may be monophasic (one phase per pulse, as in high volt pulsed current), biphasic (two opposite phases, symmetric or asymmetric, balanced or unbalanced), or polyphasic (bursts of many phases). Most portable TENS and NMES units deliver biphasic pulsed current, which leaves no net charge under the electrodes when balanced, so skin irritation is minimal.

ParameterDefinitionClinical effect
Amplitude (intensity)Peak current or voltage of a phaseHigher amplitude recruits more and deeper nerve fibers, sensory first, then motor, then pain
Phase duration (pulse width)Time of one phase, usually in microsecondsShort phases favor sensory fibers; longer phases recruit motor and then pain fibers; very long (over about 10 ms) needed for denervated muscle
Frequency (pulse rate)Pulses per second (pps) or hertzAbout 1 to 10 pps produces twitches; about 30 to 50 pps produces a smooth tetanic contraction with less fatigue; higher rates fatigue muscle faster
On:off time (duty cycle)Ratio of stimulation time to restEarly strengthening uses about 1:3 to 1:5 to limit fatigue; progress toward 1:1
Ramp timeTime to rise to and fall from peak amplitudeSmooth, comfortable onset; avoids sudden jerks and stretch reflex triggering in spastic muscle
PolarityPositive (anode) or negative (cathode) electrode with DC or monophasic currentMatters for iontophoresis and wound healing; the cathode is usually the more excitatory electrode

Electrode placement follows physics. Current density is highest under the smaller electrode, so a small active electrode over the motor point concentrates the effect and a large dispersive electrode spreads it comfortably. Electrodes placed closer together stimulate more superficially; electrodes placed farther apart drive current deeper. Impedance falls when skin is clean, warm and moist and rises with oil, hair and dry skin. Electrodes should not touch each other, and current should never cross the heart or chest in a patient with a cardiac device.

A. Monophasic (high volt, twin peak)B. Symmetric biphasic pulsedC. Russian: 2,500 Hz in burstsD. Interferential: two crossing currents Very short twin pulses,one direction only (wounds,edema, pain) Phase duration Interpulse interval Balanced phases: zero net charge 10 ms burst, 10 ms off:50 bursts per second(strengthening) Off Beat envelope 4,000 Hz carrier and a slightlydifferent second current; the beatfrequency is their difference
Figure 12.2 Common clinical waveforms. A: high volt pulsed current is monophasic, so it has polarity. B: symmetric biphasic pulses leave no net charge, which makes them comfortable for TENS and NMES. C: Russian current packages a 2,500 Hz carrier into 50 bursts per second. D: interferential current produces an amplitude modulated beat deep in tissue.

TENS for pain

Transcutaneous electrical nerve stimulation (TENS) reduces pain through two main mechanisms. Sensory level, high rate stimulation activates large diameter A beta afferents that inhibit nociceptive transmission in the dorsal horn (the gate control theory). Motor level, low rate stimulation triggers release of endogenous opioids (endorphins and enkephalins) with a slower onset and longer carryover. Electrodes go over or around the painful area, along the involved dermatome or over the peripheral nerve.

ModeFrequencyPhase durationIntensityMechanism and use
Conventional (high rate)About 80 to 150 pps (often 100)Short, about 50 to 100 µsComfortable tingling, sensory level, no contractionGate control; acute and chronic pain; relief mostly during stimulation; may be worn for hours
Acupuncture-like (low rate)About 2 to 10 ppsLonger, about 150 to 250 µs or moreStrong, visible twitch (motor level)Endogenous opioid release; chronic pain; 20 to 45 minutes; longer carryover
Brief intenseAbout 100 to 150 ppsLong, about 150 to 250 µsHighest tolerableShort procedures such as wound debridement or painful mobilization; 15 minutes or less
Interferential currentCarrier near 4,000 Hz; beat frequency 80 to 150 Hz for sensory effects or 1 to 10 Hz for motorVery short within the carrierSensory or motorLower skin impedance, comfortable deep stimulation over a larger area

Patients habituate to constant stimulation, so modulating amplitude, rate or phase duration helps; opioids may blunt low rate TENS.

NMES for strengthening and function

Neuromuscular electrical stimulation (NMES) produces muscle contractions through the intact peripheral nerve. Its best supported use is quadriceps strengthening after total knee arthroplasty and ACL reconstruction, where reflex inhibition (arthrogenic muscle inhibition) limits voluntary activation. Commonly taught parameters: frequency about 35 to 50 pps (Russian current uses 50 bursts per second), phase duration about 200 to 400 µs for large muscles, ramp up about 2 seconds, on:off ratio about 1:3 to 1:5 initially (for example 10 seconds on and 50 seconds off), around 10 to 15 contractions per session, and intensity high enough to reach a meaningful percentage of maximal voluntary contraction (often at least 50% for strengthening). Electrically elicited contractions recruit motor units in a nonphysiologic order, with large, fast fatiguing units recruited earlier than in voluntary contraction (often described as a reversal of the Henneman size principle) and synchronous firing, so electrically driven contractions fatigue faster.

Functional electrical stimulation (FES) times stimulation to a task, such as dorsiflexion in swing after stroke or cycling after spinal cord injury. NMES can also reduce shoulder subluxation after stroke (posterior deltoid and supraspinatus).

Denervated muscle needs long pulses (over about 10 ms) or DC, with weak evidence of benefit; its strength duration curve shifts right, raising chronaxie (the duration needed at twice rheobase).

High volt pulsed current and wound healing

High volt pulsed current (HVPC) delivers very short twin peak monophasic pulses at high voltage, so it has polarity. It is an evidence supported adjunct for chronic wounds; the commonly taught pattern is the cathode over the wound early (antibacterial, attracts neutrophils and fibroblasts) and the anode later (epithelial migration), placed over saline moistened gauze.

Iontophoresis

Iontophoresis uses continuous direct current to drive charged medication ions through the skin. The principle is that like charges repel: a negatively charged drug is placed under the negative electrode (cathode) and a positively charged drug under the positive electrode (anode). The dose is current multiplied by time, expressed in milliampere minutes; a common dose is 40 mA·min (for example 4 mA for 10 minutes), with current usually limited to about 4 mA or less for comfort and safety. The cathode produces an alkaline reaction (sodium hydroxide) that causes more skin irritation than the acidic reaction at the anode, so the negative electrode is often made larger to lower current density, and skin is inspected after each treatment.

Ion or drugPolarityCommon use
Dexamethasone sodium phosphateNegativeInflammation (tendinopathy, bursitis)
Acetic acid (acetate)NegativeCalcific deposits (calcific tendinitis, myositis ossificans)
LidocainePositiveLocal anesthesia
SalicylateNegativePain and inflammation
IodineNegativeScar tissue and adhesions (sclerolytic)
HyaluronidasePositiveEdema
Calcium chloridePositiveMuscle spasm
Tap waterEither (alternating)Hyperhidrosis

EMG biofeedback

Surface electromyographic biofeedback converts the electrical activity of muscle into a visual or auditory signal, so the patient can see and hear contraction or relaxation. It does not stimulate the muscle. For uptraining a weak muscle, the gain (sensitivity) is set high so that small signals register, with electrodes often placed farther apart to sample more motor units, and the threshold is raised as the patient improves. For downtraining or relaxation of an overactive muscle (for example upper trapezius guarding or a high tone pelvic floor), electrodes are placed close together over the target, and the patient tries to keep the signal below a threshold that is gradually lowered. Biofeedback is useful in pelvic floor training, after knee surgery to restore quadriceps activation, in stroke rehabilitation and for postural muscle relaxation.

Safety in electrical stimulation

Contraindications (do not apply)Precautions (apply with care)
Over or near a demand type pacemaker or implanted defibrillator, or across the chest in unstable arrhythmiaImpaired sensation or impaired cognition or communication
Over the carotid sinus (can trigger bradycardia and hypotension)Skin irritation or open wounds (except when treating the wound)
Over the pregnant abdomen or low back (TENS for labor pain is an accepted exception)Cardiac disease, uncontrolled hypertension or hypotension
Over a known or suspected DVT or thrombophlebitisAreas of recent fracture where contraction could displace fragments
Over active malignancyPatients with seizure disorders (avoid head and neck)
Over the anterior neck (laryngeal and pharyngeal muscles), the eyes, or transcranially except in specialized protocolsAreas of excess adipose tissue, which raise the current needed
Over areas of active bleedingOver the trunk in a patient with an implanted stimulator
Board tip. For iontophoresis, remember three items: direct current, like repels like (dexamethasone and acetic acid under the negative electrode, lidocaine under the positive), and dose = current × time (40 mA·min is typical). For NMES, remember 35 to 50 pps and a long rest (about 1:3 to 1:5) at first.
Case. Two weeks after total knee arthroplasty, a 66 year old woman cannot perform a straight leg raise without a 20 degree extensor lag. Her voluntary quadriceps contraction is weak despite good effort, and her pain is controlled.
Reasoning: The problem is arthrogenic inhibition of the quadriceps, not lack of effort, and the best evidence supported adjunct is NMES. Choose about 35 to 50 pps, a phase duration of about 250 to 400 µs, a 1:3 to 1:5 on:off cycle, a 2 second ramp and the highest tolerated intensity, with the patient attempting a voluntary contraction during each stimulus. Conventional TENS would reduce pain but not strengthen, and HVPC is used mainly for wounds and edema. Safety point: check for signs of DVT (calf swelling, warmth, tenderness) before stimulating the lower limb and inspect the incision.
Key point

Set stimulation by goal: short phases and high rates at sensory level for gate control pain relief, low rates at motor level for opioid mediated relief, 35 to 50 pps with long rests for strengthening, and DC for iontophoresis with like charges repelling. Small or close electrodes concentrate and superficialize current. Never stimulate over a pacemaker, the carotid sinus, a DVT, a malignancy or the pregnant uterus.

Section 3Mechanical modalities

Spinal traction

Traction applies a distractive force to separate joint surfaces, reduce pressure on discs and nerve roots, stretch soft tissue and reduce muscle guarding. It may be mechanical, manual, positional or self applied, and static (sustained) or intermittent. Intermittent traction is often more comfortable; static traction is often chosen for disc protrusion, where sustained force allows gradual disc unloading. Evidence supports traction mainly for subgroups: cervical radiculopathy combined with exercise and manual therapy, and lumbar radicular pain with signs of nerve root compression, especially when symptoms peripheralize with extension or the crossed straight leg raise is positive.

Cervical traction is usually applied supine with a head halter or occipital wedge. The neck is flexed about 20 to 30 degrees to open the posterior elements and intervertebral foramina of the lower cervical spine; a more neutral position (0 to 5 degrees) targets the upper cervical region. An occipital harness avoids pressure on the temporomandibular joints. Lumbar traction uses a thoracic and pelvic harness on a split table, which eliminates the friction of the lower half of the body (roughly half of body weight), so less force is needed. Supine hook lying flexes the lumbar spine and opens the posterior elements and foramina; prone with neutral lumbar alignment may suit a patient whose symptoms improve with extension.

GoalCervical force (commonly taught)Lumbar force (commonly taught)
Initial treatment, muscle relaxation, disc unloadingAbout 3.5 to 4.5 kg (8 to 10 lb), or about 7 to 10% of body weightAbout 25% of body weight
Joint distraction (separation of vertebrae)About 9 to 13.5 kg (20 to 30 lb)About 50% of body weight
Typical timeAbout 10 to 20 minutes (shorter for disc protrusion)About 10 to 20 minutes (shorter for disc protrusion)
Intermittent cycleFor example 30 to 60 seconds on, 10 to 30 seconds off; off force about 50% of on forceSimilar ratios

Sources differ; remember that cervical forces are small (start near 4 kg, never above about 13.5 kg) and that lumbar separation needs about half of body weight. Contraindications: spinal instability (including atlantoaxial instability in rheumatoid arthritis or Down syndrome), acute injury or inflammation, fracture, spinal malignancy or infection, spinal cord compression, osteoporosis (relative for mechanical force), vertebral artery compromise, pregnancy (lumbar), uncontrolled hypertension and conditions in which movement is undesired. Precautions: TMJ problems and dentures (cervical halter), claustrophobia, respiratory or cardiac problems that limit supine lying or harness pressure, and hiatal hernia or aortic aneurysm under the thoracic harness. If symptoms peripheralize during traction, reduce the force or stop.

Traction force for a 70 kg patient (commonly taught values) 010 kg20 kg30 kg40 kg Cervical, initialand relaxation Cervical jointseparation Lumbar, initial(25% body weight) Lumbar separation(50% body weight) About 4 kg (8 to 10 lb) 9 to 13.5 kg (20 to 30 lb) About 17.5 kg 35 kg Lumbar values assume a split table; without one, friction absorbs much of the force.
Figure 12.3 Cervical traction uses small absolute forces, while lumbar traction is scaled to body weight. The lighter band on the cervical separation bar shows the 9 to 13.5 kg range.

Compression

External compression reduces edema by raising interstitial hydrostatic pressure, aids venous and lymphatic return and shapes residual limbs. Options include bandages (short stretch for lymphedema and venous insufficiency, long stretch elastic for acute injury support), garments (graduated compression stockings and sleeves, greatest pressure distally) and intermittent pneumatic compression (IPC). Commonly taught IPC pressures are about 30 to 60 mm Hg for the upper limb and 40 to 80 mm Hg for the lower limb, kept below diastolic blood pressure, with inflation and deflation cycles chosen for comfort (for example 3:1 on:off), for about 1 to 3 hours per day for edema; the limb is elevated during treatment. IPC is also used to prevent DVT in surgical patients who cannot take anticoagulants. Gradient compression garments are commonly grouped as about 15 to 20 mm Hg (mild), 20 to 30 mm Hg (moderate, common for venous disease), 30 to 40 mm Hg (firm, lymphedema and venous ulcers) and higher.

Before compressing a lower limb, check arterial status with the ankle brachial index: about 1.0 to 1.3 is normal, below about 0.9 indicates peripheral arterial disease, below about 0.8 calls for reduced or modified compression, and below about 0.5 contraindicates compression; values above 1.3 suggest noncompressible, calcified vessels (common in diabetes) and need further testing. Contraindications to compression: acute DVT (until anticoagulated and cleared), severe arterial insufficiency, acute pulmonary edema or decompensated heart failure, acute local infection, fracture or acute trauma, and, for IPC, a malignancy in the area as a relative contraindication.

Continuous passive motion

A CPM device moves a joint passively through a set arc. Evidence shows little long term benefit after uncomplicated TKA, and routine use is not recommended, though it may follow cartilage repair or joint release. When used, the arc is increased about 5 to 10 degrees per day, aligned to the anatomic axis, and knee extension must be preserved.

Hydrotherapy and aquatic therapy

Water has properties the therapist exploits. Buoyancy (Archimedes principle) is an upward force equal to the weight of displaced water; it assists movement toward the surface, resists movement away from it and unloads joints. Approximate weight bearing at different immersion levels: neck (C7) about 10% of body weight, xiphoid about 25 to 35%, and waist or ASIS about 50%. Hydrostatic pressure (Pascal law) increases with depth, assisting venous return and reducing edema; on immersion to the neck, central blood volume and cardiac preload rise and vital capacity falls slightly, so patients with heart failure or severe lung disease need caution. Viscosity and turbulence provide resistance that increases with speed and frontal area, so resistance is self graded. Specific heat and thermal conductivity make water efficient at transferring heat.

Water temperatureApproximate rangeTypical use
Cold0 to 27 °C (32 to 80 °F)Acute inflammation of distal limbs
Tepid27 to 33.5 °C (80 to 92 °F)Vigorous aquatic exercise
Thermoneutral33.5 to 35.5 °C (92 to 96 °F)Open wounds, patients with sensory or cardiac issues, spasticity
Warm35.5 to 37 °C (96 to 99 °F)Therapeutic pools, relaxation, arthritis
Hot37 to 40 °C (99 to 104 °F)Limb immersion for stiffness and pain; avoid for full body immersion

Whirlpools are no longer recommended for routine wound care (cross contamination, maceration, dependent edema); pulsed lavage with suction has largely replaced them. Contraindications to pool therapy: fever, infection or uncovered open wounds, unmanaged incontinence, uncontrolled seizures, unstable cardiac status, vital capacity below about 1 L and severe fear of water. Keep water cooler for multiple sclerosis.

Board tip. Water depth sets weight bearing: about 10% at neck depth, 25 to 35% at the xiphoid and 50% at the waist. A patient who is limited to partial weight bearing can often begin gait training in a chest deep pool well before land walking at the same load.
Case. A 58 year old man with chronic venous insufficiency and leg edema is referred for intermittent pneumatic compression. He has diabetes, absent dorsalis pedis pulses and an ankle brachial index of 0.45.
Reasoning: An ABI below about 0.5 indicates severe arterial disease; compression would further reduce arterial inflow and could cause tissue necrosis. The best action is to withhold compression and contact the physician for vascular evaluation, while using elevation within comfort and skin care. Applying IPC at a lower pressure, or applying a 30 to 40 mm Hg stocking, are the tempting wrong answers. Safety point: in diabetes an ABI above 1.3 can falsely reassure, because calcified arteries resist cuff compression, so toe pressures may be needed.
Key point

Traction is a subgroup intervention: small fixed forces for the cervical spine with about 20 to 30 degrees of flexion, and body weight scaled forces on a split table for the lumbar spine. Compression requires an arterial check first, with an ABI below about 0.5 ruling it out. CPM is no longer routine after TKA. Water unloads the body by depth, resists by speed and supports venous return through hydrostatic pressure.

Section 4Assistive devices, wheelchairs and transfers

Choosing an ambulatory device

Assistive devices widen the base of support, unload a painful or weak limb, and improve balance. In general, stability and weight unloading increase in this order: single point cane, quad cane (small then large base), hemi walker, forearm crutches, axillary crutches, standard walker, and parallel bars, while the speed and ease of use for community walking decrease. A standard (pickup) walker is the most stable but produces a slow, interrupted gait; a front wheeled walker allows a more continuous step pattern and is often preferred for patients with parkinsonism or limited upper limb strength; a four wheeled walker (rollator) with hand brakes and a seat suits patients who need endurance support but have adequate balance. Axillary crutches allow non weight bearing but require good upper body strength and balance; forearm crutches suit long term users such as those with paraplegia or spina bifida. A cane is held in the hand opposite the affected limb, which shifts the center of mass toward the cane and reduces the moment of the hip abductors on the affected side; a cane can unload the opposite limb by about 10 to 20%.

DeviceHeight fittingAdditional checks
CaneTop of handle at the greater trochanter or the distal wrist crease with the arm hanging relaxedElbow flexed about 20 to 30 degrees; tip about 15 cm (6 in) lateral to the fifth toe
Axillary crutchesTop about 5 cm (2 to 3 finger widths) below the axilla with the tips about 5 cm lateral and 15 cm anterior to the toesHandgrip at the wrist crease, elbow flexed about 20 to 30 degrees; weight on the hands, never on the axilla (radial nerve compression)
Forearm crutchesHandgrip at the wrist creaseCuff on the proximal forearm about 2.5 to 4 cm below the olecranon; elbow flexed about 20 to 30 degrees
WalkerHandgrips at the wrist crease or greater trochanterElbow flexed about 20 to 30 degrees; patient steps into the walker, not behind it

Gait patterns

  • Two point (with a cane or with bilateral crutches): the device and the opposite limb move together, then the other limb. With a cane in the right hand for a weak left limb, the cane and left foot advance together.
  • Three point (non weight bearing or partial weight bearing): both crutches (or the walker) and the involved limb advance together, then the uninvolved limb steps through. A modified three point pattern allows partial weight bearing on the involved limb.
  • Four point (slow, stable, bilateral involvement): right crutch, left foot, left crutch, right foot, so three points are always in contact.
  • Two point with bilateral crutches: right crutch with left foot, then left crutch with right foot; faster than four point and closer to normal reciprocal gait.
  • Swing to and swing through: both crutches advance, then both legs swing to (or past) the crutches; used in paraplegia with KAFOs. Swing through is the fastest crutch gait.

Weight bearing status determines the pattern: non weight bearing (no contact), toe touch or touchdown (contact for balance only), partial (a stated percentage or amount, trained with a scale), weight bearing as tolerated, and full. Patients who are non weight bearing on a lower limb and have poor balance or limited upper limb strength usually need a walker rather than crutches.

Stairs, curbs and guarding

The rule for stairs is "up with the good, down with the bad." Ascending, the uninvolved limb leads, followed by the involved limb and the device; descending, the device and the involved limb lead, followed by the uninvolved limb. With a handrail, the patient holds the rail with one hand and both crutches (or the cane) in the other. The guarding therapist stands behind and slightly to the involved side during level gait, behind and below the patient when ascending stairs, and in front of and below the patient when descending, always using a gait belt. If a patient begins to fall, the therapist guides the patient toward the therapist's body or lowers them to the floor rather than trying to hold them upright.

BCDE A Seat width (front view)Widest hip or thigh width + 5 cm (2 in) B Seat depthPosterior buttock to popliteal fossaminus about 5 cm (2 in) C Seat heightHeel to popliteal fold + 5 cm; footplateat least 5 cm (2 in) above the floor D Back heightSeat to axilla minus about 10 cm (4 in);lower for active self propellers E Armrest heightSeat to olecranon, elbow at 90 degrees,plus about 2.5 cm (1 in)
Figure 12.4 Wheelchair measurement. Each dimension protects a specific tissue: width and depth prevent pressure on the greater trochanters and popliteal fossa, seat height keeps the footplate clear of the floor, and armrest height supports the shoulders without elevating them.

Wheelchair measurement and seating

Measurements are taken with the patient seated on a firm surface in the posture they will use. A seat that is too wide makes propulsion difficult and encourages leaning and scoliosis; too narrow causes pressure on the greater trochanters. A seat that is too deep presses into the popliteal fossa and pulls the pelvis into a posterior tilt (sacral sitting); too shallow increases pressure under the ischial tuberosities. A seat that is too high makes the chair hard to propel and to fit under tables; too low raises the knees and loads the ischial tuberosities. A standard adult chair is about 46 cm (18 in) wide, 41 cm (16 in) deep and 50 cm (19.5 to 20 in) high from the floor; a hemi height chair is lower (about 43 to 45 cm, 17 to 17.5 in) so a patient with hemiplegia can propel with the uninvolved foot and hand.

Ultralight rigid frames with adjustable axles suit active users; moving the rear axle forward eases propulsion and wheelies but reduces backward stability, so anti tip bars help. Elevating leg rests manage edema but are contraindicated with knee flexion contractures. Tilt in space rotates the whole seat backward, redistributing pressure without shear or triggering extensor spasm; recline opens the hip angle, which helps catheterization and orthostatic hypotension but creates shear. Power mobility suits patients who cannot propel functionally, such as C4 tetraplegia with sip and puff or head array controls. At risk patients need a pressure redistribution cushion and weight shifts at least every 15 to 30 minutes, held about 1 to 2 minutes.

Wheelchair skills and accessibility

To go up a curb, the user pops the casters up, then pushes the rear wheels up; going down, rear wheels go first (or a controlled wheelie for skilled users). Commonly tested accessibility values: ramp slope no steeper than 1:12, ramp width at least 36 in (91 cm), level landings 60 in (152 cm) long at each end and after every 30 in (76 cm) of rise, handrails when rise exceeds 6 in (15 cm), doorway clear width at least 32 in (81 cm), and a 60 in (152 cm) turning circle.

Transfers and bed mobility

Before a transfer, lock the brakes, remove the armrest and footrest on the transfer side, angle the chair about 30 to 45 degrees to the target, and apply a gait belt. A stand pivot transfer moves toward the stronger side; a sliding board transfer suits patients with good sitting balance who cannot stand; a depression transfer needs strong shoulder depressors and triceps; and a mechanical lift is used for patients who cannot assist. The therapist keeps a wide base, neutral spine and the load close, and pivots with the feet. Assistance levels: independent, modified independent, supervision, contact guard, minimal assist (patient does 75% or more), moderate (50 to 74%), maximal (25 to 49%) and dependent (less than 25%).

Board tip. Guard on the involved side, behind on level ground and stairs up, in front and below on stairs down. The cane goes in the hand opposite the weak or painful leg and moves with it. On stairs: up with the good, down with the bad.
Case. A 72 year old woman with a painful left hip osteoarthritis uses a cane in her left hand and walks with a marked lateral lean to the left. She wants to climb the three stairs at her front door, which have a rail on the right going up.
Reasoning: The cane belongs in the right hand, opposite the painful left hip, so that it shares load with the left limb and reduces the abductor force needed on the left; correcting the side should reduce her compensatory trunk lean. Fit the cane at the wrist crease with 20 to 30 degrees of elbow flexion. On the stairs going up, she holds the right rail and carries the cane in the left hand (or holds both rail and cane on the same side), steps up with the right leg first, then brings the left leg and cane; coming down, the cane and left leg lead. The therapist guards from behind and below going up and in front and below going down. Safety point: check footwear and lighting and add a second rail if possible.
Key point

Fit every device to the wrist crease with 20 to 30 degrees of elbow flexion, keep axillary crutches about 5 cm below the axilla, put a cane opposite the involved limb, and pick a gait pattern that matches weight bearing status. Wheelchair dimensions protect tissue and posture, tilt redistributes pressure without shear, and accessibility rests on a 1:12 ramp and a 32 in doorway. Transfers go toward the stronger side with brakes locked and a gait belt on.

Section 5Orthotics and prosthetics

Preprosthetic care and the residual limb

Prosthetic success starts with the residual limb. Goals are wound healing, edema control, shaping into a cylinder (transfemoral) or tapered form (transtibial), desensitization, contracture prevention, strengthening and single limb mobility. Shaping uses elastic bandages wrapped in a figure of eight pattern with greater pressure distally and no circular turns that could act as a tourniquet, rewrapped every 4 to 6 hours, or a shrinker sock, or a rigid removable dressing for transtibial amputation. Contracture prevention is critical: transfemoral limbs tend toward hip flexion, abduction and external rotation, and transtibial limbs toward knee flexion. Patients lie prone for periods each day, avoid pillows under the residual limb or between the thighs, avoid prolonged sitting with the knee flexed, and use a board to keep the knee extended in the wheelchair after transtibial amputation. Phantom sensation is common and normal; phantom pain may respond to mirror therapy, desensitization and medication.

Energy cost rises with level: commonly quoted increases are about 10 to 20% for unilateral transtibial and about 60 to 70% for transfemoral amputation (sources vary), so the most distal level that heals is preferred, and vascular patients need cardiac monitoring.

Prosthetic components

Medicare functional levels (K levels) guide prescription: K0 no ability to ambulate or transfer safely with a prosthesis; K1 household ambulator at fixed cadence on level surfaces; K2 limited community ambulator who can manage curbs, stairs and uneven surfaces; K3 community ambulator with variable cadence; K4 exceeds basic ambulation with high impact or stress (children, active adults, athletes).

ComponentMain optionsTypical user
Transtibial socketPatellar tendon bearing (loads the patellar tendon, medial tibial flare, pretibial muscles and popliteal area) or total surface bearing (spreads load across the whole limb with a gel liner)Most transtibial users; total surface bearing is now common
Transfemoral socketQuadrilateral (ischial tuberosity sits on a posterior shelf, narrow anteroposterior dimension) or ischial containment (narrow mediolateral dimension, ischium inside the socket for better femoral adduction and pelvic stability)Ischial containment is now preferred for most
SuspensionPin lock liner, suction or vacuum, sleeve, supracondylar cuff (transtibial), Silesian belt or hip joint and belt (transfemoral)Chosen for limb shape, hand function and activity
KneeSingle axis with manual lock (most stable), weight activated stance control, polycentric (shortens in swing, stable), fluid controlled (hydraulic or pneumatic, variable cadence), microprocessorManual lock for K1; fluid or microprocessor for K3 and K4
FootSACH (solid ankle cushion heel), single axis, multiaxial (uneven ground), dynamic response or energy storingSACH or single axis for K1; dynamic response for K3 and K4

In a transtibial socket, pressure tolerant areas are the patellar tendon, medial tibial flare, pretibial muscles, popliteal fossa (moderate) and the shaft of the fibula; pressure sensitive areas are the fibular head (common fibular nerve), the tibial crest and tubercle, the distal tibia and fibula, and the hamstring tendons. Skin is inspected after every wearing session; redness that persists longer than about 20 to 30 minutes after removal means excessive pressure. Sock ply is adjusted as the limb volume changes during the day: a limb that shrinks needs more ply.

Prosthetic gait deviations

The exam typically gives a deviation and asks for the most likely cause, which may be in the prosthesis or in the patient. The approach is to ask what the deviation achieves (often clearing a limb that is functionally too long, or stabilizing a knee that might buckle) and then which alignment or impairment explains it.

Stance (about 60% of the cycle)Swing (about 40%) 0%60%100% Lateral trunk bending toward prosthesis Short prosthesis, weak abductors, poor lateral wall support, pain at the distal lateral femur Abducted gait (wide base) Prosthesis too long, high medial wall, abduction contracture Knee instability (buckling) Knee axis too anterior, foot too dorsiflexed, weak hip extensors, hip flexion contracture Foot rotation at heel strike Heel cushion or plantar flexion bumper too stiff Excessive lumbar lordosis Hip flexion contracture, weak hip extensors, too little initial socket flexion Circumduction Long prosthesis, knee too stiff or locked, poor suspension Vaulting (sound side) Long prosthesis, poor suspension, fear of knee flexion Medial or lateral whip Knee axis rotated, socket donned rotated Excessive heel rise Too little knee friction Terminal swing impact Too little friction, strong extension aid, forceful hip flexion
Figure 12.5 Transfemoral prosthetic gait deviations organized by phase. Many swing deviations (circumduction, vaulting) are ways to clear a limb that is functionally too long; many stance deviations reflect alignment, socket fit or hip muscle weakness and contracture.
Transtibial deviationWhenCommon prosthetic causes
Excessive knee flexion (knee buckles forward)Early stanceFoot set too far anterior or too dorsiflexed, heel cushion too stiff, socket set in excessive flexion; also knee flexion contracture or weak quadriceps
Insufficient knee flexion (knee stays extended, hyperextension)Early stanceFoot set too far posterior or too plantarflexed, heel cushion too soft; also quadriceps weakness or pain avoidance
Early knee flexion ("drop off")Late stanceFoot too far posterior or dorsiflexed, keel too short
Delayed knee flexion ("walking uphill")Late stanceFoot too far anterior or plantarflexed, keel too long
PistoningSwingLoose socket or inadequate suspension; limb volume loss

Upper limb prostheses

Body powered upper limb prostheses use a figure of eight harness and cable; scapular protraction and humeral flexion operate the terminal device (and flex an unlocked transhumeral elbow). A voluntary opening device is closed at rest with grip set by bands; a voluntary closing device lets the user grade grip. Body powered devices are durable, light and give harness feedback; myoelectric devices use surface electrodes and motors for stronger grip and better cosmesis but are heavier and costlier. Early fitting improves acceptance.

Lower limb orthoses

OrthosisWhat it doesTypical indication
Posterior leaf spring AFOFlexible posterior upright lifts the foot in swingIsolated dorsiflexor weakness (foot drop) without significant spasticity or mediolateral instability, as in common fibular nerve palsy
Solid ankle AFOBlocks all ankle motion; controls the foot in all planesSignificant spasticity, mediolateral ankle instability, combined dorsiflexor and plantarflexor weakness
Hinged (articulated) AFO with plantarflexion stopAllows dorsiflexion, limits plantarflexionFoot drop with mild spasticity, genu recurvatum control in stroke, allows smoother stair and sit to stand motion
Floor reaction (ground reaction) AFOAnterior shell at the proximal tibia creates a knee extension moment in stanceCrouch gait with weak quadriceps or plantarflexors (for example in cerebral palsy or spina bifida)
Supramalleolar and molded heel cup foot orthosesControl subtalar and midfoot alignmentFlexible flatfoot, mild pronation in children
KAFOControls knee and ankle; knee joints may lock in extension (drop locks, bail locks) or use stance controlParaplegia (low thoracic and high lumbar), polio with quadriceps weakness
Reciprocating gait orthosis (RGO)Bilateral HKAFOs linked by a cable so hip flexion on one side extends the otherHigher level paraplegia, spina bifida
Knee orthosesFunctional braces for ligament deficiency, hyperextension blocks for genu recurvatum, patellar stabilizersACL deficiency, recurvatum, patellar instability

Shoe modifications include a metatarsal pad placed just proximal to the metatarsal heads to unload them in metatarsalgia, a metatarsal bar or rocker bottom sole to reduce forefoot motion and pressure (hallux rigidus, diabetic forefoot ulcer risk), a heel lift for leg length difference or Achilles tendinopathy, medial wedges for pronation and lateral wedges for supination, and an extra depth shoe with custom insoles for the insensate diabetic foot.

Spinal and upper limb orthoses

Cervical orthoses range from a soft collar (a reminder) through rigid collars and cervicothoracic orthoses to the halo vest, the most restrictive (never lift the patient by the halo). A hyperextension TLSO limits flexion after stable thoracolumbar compression fractures. A custom TLSO treats idiopathic scoliosis of about 25 to 45 degrees in skeletally immature patients; curves above about 45 to 50 degrees usually go to surgical consultation. Upper limb orthoses include a resting hand orthosis (rheumatoid arthritis, stroke), a wrist cock up for radial nerve palsy and carpal tunnel syndrome, a thumb spica for de Quervain tenosynovitis and CMC arthritis, and a tenodesis orthosis for C6 to C7 tetraplegia.

Board tip. Match AFO to impairment: isolated foot drop without spasticity, posterior leaf spring; spasticity or mediolateral instability, solid AFO; crouch gait with weak quadriceps or plantarflexors, floor reaction AFO. For a transfemoral prosthesis, swing deviations such as circumduction and vaulting usually mean the prosthesis is functionally too long.
Case. A 61 year old man with a recent transfemoral amputation from vascular disease uses an ischial containment socket and a single axis knee. During training he vaults on the sound limb throughout swing of the prosthesis. Limb length measured in standing is equal.
Reasoning: Vaulting raises the body so a prosthesis that is functionally too long can clear the floor. With measured length equal, look for causes that make the limb functionally long in swing: inadequate suspension (the limb drops in the socket), excessive knee friction or a knee that does not flex because of the patient's fear of buckling. The best next step is to check suspension and knee friction with the prosthetist and train controlled knee flexion during swing; shortening the pylon is the tempting wrong answer when length is already equal. Safety point: vaulting raises energy cost and stresses the sound limb, which in a patient with vascular disease is the limb most at risk for the next ulcer or amputation, so inspect the sound foot every session.
Key point

Prosthetic outcome depends on residual limb shaping and contracture prevention, components matched to K level, and socket loading on pressure tolerant areas. Trace deviations to their purpose: clearing a long limb in swing, stabilizing a knee in stance, or compensating for weak or contracted hip muscles. Choose orthoses by the impairment they must control, from posterior leaf spring AFOs for simple foot drop to halo vests for unstable cervical fractures.

The chapter in one breath

  • Superficial heat and cold reach about 1 to 2 cm; 1 MHz ultrasound reaches about 2 to 5 cm and 3 MHz about 1 to 2 cm with faster heating.
  • Continuous ultrasound heats (mild, moderate, vigorous); pulsed ultrasound is used for nonthermal effects; treat two to four times the ERA.
  • No heat on acute, bleeding, clotting, malignant or insensate tissue; no cold with cold urticaria, cryoglobulinemia, cold hemoglobinuria or Raynaud phenomenon.
  • Conventional TENS is high rate, short phase, sensory level (gate control); low rate TENS is motor level and opioid mediated.
  • NMES for strengthening uses about 35 to 50 pps with a 1:3 to 1:5 on:off ratio at first; it is best supported after TKA and ACL reconstruction.
  • Iontophoresis uses DC, like repels like, and a dose of current times time (often 40 mA·min).
  • Cervical traction uses small forces with 20 to 30 degrees of flexion; lumbar separation needs about 50% of body weight on a split table.
  • Check the ABI before compression (below about 0.5 contraindicates it); IPC stays below diastolic pressure.
  • Water unloads by depth: about 10% at the neck, 25 to 35% at the xiphoid and 50% at the waist.
  • Fit devices to the wrist crease with 20 to 30 degrees of elbow flexion; cane opposite the involved limb; up with the good, down with the bad.
  • Wheelchair seat width is hip width plus 5 cm, depth is buttock to popliteal fossa minus 5 cm, and ramps are 1:12.
  • Prosthetic deviations reflect a long or poorly suspended limb, alignment errors or hip weakness and contracture; AFOs are chosen by the impairment they control.

Words worth knowing

TermWhat it means
ConversionProduction of heat within tissue from another energy form, such as ultrasound or diathermy.
Effective radiating area (ERA)The part of an ultrasound transducer face that actually emits energy; the treatment area should be two to four times it.
Beam nonuniformity ratioRatio of peak to average ultrasound intensity; lower values mean more even energy and fewer hot spots.
Duty cycleThe percentage of time energy is delivered; 100% is continuous and 20% is a common pulsed setting.
PhonophoresisUse of ultrasound to enhance absorption of a topical medication.
Inductive diathermyShortwave diathermy that uses a coil to induce currents, preferentially heating deep, well perfused muscle.
Phase durationThe time of one phase of a pulse; longer durations recruit motor and pain fibers.
RheobaseThe lowest current amplitude that produces a response at a long pulse duration.
ChronaxieThe pulse duration needed to excite tissue at twice the rheobase; it rises after denervation.
Gate control theoryThe idea that large fiber sensory input inhibits pain transmission in the dorsal horn, explaining conventional TENS.
Interferential currentTwo medium frequency currents that intersect in tissue to create a lower beat frequency, allowing comfortable deep stimulation.
Russian currentA 2,500 Hz alternating current delivered in 50 bursts per second for muscle strengthening.
IontophoresisTransdermal delivery of charged medication ions by direct current, using like charge repulsion.
Intermittent pneumatic compressionA sleeve that inflates and deflates cyclically to reduce edema or prevent DVT.
Ankle brachial indexAnkle systolic pressure divided by arm systolic pressure; below about 0.9 suggests arterial disease.
Hydrostatic pressurePressure exerted by water that increases with depth, aiding venous return and reducing edema.
Tilt in spaceA wheelchair feature that rotates the whole seat backward without changing hip and knee angles, relieving pressure without shear.
K levelA functional classification (K0 to K4) used to match prosthetic components to a patient's ambulation potential.
Patellar tendon bearing socketA transtibial socket that loads pressure tolerant areas, especially the patellar tendon.
Ischial containment socketA transfemoral socket with a narrow mediolateral shape that encloses the ischium for pelvic stability.
VaultingRising on the toes of the sound limb during prosthetic swing to clear a functionally long prosthesis.
PistoningVertical movement of the residual limb within the socket during gait, from a loose fit or poor suspension.
Floor reaction AFOAn ankle foot orthosis with an anterior tibial shell that creates a knee extension moment in stance.
Tenodesis orthosisA wrist driven hand orthosis that uses active wrist extension to close the fingers, used in C6 to C7 tetraplegia.

Check yourself

A therapist wants to increase the extensibility of a thickened patellar tendon before cross friction and stretching. Which ultrasound frequency and duty cycle are best?
Answer. 3 MHz continuous (100% duty cycle). The patellar tendon is superficial, 3 MHz is absorbed within about 1 to 2 cm and heats faster, and continuous output is needed for thermal effects.
Which condition is a contraindication to a cold pack: osteoarthritis, cryoglobulinemia, acute ankle sprain or muscle spasm?
Answer. Cryoglobulinemia. Cold causes abnormal serum proteins to precipitate, impairing circulation. The other conditions are common indications for cold.
Describe parameters for conventional TENS for postoperative incision pain.
Answer. High rate (about 80 to 150 pps), short phase duration (about 50 to 100 µs), sensory level intensity producing comfortable tingling without contraction, with electrodes on either side of the incision. It works through gate control and can be used for long periods.
Dexamethasone is ordered for iontophoresis at the lateral elbow. Under which electrode does it go, and what dose is typical?
Answer. Under the negative electrode (cathode), because dexamethasone sodium phosphate is negatively charged and like charges repel. A typical dose is about 40 mA·min, for example 4 mA for 10 minutes.
A patient weighing 80 kg with lumbar radiculopathy is set up for mechanical traction on a split table. What force is commonly used to achieve vertebral separation?
Answer. About 50% of body weight, or about 40 kg. Lower forces (about 25% of body weight) are used at the first session or for muscle relaxation.
A patient needs aquatic gait training with about 50% weight bearing. To what depth should the water reach?
Answer. About waist (ASIS) level. Xiphoid depth reduces weight bearing to about 25 to 35% and neck depth to about 10%.
A patient who is non weight bearing on the right leg has good balance and strong arms. Which gait pattern and device are appropriate, and how does the patient go up stairs?
Answer. Axillary crutches with a three point (non weight bearing) gait. Going up stairs, the left (uninvolved) leg steps up first, then the crutches follow with the right leg held off the floor: up with the good, down with the bad.
The seat of a wheelchair presses into the back of the patient's knees and the patient slides into a posterior pelvic tilt. Which dimension is wrong?
Answer. The seat is too deep. Seat depth should equal posterior buttock to popliteal fossa minus about 5 cm (2 in), leaving clearance behind the knee.
A patient with a transfemoral prosthesis leans toward the prosthetic side during stance. Give two prosthetic and one patient related cause.
Answer. Prosthetic causes include a prosthesis that is too short and inadequate lateral wall support of the femur. Patient related causes include weak hip abductors, a short residual limb, an abduction contracture or pain at the distal lateral residual limb.
A patient has foot drop from a common fibular nerve injury with no spasticity and a stable ankle. Which orthosis is most appropriate?
Answer. A posterior leaf spring AFO, which lifts the foot in swing and allows some plantarflexion at loading. A solid AFO is reserved for spasticity, instability or combined weakness.
Chapter 13 · Non Systems

Safety, Professional Responsibilities and Evidence

Every NPTE form carries questions that have nothing to do with a joint or a nerve: which mask to wear, who may write a discharge summary, what to do when a patient discloses abuse, and whether a test with a likelihood ratio of 8 is worth using. These items are often the easiest points on the exam once the rules are clear, and they are the rules that keep patients safe and keep a license intact. This chapter covers safety and protection, professional and legal responsibilities, research statistics, and the craft of turning evidence into teaching a patient can use.

By the end of this chapter you can

  • Choose the correct standard and transmission based precautions for common infections and put on and remove personal protective equipment in the safe order.
  • Apply sound body mechanics, respond to common clinical emergencies, and follow the principles of restraint and fall prevention policies.
  • Resolve ethical dilemmas with the Code of Ethics and the biomedical principles, and obtain valid informed consent.
  • State what a physical therapist assistant, an aide and a student may and may not do, and how each is supervised.
  • Write defensible documentation and apply the 8 minute rule, medical necessity and the Medicare plan of care rules.
  • Explain practice acts, direct access, HIPAA, mandatory abuse reporting, the ADA and the main payer systems.
  • Rank study designs by level of evidence and identify threats to validity and measures of reliability.
  • Calculate sensitivity, specificity, predictive values, likelihood ratios, MDC and number needed to treat, and interpret the MCID.
  • Use clinical practice guidelines, plain language, teach back and behavior change models to educate patients and promote health.

Section 1Safety and protection

The chain of infection and standard precautions

Infection spreads through a chain: agent, reservoir, portal of exit, mode of transmission, portal of entry and susceptible host. Every precaution breaks a link. Because PTs share equipment (parallel bars, mats, gait belts) across many patients, rehabilitation gyms are a recognized route of spread for MRSA and Clostridioides difficile.

Standard precautions apply to every patient regardless of diagnosis, because infection status is often unknown. They assume that blood, all body fluids, secretions and excretions (except sweat), nonintact skin and mucous membranes may carry pathogens. The core elements are:

  • Hand hygiene before and after every patient contact, after touching the patient's surroundings, before an aseptic task, after removing gloves and after exposure to body fluid. An alcohol based hand rub is preferred when hands are not visibly soiled because it is faster and kills more organisms than soap. Soap and water are required when hands are visibly soiled and after caring for a patient with C. difficile or norovirus, because alcohol does not destroy bacterial spores and is less effective against norovirus. Friction for at least 15 to 20 seconds matters more than the product.
  • PPE matched to the expected exposure: gloves for body fluids, a gown for soiling, mask and eye protection for splashing (wound irrigation, pulsed lavage).
  • Sharps: never recap; use a puncture resistant container; report needlesticks at once.
  • Disinfection of shared equipment between patients.

Transmission based precautions

When a patient is known or suspected to carry an organism that standard precautions alone will not contain, one of three transmission based categories is added on top of standard precautions. The exam expects you to match the organism to the category and the category to the equipment.

CategoryHow it spreadsClassic organismsWhat the PT does
ContactDirect touch or contaminated surfaces and equipmentMRSA, VRE, C. difficile, multidrug resistant gram negative organisms, scabies, lice, impetigo, draining wounds, RSV (contact and droplet)Gown and gloves on entry; dedicated or disinfected equipment; treat in the room when possible; soap and water after C. difficile
DropletLarge particles (larger than 5 micrometers) that travel a short distance, roughly 3 to 6 feetInfluenza, pertussis, Neisseria meningitidis, mumps, rubella, Mycoplasma pneumonia, adenovirusSurgical mask within close range (most policies: on entering the room); patient wears a mask during transport; private room or spatial separation
AirborneSmall particles that stay suspended and move with air currentsTuberculosis, measles (rubeola), varicella (chickenpox) and disseminated herpes zosterFit tested N95 respirator or higher; airborne infection isolation room with negative pressure; door closed; patient wears a surgical mask if transport is unavoidable

Some organisms need more than one category: varicella and disseminated zoster need airborne plus contact precautions, and many institutions add eye protection and contact precautions for novel respiratory viruses. A patient in protective (reverse) isolation, such as one with severe neutropenia (below about 500 neutrophils per microliter), is protected from the clinician: no one with an active infection enters, and hand hygiene is strict.

Donning and doffing personal protective equipment

The order of putting on and removing PPE is tested because errors at removal contaminate the clinician. Donning moves from the item that covers the most body area to the item that must be cleanest: gown, mask or respirator, goggles or face shield, gloves, with the gloves pulled over the gown cuffs. Removal starts with the most contaminated item: gloves, goggles or face shield, gown, mask or respirator, then hand hygiene. An acceptable alternative is to peel off gown and gloves together, rolling the gown inside out.

Donning (putting on): outside the room 1. Gowntie at neck, waist 2. Mask or N95fit check seal 3. Eye protectiongoggles or shield 4. Glovesover gown cuffs Doffing (taking off): most contaminated first 1. Glovesglove to glove 2. Eye protectionby the earpieces 3. Gownroll inside out 4. Mask or N95by the ties 5. Handhygiene Remove gloves, eyewear and gown at the door or in the anteroom. Remove an N95 only after leaving an airborne isolation room and closing the door.
Figure 13.1 Donning runs from the gown to the gloves; doffing starts with the dirtiest item (gloves) and ends with hand hygiene. Notice that the mask goes on second but comes off last.
Board tip. Two hand hygiene traps recur: alcohol rub is the default, but soap and water are required for visible soil, C. difficile and norovirus. Gloves never replace hand hygiene; clean hands after removing them.

Body mechanics and safe patient handling

Lifting injuries among clinicians come from load, distance from the body, twisting and repetition. The principles are simple: keep a wide base of support with one foot ahead of the other; keep the load or the patient close to your center of mass; bend at the hips and knees while keeping the spine near neutral; tighten the trunk before the lift; pivot with the feet instead of twisting the spine; push rather than pull when moving a bed or cart; and raise the bed to roughly waist height for bed level care.

Safe patient handling programs replace manual lifting of dependent patients with mechanical lifts, friction reducing sheets and team lifts; a common guideline caps a manual lift at about 35 pounds of patient weight. Use a snug gait belt for any patient with impaired balance, placed to avoid incisions and tubes. Guard on the patient's weaker or more involved side, slightly behind, and on stairs stand below the patient (behind them going up, in front of them going down).

Emergency response

Recognize the emergency, stop the activity, call for help and begin basic care.

EventRecognizeImmediate PT action
Cardiac arrestUnresponsive, no normal breathing, no pulse within 10 secondsCall a code or 911, start chest compressions (CAB order), get the AED. Adult compressions 100 to 120 per minute, at least 2 inches (5 cm) deep, full recoil, 30 compressions to 2 breaths without an advanced airway
HypoglycemiaBlood glucose below 70 mg/dL; shaky, sweaty, pale, anxious, confused, tachycardicStop exercise; if conscious and able to swallow, give 15 g of fast carbohydrate (4 oz juice, glucose tablets), recheck in 15 minutes, repeat if still low; call for help if unconscious (nothing by mouth)
SeizureTonic clonic activity, loss of awarenessProtect the head, move objects away, do not restrain, put nothing in the mouth, time it, turn to side lying afterward; call EMS if it lasts more than 5 minutes, repeats, or it is a first seizure or injury occurred
Fall during treatmentPatient on the floorDo not lift immediately; check responsiveness, vital signs and for injury (shortened, externally rotated leg suggests hip fracture; neck pain suggests spinal injury); get help and equipment; document and file an incident report
Autonomic dysreflexiaSCI at T6 or above, sudden hypertension, pounding headache, flushing above the lesionSit the patient upright, lower the legs, loosen tight clothing and leg bag straps, check the catheter and bladder, monitor blood pressure, get medical help
FireSmoke or flameRACE: Rescue, Alarm, Contain (close doors), Extinguish or Evacuate. Extinguisher use is PASS: Pull, Aim at the base, Squeeze, Sweep

Stop exercise for warning signs: anginal chest pain, a drop in systolic blood pressure of more than 10 mmHg as workload rises, systolic pressure above about 250 mmHg or diastolic above about 115 mmHg, new arrhythmia, marked dyspnea, dizziness or confusion, pallor or cyanosis, or the patient's request.

Restraints and fall prevention policies

A restraint is any manual method, physical or mechanical device, or drug that restricts a patient's freedom of movement or normal access to the body and that the patient cannot easily remove. Full bed rails, a lap belt the patient cannot release and a fixed chair tray can all count. Restraints may be used only to protect the patient or others when less restrictive measures have failed, never for staff convenience or discipline, by a provider's order that is time limited (orders are not written as needed), with frequent monitoring for circulation, skin, hydration and toileting, and with release and reassessment at set intervals. Restraints do not reliably prevent falls and increase agitation, injury and deconditioning.

Fall prevention policies pair a screening tool with a tailored bundle: low locked bed, call light within reach, nonslip footwear, scheduled toileting and hourly rounding, lighting, alarms where appropriate and medication review. After any inpatient fall, the patient is assessed for injury before being moved, the provider is notified, and an incident report is filed; the incident report is not mentioned in the medical record.

Case. A PT is asked to ambulate a 72 year old man on a medical unit whose door shows contact precautions for C. difficile. He has had diarrhea for two days and needs a gait belt and a rolling walker.
Reasoning: Contact precautions mean a gown and gloves on entry, a dedicated walker and gait belt kept in the room or disinfected with a sporicidal agent, and ambulation in the room or as the facility permits. After removing gloves and gown, the PT must wash with soap and water, because alcohol rub does not kill spores. A mask is tempting but is not required for C. difficile (it is not droplet or airborne). Bringing a shared gym walker in and taking it back out without sporicidal cleaning is the error that spreads the organism.
Key point

Safety questions reward rule recall: standard precautions for everyone, contact, droplet or airborne precautions added by organism, PPE on in the order gown, mask, eyewear, gloves and off starting with gloves, soap and water for spores, a gait belt and close guarding for any balance problem, the least restrictive alternative before any restraint, and a clear sequence for every emergency.

Section 2Professional responsibilities

Ethics: principles and the Code

Ethical questions on the exam present a conflict and ask for the most appropriate action. Six biomedical principles frame the answer. Autonomy is respect for a competent patient's right to make decisions, including the right to refuse treatment. Beneficence is the duty to act for the patient's good. Nonmaleficence is the duty to avoid harm. Justice is fair distribution of care and resources. Veracity is truthfulness. Fidelity is keeping promises and loyalty to the patient, including confidentiality. When principles collide, the exam usually favors the competent patient's informed choice over the clinician's preference, and patient safety over loyalty to a colleague.

The professional Code of Ethics applies these ideas in eight principles (dignity and rights of all, trustworthiness and compassion, accountable judgment, integrity, legal and professional obligations, lifelong learning, sound business practices, and meeting society's health needs); Standards of Ethical Conduct govern the PTA. The Code is a professional standard; a state practice act is law. A licensing board disciplines under the practice act, and a professional association can discipline only its members.

DilemmaPrinciple at stakeBest response
Competent patient refuses therapy after educationAutonomyRespect the refusal, explain consequences, document the education and the refusal, inform the team
Manager asks you to bill a group session as individual careVeracity, justice, legal dutyRefuse; bill only what was provided; report through the compliance channel if it persists
Colleague appears impaired at workNonmaleficenceRemove the colleague from patient care and report to the supervisor
Romantic interest from a current patientIntegrity, boundariesSexual relationships with current patients are always prohibited; transfer care if the boundary cannot be maintained

Informed consent

Informed consent is a process, not a signature. The patient must receive, in understandable language, the nature of the condition, the proposed intervention, its expected benefits, its material risks (those a reasonable person would want to know), reasonable alternatives including no treatment, and the likely outcome of declining. The patient must have capacity to decide and must decide voluntarily. Consent may be withdrawn at any time. New consent is needed for higher risk interventions such as thrust manipulation or internal pelvic floor examination, which also calls for the option of a chaperone.

A minor's parent or guardian consents (the child assents when able). For an adult who lacks capacity, a court appointed guardian or a health care agent named in a durable power of attorney for health care consents. In an emergency, consent is implied.

Supervision of physical therapist assistants, aides and students

The physical therapist alone performs the initial examination and evaluation, establishes the diagnosis, prognosis and plan of care, performs reevaluations, and writes the discharge summary. The physical therapist assistant (PTA) is a licensed or certified clinician who carries out selected interventions within the plan of care, collects data (goniometry, manual muscle testing, vital signs, girth, standardized balance tests), progresses or adjusts an intervention within the limits of the plan, and documents treatment and progress. The PTA may not change the plan of care, may not perform an evaluation or reevaluation, and in many states and practice settings should not perform certain high risk interventions such as spinal and peripheral joint high velocity thrust manipulation or sharp selective debridement. If a patient's status changes, or the patient is not responding, the PTA stops and consults the supervising PT.

States set supervision levels, which vary widely: general supervision (PT reachable by telecommunication, not on site), direct supervision (PT on site and immediately available), and direct personal supervision (PT in the room, within line of sight). Medicare relaxed PTA supervision in private practice to general supervision recently; check current rules.

Aides (rehabilitation technicians) are unlicensed personnel trained on the job. They perform only designated tasks that require no clinical decision making, such as preparing the treatment area, transporting patients and assisting with routine tasks under direct personal supervision by a PT (or by a PTA where state law allows). Students work under supervision of a licensed clinician; for Medicare Part B, the supervising therapist must be present and directing the service for it to be billable, while Part A settings allow somewhat more flexibility.

Physical therapist PT assistant (PTA) Aide or technician Initial examinationEvaluation and diagnosisPrognosis, plan of careChanges the planReevaluationDischarge summaryDelegates and supervisesThrust manipulation,sharp debridement Interventions withinthe plan of careData collection (ROM,MMT, vitals, balance)Progresses within planTreatment notesStops and contacts PTon status changeNo evals, no plan change Prepares equipmentTransports patientsCleans, stocks, filesAssists under directpersonal supervisionNo clinical decisionsNot billed as skilledcare under Medicare Supervision: set by state law and payer, from general to direct personal
Figure 13.2 Who does what. Clinical judgment about the plan of care stays with the physical therapist; the assistant works inside that plan; the aide performs only nonskilled tasks.

Documentation principles

Documentation is the legal record of care, the basis for payment and the communication tool for the team. If it was not documented, it was not done. Errors in a paper record are corrected with a single line through the error, the correction, the date and the clinician's initials; nothing is erased, covered or obliterated. Electronic records use addenda; a late entry is labeled with the current date and time.

An episode includes the initial evaluation with plan of care, daily notes (PT or PTA, often SOAP format), progress reports, reevaluations and the discharge summary. Goals should be measurable, functional and time bound. The ABCD format states the Audience (the patient), the Behavior (the functional task), the Condition (assistance level, device, environment) and the Degree (distance, time, repetitions or accuracy): for example, "The patient will ambulate 150 feet on level indoor surfaces with a single point cane and supervision within 3 weeks, to reach the dining room independently."

Medicare outpatient rules are frequently tested in principle. The PT establishes a plan of care, and a physician or nonphysician practitioner must certify it (signature within 30 days of the initial evaluation is the standard for timeliness), with recertification at least every 90 days or when the plan changes significantly. A progress report written by the PT is required at least once every 10 treatment days. Services must be skilled (requiring the knowledge and judgment of a therapist) and medically necessary, which is why notes describe the clinical reasoning and the patient's response, not merely a list of exercises. Skilled maintenance therapy is covered when a therapist's skill is needed; improvement is not required.

Billing principles

Procedures are billed with CPT codes, and diagnoses are coded with ICD-10-CM. PT evaluation codes are tiered by complexity (low, moderate, high). Many intervention codes are timed in 15 minute units (therapeutic exercise, gait training, manual therapy); others are untimed and billed once per session (unattended electrical stimulation, mechanical traction, evaluations).

Medicare uses the 8 minute rule: add up total timed minutes, and bill a unit for each full 15 minutes, with a remainder of 8 or more minutes counting as one more unit. In practice, 8 to 22 minutes is 1 unit, 23 to 37 minutes is 2 units, 38 to 52 minutes is 3 units, and 53 to 67 minutes is 4 units. When remaining minutes are split across codes, assign the extra unit to the service with the most leftover minutes. Fraud includes billing services not provided, upcoding, unbundling, and billing aide or group time as individual skilled care. An Advance Beneficiary Notice warns the patient before a service Medicare is not expected to cover.

Total timed minutesUnits billed (Medicare)Example split
Under 807 minutes of manual therapy alone is not billable as a timed unit
8 to 22120 minutes therapeutic exercise: 1 unit
23 to 37224 minutes exercise plus 9 minutes gait (33 total): 1 exercise, 1 gait
38 to 52333 minutes exercise plus 7 minutes manual (40 total): 2 exercise, 1 manual (the leftover 7 manual minutes exceed the leftover 3 exercise minutes)
53 to 674Continue adding 15 minutes per unit
Board tip. A PTA may write daily notes and may contribute data to a progress report, but the evaluation, reevaluation, plan of care changes and discharge summary belong to the PT. If an answer has the PTA "reevaluating and updating goals," it is wrong.
Case. A PTA treating a patient 3 weeks after total knee arthroplasty finds new calf swelling, warmth and tenderness, and the patient asks the PTA to just "do the exercises today and see." The plan of care calls for progressive strengthening.
Reasoning: The finding raises concern for deep vein thrombosis, a change in medical status. The PTA should hold the session's exercise, notify the supervising PT and the referring provider per policy, and document the findings. Continuing as planned honors the patient's preference but violates nonmaleficence; modifying the plan of care independently exceeds the PTA's role; massaging the calf could dislodge a clot. Safety comes first, and a medical status change always returns the decision to the PT.
Key point

Professional responsibility questions test whether you protect the patient and stay within scope: respect a competent person's informed choices, obtain real informed consent, keep evaluation and plan of care decisions with the PT, delegate only to the level of training and supervision the law allows, and document and bill exactly what was skilled, necessary and delivered.

Section 3Law and health systems

Practice acts, licensure and liability

Each state (and the District of Columbia and territories) has a physical therapy practice act, a statute that defines physical therapy, sets the scope of practice, establishes requirements for licensure of PTs and for licensure or certification of PTAs, defines supervision, lists grounds for discipline and creates a state board to enforce it. Boards write rules (regulations) that carry out the act. Licensure protects both title and practice; its purpose of licensure is protection of the public, not protection of the profession. Practicing in another state requires that state's license or an interstate compact privilege; telehealth follows the law of the patient's state.

Malpractice (professional negligence) requires four elements: a duty owed to the patient, a breach of the standard of care (what a reasonable PT would do in similar circumstances), causation, and actual damages. Burns from a hot pack without adequate toweling, a fall from an unguarded transfer and a fracture from overly forceful range of motion in a patient with osteoporosis are typical negligence scenarios. Battery is touching without consent; abandonment is ending care without notice or arrangements.

Direct access

Direct access is the patient's ability to see a physical therapist without a physician's referral. All states now allow at least evaluation without referral, but they differ: some allow unrestricted evaluation and treatment, while others limit treatment by days or visits (for example, requiring a referral or provider notification after a set number of days or visits), require specific experience, or exclude certain interventions. Medicare does not require a physician referral for a PT evaluation, but it does require a certified plan of care for payment; many private insurers set their own referral rules. With direct access comes a heightened duty to screen for medical conditions: the PT must recognize red flags, determine whether the problem is within the scope of physical therapy, and refer when it is not.

The decision after screening has three outcomes: treat (within scope, no red flags), treat and refer (within scope but a coexisting problem needs medical attention, such as uncontrolled hypertension found at intake), or refer without treatment (findings suggest a serious condition, such as cauda equina syndrome, which is an emergency).

Privacy and confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects protected health information (PHI): individually identifiable health information in any form, held by covered entities (providers who bill electronically, health plans, clearinghouses) and their business associates. Key rules:

  • PHI may be disclosed without authorization for treatment, payment and health care operations and for mandated reporting, public health and court orders.
  • Other uses, such as marketing or giving information to an employer, require the patient's written authorization.
  • The minimum necessary standard limits most disclosures to the least information needed for the purpose (it does not apply to disclosures to another provider for treatment).
  • Patients may receive a Notice of Privacy Practices, obtain copies of their records and request amendments.

Do not discuss patients in public areas; speak with family only with the patient's agreement (which may be inferred if the patient is present and does not object). Education records in public schools fall under FERPA rather than HIPAA.

Abuse, neglect and exploitation

Physical therapists see patients often, touch them and observe their function, so they are well placed to detect abuse. All states make health care professionals mandated reporters of suspected child abuse, and nearly all impose a duty to report suspected abuse, neglect or exploitation of older adults or vulnerable adults (dependent adults, people with disabilities, residents of long term care). The standard is reasonable suspicion, not proof. The report goes to child protective services, adult protective services or law enforcement as the state specifies, and good faith reporters are protected from liability. The duty is personal (telling a supervisor usually does not discharge it), and the clinician should not investigate or confront the suspected abuser.

Warning signs include injuries that do not fit the history, patterned bruises or burns, injuries of different ages, fractures in nonambulatory infants, untreated pressure injuries or poor hygiene, fear of a caregiver, and unexplained financial changes. For intimate partner violence in a competent adult, reporting laws vary by state and many require reporting only certain injuries; the core response is to screen privately, document carefully, provide safety resources and respect the adult's choices.

Disability law and accessibility

The Americans with Disabilities Act (1990, amended 2008) prohibits discrimination against people with disabilities, defined as a physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having one. Title I covers employment by employers with 15 or more employees and requires reasonable accommodations unless they cause undue hardship. Title II covers state and local government services, including public transportation and public schools. Title III covers public accommodations such as stores, restaurants, hotels and private clinics.

Related laws: Section 504 of the Rehabilitation Act (1973) bars disability discrimination by programs receiving federal funds and underlies 504 plans in schools; the Individuals with Disabilities Education Act (IDEA) provides early intervention (Part C, birth to age 3) and special education with related services such as PT (Part B, ages 3 to 21), covered in Chapter 14.

Home and community accessibility questions use the federal accessibility standards. The numbers below are the commonly tested values.

FeatureStandard
Ramp slopeMaximum 1:12 (1 inch of rise per 12 inches, or 1 foot, of run); 30 inches maximum rise per run
Ramp width and landingsAt least 36 inches clear between handrails; level landing at least 60 inches long at top and bottom and at each change of direction
HandrailsBoth sides when rise exceeds 6 inches; top 34 to 38 inches high; extend 12 inches beyond top and bottom
DoorwayAt least 32 inches clear width (36 inch door typically needed); thresholds no higher than 1/2 inch
Wheelchair turning space60 inch diameter circle (or T shaped space)
Hallway36 inches minimum for one wheelchair; 60 inches for two to pass
ToiletSeat 17 to 19 inches high; grab bars 33 to 36 inches above the floor
Counters and sinksSink no higher than 34 inches with knee clearance about 27 inches
Rise30 in max Run: 12 in for every 1 in of rise (30 ft for 30 in) 60 in landing 60 in landing Handrail top 34 to 38 in, both sides Slope 1:12 (about 4.8 degrees) Accessible ramp, side view (not to scale) Clear width at least 36 in; a longer run needs an intermediate 60 in landing
Figure 13.3 Ramp geometry. Multiply the total rise in inches by 12 to get the minimum run in inches: a 24 inch rise needs at least 288 inches (24 feet) of ramp.
Board tip. Ramp math is a free point. Rise in inches times 12 equals minimum run in inches; divide by 12 to convert to feet. Three 7 inch steps (21 inches) need at least 21 feet of ramp, plus landings.

Health systems and payers

Medicare is the federal insurance program for people 65 and older, people under 65 who have received Social Security disability benefits for 24 months, and people with end stage renal disease or ALS. Part A (hospital insurance) covers inpatient hospital care, inpatient rehabilitation, skilled nursing facility care after a qualifying hospital stay, home health and hospice. Part B (medical insurance) covers outpatient services including outpatient physical therapy, physician services and durable medical equipment. Part C (Medicare Advantage) delivers Part A and B benefits through private plans that may require prior authorization. Part D covers prescription drugs. Medicaid is a joint federal and state program for people with low income and some people with disabilities; benefits vary by state, and children receive comprehensive screening and treatment benefits. Workers' compensation covers work injuries without regard to fault.

SettingUsual payer rules the exam usesPT focus
Acute hospitalPart A pays the facility a fixed amount per diagnosis related group (DRG)Mobility, safety, discharge recommendation
Inpatient rehabilitation facilityPatient must tolerate and need intensive therapy, generally 3 hours a day at least 5 days a week, from at least two disciplines, one of which is PT or OT; physician supervision and an interdisciplinary teamIntensive functional restoration
Skilled nursing facilityPart A after a qualifying inpatient stay of at least 3 midnights (Medicare Advantage plans may waive it), up to 100 days per benefit period with daily coinsurance after day 20; daily skilled needLower intensity rehab, transition home or to long term care
Home healthPatient must be homebound (leaving home requires considerable and taxing effort or is medically contraindicated) and need intermittent skilled care; OASIS assessmentFunction in the real environment, home safety
OutpatientPart B; certified plan of care; progress report at least every 10 visits; KX thresholdImpairments, activity and participation
HospiceLife expectancy of 6 months or less if the disease runs its usual course; comfort focusComfort, positioning, caregiver training
Case. An 8 year old boy is seen in outpatient PT after a "fall from his bike." He has bruises on both upper arms in the shape of fingers and older yellow bruises on the back, and his father answers every question for him. The PT has no proof of abuse.
Reasoning: The legal standard for mandated reporters is reasonable suspicion, and these signs (patterned bruising, injuries of different ages, a history that does not fit, a controlling caregiver) meet it. The best action is to report to child protective services as the state requires and document objective findings in the child's own words if he speaks. Confronting the father or waiting to gather more evidence are wrong because they delay protection and may endanger the child. HIPAA does not block the report, because mandated reporting is a permitted disclosure.
Key point

The state practice act defines what a PT and PTA may do; direct access shifts the duty to screen and refer onto the PT; HIPAA allows sharing for treatment, payment and operations and for mandated reporting but otherwise requires authorization and minimum necessary use; reasonable suspicion triggers abuse reports; the ADA and accessibility standards set the numbers for ramps and doorways; and each payer and setting has qualifying rules that shape the plan.

Section 4Research design and statistics

Levels of evidence and study designs

Evidence hierarchies rank designs by how well they protect against bias for questions about intervention. At the top are systematic reviews and meta-analyses of high quality randomized controlled trials. Next is the individual randomized controlled trial (RCT), in which participants are randomly allocated to groups, ideally with concealed allocation, blinded assessors and intention to treat analysis. Below these come cohort studies (groups defined by exposure and followed forward, prospective or retrospective), case control studies (people with and without an outcome compared for past exposures, efficient for rare outcomes), cross sectional studies (exposure and outcome measured at one time), case series and case reports, and finally expert opinion and bench research. Prognosis questions are best answered by prospective cohorts; diagnostic questions by cross sectional comparison with a reference standard.

Also recognize single subject (A-B-A-B), crossover, qualitative and quasi-experimental (no randomization) designs. Quality within a level still matters; the PEDro scale rates rehabilitation trials.

1. Systematic review, meta-analysis 2. Randomized controlled trial 3. Cohort study 4. Case control study 5. Case series, case report 6. Expert opinion Risk ofbias risestowardthe base
Figure 13.4 The evidence pyramid for questions of intervention. Each step down offers less protection against bias; within any level, study quality still has to be appraised.

Validity

Validity is whether a study or a measure captures what it claims. For studies, internal validity is confidence that the intervention caused the outcome. Threats include history (outside events), maturation (natural change over time, such as healing), testing (learning from repeated tests), instrumentation (changes in the measuring tool or rater), regression to the mean (extreme scores drifting toward average on retest), selection bias (groups that differ at baseline), attrition (dropouts that differ by group), and contamination between groups. Randomization, control groups, blinding and intention to treat protect it. External validity is generalizability to other people, settings and times; tightly restricted samples and artificial conditions reduce it.

For measures: content validity covers the whole construct; criterion validity compares with a gold standard now (concurrent) or later (predictive, such as a balance test predicting falls); construct validity behaves as theory predicts.

Reliability and measurement error

Reliability is consistency. Test retest reliability is agreement across occasions when the trait is stable; intrarater is one examiner's agreement with themselves; interrater is agreement between examiners; and internal consistency (Cronbach alpha) is how well the items of a questionnaire hang together. Continuous data are judged with the intraclass correlation coefficient (ICC); a common interpretation is above 0.75 good, 0.50 to 0.75 moderate and below 0.50 poor. Categorical agreement uses the kappa statistic, which corrects for chance; above about 0.80 is excellent, 0.60 to 0.80 substantial, 0.40 to 0.60 moderate. A measure can be reliable without being valid (a miscalibrated scale gives the same wrong weight every time), but it cannot be valid without being reliable.

The standard error of measurement (SEM) converts reliability into the units of the test: SEM equals the standard deviation times the square root of (1 minus reliability). The minimal detectable change at 95% confidence (MDC95) equals SEM times 1.96 times the square root of 2, and represents the smallest change that exceeds measurement error. The minimal clinically important difference (MCID) is the smallest change patients perceive as beneficial, usually established by anchoring to a global rating of change. A change must exceed the MDC to be real and should reach the MCID to matter. In older adults, a gait speed gain of about 0.1 m/s is a commonly cited meaningful change.

Diagnostic accuracy

Diagnostic test studies compare an index test with a reference standard and arrange results in a 2 by 2 table. Sensitivity is the proportion of people with the condition who test positive: true positives divided by all with the condition. Specificity is the proportion of people without the condition who test negative: true negatives divided by all without the condition. A highly sensitive test, when negative, helps rule the condition out (SnNout); a highly specific test, when positive, helps rule it in (SpPin). Sensitivity and specificity do not change with prevalence, but positive predictive value (the probability of disease given a positive test) and negative predictive value do: in a low prevalence population, even a good test produces many false positives.

Reference standard Condition present Condition absent aTrue positivebFalse positivecFalse negativedTrue negative Test +Test - Sensitivity = a / (a + c) Specificity = d / (b + d) PPV = a / (a + b) NPV = d / (c + d) LR+ = sens / (1 - spec) LR- = (1 - sens) / spec Worked numbers: 100 people with the condition, 100 without a = 90, c = 10, b = 20, d = 80: sensitivity 0.90, specificity 0.80 LR+ = 0.90 / 0.20 = 4.5 (small shift up) LR- = 0.10 / 0.80 = 0.125 (moderate shift down): a negative result is more useful here
Figure 13.5 The 2 by 2 table. Sensitivity and specificity read down the columns; predictive values read across the rows, which is why they change with prevalence.

Likelihood ratios combine sensitivity and specificity and tell how much a result changes the probability of disease. The positive likelihood ratio (LR+) is sensitivity divided by (1 minus specificity); the negative likelihood ratio (LR-) is (1 minus sensitivity) divided by specificity. To apply them, convert pretest probability to odds (odds = p / (1 - p)), multiply by the LR, and convert back (p = odds / (1 + odds)), or use a nomogram. The usual interpretation: LR+ above 10 or LR- below 0.1 produce large, often conclusive shifts; 5 to 10 and 0.1 to 0.2 moderate shifts; 2 to 5 and 0.2 to 0.5 small but sometimes important shifts; values near 1 change almost nothing. A clinical prediction rule combines findings and should be validated before routine use.

Statistics you need

Levels of measurement decide which statistics are allowed. Nominal data are named categories without order (sex, diagnosis). Ordinal data are ordered categories with unequal intervals (manual muscle test grades, pain rating categories, Berg item scores, the ASIA scale). Interval data have equal intervals but no true zero (temperature in Celsius). Ratio data have equal intervals and a true zero (force, distance, time, range of motion in degrees). In a right skewed distribution the mean exceeds the median. In a normal distribution, about 68% of values lie within 1 standard deviation of the mean, 95% within 2 and 99.7% within 3.

Hypothesis testing compares the observed result with what chance would produce. A type I error (alpha, usually set at 0.05) is concluding there is a difference when none exists: a false positive. A type II error (beta) is missing a real difference: a false negative, most often from too small a sample. Power is 1 minus beta, usually set at 0.80, and rises with sample size, effect size and alpha. A p value says nothing about the size of an effect. The 95% confidence interval gives the range of plausible values for the true effect; if a confidence interval for a difference crosses zero (or for a ratio crosses 1), the result is not statistically significant.

QuestionParametric test (interval or ratio, roughly normal)Nonparametric alternative (ordinal or skewed)
Two independent groupsIndependent t testMann-Whitney U
Two related measures (pre and post)Paired t testWilcoxon signed rank
Three or more independent groupsOne way ANOVA (with post hoc tests)Kruskal-Wallis
Three or more repeated measuresRepeated measures ANOVAFriedman
Association between two variablesPearson rSpearman rho
Nominal frequenciesChi square test

Correlation (r, -1 to +1) does not prove causation. For risk: the absolute risk reduction (ARR) is the control event rate minus the experimental event rate; the number needed to treat (NNT) equals 1 divided by ARR, rounded up; the relative risk is the risk in the exposed divided by the risk in the unexposed; and the odds ratio, used in case control studies, compares odds of exposure. If falls occur in 30% of controls and 20% of an exercise group, ARR is 0.10 and NNT is 10: treat 10 people to prevent one additional fall.

Board tip. Remember which values are fixed: sensitivity and specificity belong to the test; predictive values belong to the test in a particular population. If a question changes the prevalence, only PPV and NPV change.
Case. A PT reads that a ligament stress test has sensitivity 0.95 and specificity 0.60 and wants to screen athletes for a ligament tear. A patient's result is negative.
Reasoning: High sensitivity means few false negatives, so a negative result helps rule the tear out (SnNout). The LR- is 0.05 / 0.60, about 0.08, which produces a large shift down. A positive result is much less informative: LR+ is 0.95 / 0.40, about 2.4, a small shift. The tempting wrong answer is "a positive result confirms the tear," which confuses sensitivity with specificity. The safety point: a negative screen lowers probability but does not override a convincing history and examination; refer for imaging when the picture still suggests instability.
Key point

Know the hierarchy of designs and the threats to internal validity; judge reliability with ICC or kappa and turn it into SEM and MDC; demand that change exceed the MDC and reach the MCID; compute sensitivity, specificity, predictive values and likelihood ratios from a 2 by 2 table; and pick statistical tests by level of measurement and design.

Section 5Applying evidence and teaching

Evidence based practice and clinical practice guidelines

Evidence based practice integrates three sources: the best available research, the clinician's expertise, and the patient's values and circumstances. The process has five steps: ask a focused question, acquire the evidence, appraise it for validity and relevance, apply it with the patient, and assess the outcome. Questions are framed with PICO: Patient or problem, Intervention (or test or exposure), Comparison, and Outcome (some add T for time frame).

Clinical practice guidelines (CPGs) are systematically developed recommendations based on a review of the evidence and a judgment of benefits and harms. Physical therapy guidelines from the professional association's sections commonly grade recommendations with letters:

GradeStrengthBasis
AStrong evidenceA preponderance of level I and/or level II studies; must or should
BModerate evidenceA single high quality RCT or a preponderance of level II studies; should
CWeak evidenceA single level II study or a preponderance of level III and IV studies; may
DConflicting evidenceHigher quality studies disagree
ETheoretical or foundational evidenceAnimal, cadaver or basic science studies or theory
FExpert opinionBest practice from the clinical experience of the guideline team

Some newer guidelines use the GRADE approach, which rates certainty of evidence as high, moderate, low or very low and gives strong or conditional recommendations. Examples of guideline content the exam draws on include: staying active and exercise for acute low back pain rather than bed rest; exercise and education as first line care for knee osteoarthritis; canalith repositioning for posterior canal BPPV; strength, balance and gait training for fall prevention in older adults; and early mobilization in critical care when safe.

Patient education and learning

Patient education is an intervention in its own right and is part of every plan of care. Learning occurs in three domains: cognitive (knowledge, such as understanding hip precautions), psychomotor (skills, such as performing a transfer or using a walker on stairs) and affective (attitudes and values, such as accepting the need for a home program).

Adults learn best (principles of andragogy) when the content is immediately relevant to their problems, builds on their experience, involves them in planning, and is centered on tasks rather than abstract subjects. Assess readiness to learn (pain, fatigue, anxiety and cognition interfere), limit each session to a few key points, demonstrate, have the patient practice and involve caregivers.

The teach back method checks understanding by asking the patient to explain or demonstrate in their own words ("To make sure I explained this clearly, can you show me how you will get out of bed at home?"). It is recommended for every patient; asking "Do you understand?" is not enough.

Health literacy

Health literacy is the degree to which a person can find, understand and use health information to make decisions. It is often limited and cannot be judged by appearance. Strategies use universal precautions: assume everyone benefits from clear communication. Use plain language with no jargon (say "swelling" instead of "edema," "bend" instead of "flex"), short sentences, the active voice, the two or three most important points first, pictures and demonstrations, and written materials at about a sixth grade reading level or lower (many sources recommend fifth to sixth grade), with plenty of white space and large type. Use professional medical interpreters, never minor children, and avoid ad hoc family interpreting for consent or sensitive topics.

Behavior change and motivation

Adherence to home exercise is often poor, so the exam tests how to support behavior change. The transtheoretical model (stages of change) describes five stages: precontemplation (not intending to change in the next 6 months, often unaware of the problem), contemplation (thinking about change within 6 months, ambivalent), preparation (planning to act within the next month, may have taken small steps), action (has changed behavior within the past 6 months) and maintenance (sustained change for more than 6 months). Relapse can occur at any point and is treated as part of the process. The PT matches the strategy to the stage (Figure 13.6).

Precontemplationnot thinking of it Contemplationambivalent, weighing Preparationplan within a month Actionchanged, under 6 mo Maintenancesustained over 6 mo Relapsere-enter cycle Matching PT strategy Precontemplation: raise awareness, link to the person's goals. Contemplation: weigh pros and cons. Preparation: set a specific plan. Action: reinforce, solve problems. Maintenance: plan for setbacks.
Figure 13.6 The stages of change. People move around the cycle, and relapse returns them to an earlier stage rather than to failure; the PT matches the strategy to the stage.

The health belief model predicts action when perceived susceptibility, severity and benefit outweigh barriers. Self efficacy, confidence in a specific behavior, grows mainly through small successes. Motivational interviewing is a collaborative style for resolving ambivalence; its core skills are summarized as OARS: open ended questions, affirmations, reflective listening and summaries, with the goal of eliciting the patient's own reasons for change ("change talk") rather than arguing.

Health promotion, prevention and wellness

Prevention is described at three levels. Primary prevention stops a condition from developing (exercise to prevent osteoporosis, ergonomic programs to prevent work injury, vaccination). Secondary prevention detects and treats disease early to shorten its course (screening blood pressure at every visit, fall risk screening, bone density screening). Tertiary prevention limits disability and complications in established disease (cardiac rehabilitation, pressure injury prevention after spinal cord injury).

PopulationPhysical activity guideline (federal guidelines for Americans)
Adults150 to 300 minutes per week of moderate intensity aerobic activity, or 75 to 150 minutes of vigorous activity, or an equivalent mix, spread through the week; muscle strengthening of all major muscle groups on 2 or more days per week; less sitting
Older adultsSame aerobic and strengthening targets as able, plus multicomponent activity including balance training; adjust to fitness and chronic conditions
Children and adolescents (6 to 17 years)60 minutes or more of moderate to vigorous activity daily, mostly aerobic, with vigorous activity, muscle strengthening and bone strengthening each on at least 3 days per week
Pregnancy and postpartumAt least 150 minutes per week of moderate aerobic activity in healthy pregnancy, adjusted with the obstetric provider

Moderate intensity is about 3 to 5.9 METs (can talk, not sing); vigorous is 6 METs or more. Body mass index categories for adults are underweight below 18.5, normal 18.5 to 24.9, overweight 25 to 29.9 and obese 30 or more; BMI does not distinguish muscle from fat. Inactive people with symptoms or known cardiovascular, metabolic or renal disease need medical clearance before vigorous exercise.

Board tip. "Do you understand?" is never the best answer. Choose teach back, a demonstration with return demonstration, plain language and pictures, and a professional interpreter when language differs.
Case. A 58 year old man with type 2 diabetes and knee osteoarthritis says he knows he "should exercise" but has too much going on and is not sure it would help his knee. He has not been active for years.
Reasoning: He is in contemplation: aware, ambivalent, not yet planning. The best approach is motivational interviewing: ask open questions about what matters to him, reflect his ambivalence, and help him weigh the pros and cons, while giving clear information that exercise is first line care for knee osteoarthritis and improves glucose control. Handing him a detailed 12 exercise program fits the action stage and is likely to fail; warning him about amputation risk to frighten him tends to provoke resistance. Safety points: check blood glucose before exercise and inspect his feet, since he has diabetes.
Key point

Evidence based practice blends research, expertise and patient values; PICO focuses the question; guidelines grade recommendations from strong to expert opinion; effective teaching targets the right learning domain, uses plain language, teach back and interpreters, and matches the behavior change strategy to the patient's stage; and health promotion follows the national activity guidelines at the levels of primary, secondary and tertiary prevention.

The chapter in one breath

  • Standard precautions apply to everyone; add contact (MRSA, C. difficile), droplet (influenza, pertussis, meningococcus) or airborne (TB, measles, varicella) precautions by organism.
  • Don PPE gown, mask, eyewear, gloves; doff gloves, eyewear, gown, mask, then hand hygiene; use soap and water for spores and visible soil.
  • Use safe patient handling equipment and a gait belt; guard on the weaker side and below the patient on stairs; restraints are a last resort with an order and monitoring.
  • Competent patients may refuse care; informed consent covers nature, risks, benefits and alternatives and can be withdrawn.
  • Only the PT evaluates, sets and changes the plan of care, reevaluates and discharges; the PTA treats within the plan; aides do nonskilled tasks under direct personal supervision.
  • Document what was skilled and necessary; bill timed codes with the 8 minute rule; Medicare needs a certified plan, recertification by 90 days and progress reports every 10 visits.
  • Practice acts define scope; direct access requires screening and referral; HIPAA allows disclosure for treatment, payment, operations and mandated reports.
  • Report suspected child or vulnerable adult abuse on reasonable suspicion; ramps are 1:12, doorways 32 inches clear, turning space 60 inches.
  • Systematic reviews and RCTs top the evidence hierarchy; randomization and blinding protect internal validity.
  • SnNout and SpPin; LR+ above 10 and LR- below 0.1 are powerful; change must exceed the MDC and should reach the MCID; NNT = 1 / ARR.
  • Use teach back, plain language at about a sixth grade level, professional interpreters and stage matched behavior change strategies.

Words worth knowing

TermWhat it means
Standard precautionsInfection control practices used with every patient, treating all blood, body fluids, nonintact skin and mucous membranes as potentially infectious.
Contact precautionsGown and gloves plus dedicated equipment for organisms spread by touch, such as MRSA and C. difficile.
Droplet precautionsA surgical mask for close contact with patients whose infection spreads by large respiratory droplets, such as influenza.
Airborne precautionsA fit tested N95 respirator and a negative pressure room for tuberculosis, measles and varicella.
AutonomyThe ethical principle of respecting a competent person's right to make their own health decisions.
Informed consentVoluntary agreement by a person with capacity after learning the nature, risks, benefits and alternatives of a proposed intervention.
Direct personal supervisionThe supervising PT is physically present in the room and immediately available.
8 minute ruleMedicare method for timed codes in which a remainder of 8 or more minutes adds one 15 minute unit.
Practice actThe state law that defines physical therapy practice, licensure and grounds for discipline.
Direct accessThe ability of patients to see a physical therapist without a physician referral, within state limits.
Protected health informationIndividually identifiable health information covered by the HIPAA Privacy Rule.
Mandated reporterA professional legally required to report reasonable suspicion of child or vulnerable adult abuse.
Reasonable accommodationA change in a job or environment that lets a qualified person with a disability work, required under the ADA unless it causes undue hardship.
HomeboundMedicare home health requirement that leaving home takes considerable and taxing effort or is medically inadvisable.
Internal validityThe degree to which a study shows that the intervention, not other factors, caused the outcome.
Intraclass correlation coefficientA reliability statistic for continuous measures; values above about 0.75 are usually called good.
Minimal detectable changeThe smallest change in a score that exceeds measurement error with a stated confidence.
Minimal clinically important differenceThe smallest change in a score that patients perceive as meaningful.
SensitivityThe proportion of people with a condition who test positive; a sensitive test rules out when negative.
SpecificityThe proportion of people without a condition who test negative; a specific test rules in when positive.
Likelihood ratioA ratio that shows how much a test result raises or lowers the odds of a condition.
Number needed to treatThe number of patients who must receive an intervention to prevent one additional bad outcome; 1 divided by the absolute risk reduction.
Clinical practice guidelineSystematically developed, graded recommendations for care based on a review of evidence.
Teach backAsking the patient to explain or show what was taught, to confirm understanding.
Health literacyA person's ability to find, understand and use health information to make decisions.

Check yourself

A PT must treat a patient on airborne precautions for suspected pulmonary tuberculosis. Which respiratory protection is required, and where is it removed?
Answer. A fit tested N95 (or higher) respirator, removed after leaving the negative pressure room and closing the door. A surgical mask is adequate for droplet precautions but not for airborne organisms.
What is the correct order for removing gloves, gown, goggles and mask after treating a patient on contact and droplet precautions?
Answer. Gloves, goggles, gown, mask, then hand hygiene. The most contaminated items come off first and the mask, which protects the airway, comes off last.
A PTA notes that a patient's blood pressure is 182/104 before exercise, much higher than at the evaluation. What should the PTA do?
Answer. Withhold the planned exercise, recheck the reading, and contact the supervising PT, who will decide whether to notify the physician. A significant change in status returns decisions to the PT; the PTA should not independently change the plan of care.
A therapist provides 30 minutes of therapeutic exercise and 8 minutes of gait training to a Medicare Part B patient. How many units are billed and to which codes?
Answer. Total timed minutes are 38, which is 3 units: 2 units of therapeutic exercise and 1 unit of gait training. The 8 gait minutes are the leftover minutes and are enough for the third unit.
A competent 80 year old man refuses to walk with therapy today after the risks of immobility are explained. What principle governs, and what should the PT do?
Answer. Autonomy. Respect the refusal, explore the reasons (pain, fatigue, fear), offer alternatives, document the education and refusal, and inform the team.
A family wants a ramp to a front door that is 18 inches above the walkway. What is the minimum ramp length?
Answer. 18 inches times 12 equals 216 inches, or 18 feet, at a 1:12 slope, plus level landings of at least 60 inches at the top and bottom.
A test has sensitivity 0.80 and specificity 0.95. Calculate the positive likelihood ratio and state what a positive result does.
Answer. LR+ = 0.80 / (1 minus 0.95) = 0.80 / 0.05 = 16. A positive result produces a large increase in the probability of the condition (high specificity rules in, SpPin).
A study finds that a balance score improved by 3 points after treatment. The MDC95 is 5 points and the MCID is 6 points. How should the change be interpreted?
Answer. The change is within measurement error, so it cannot be considered a real change, and it also falls short of a clinically important difference.
Which statistical test compares pain ratings on an ordinal scale between two independent groups?
Answer. The Mann-Whitney U test, the nonparametric alternative to the independent t test, which is appropriate for ordinal or nonnormally distributed data.
After teaching a patient a home exercise program, what is the best way to confirm understanding?
Answer. Teach back with return demonstration: ask the patient to perform the exercises and explain when and how often to do them. Asking "Do you have any questions?" or "Do you understand?" does not verify learning.
Chapter 14 · Lifespan

Lifespan, Special Populations and Integrated Cases

The NPTE does not stop at adults with a single diagnosis. It asks you to recognize a 9 month old who cannot sit, to choose the right test for a school age child with cerebral palsy, to spot delirium in an older adult whose "weakness" is really a urinary tract infection, to adapt exercise for pregnancy, and to decide what matters most in a patient with five problems at once. This chapter covers development and pediatric practice, aging, women's and men's health, and closes with integrated cases that train the priority logic the exam rewards.

By the end of this chapter you can

  • State the ages of key gross motor milestones and the appearance and integration of primitive reflexes and postural reactions.
  • Classify cerebral palsy by type and GMFCS level, and describe the PT priorities for spina bifida, Down syndrome, congenital muscular torticollis and developmental dysplasia of the hip.
  • Contrast early intervention under IDEA Part C with school based therapy under Part B and Section 504, and the IFSP with the IEP.
  • Choose an appropriate developmental test and recommend adaptive equipment and orthoses.
  • Describe the physiology of normal aging, the risks of polypharmacy, and the differences among delirium, dementia and depression.
  • Screen for frailty and fall risk with standard tests and cutoffs and design a home safety and osteoporosis plan.
  • Prescribe safe exercise in pregnancy, assess and treat diastasis recti, and classify and manage urinary incontinence.
  • Outline rehabilitation after prostate cancer treatment, including pelvic floor training and exercise during androgen deprivation.
  • Prioritize problems in multisystem patients and choose the next best action across care settings.

Section 1Pediatric development and conditions

Principles of development

Motor development proceeds cephalocaudal (head control before trunk, trunk before legs), proximal to distal (shoulder before fingers), and from gross to fine and mass to specific movement. Stability generally precedes controlled mobility. Ages are averages with wide normal ranges; what matters clinically is a pattern of delay, a loss of skills, asymmetry, or persistence of reflexes beyond their usual window. For infants born before 37 weeks, use corrected (adjusted) age, chronological age minus the weeks of prematurity, until about 24 months. A baby born at 32 weeks who is 6 months old chronologically is about 4 months corrected.

Typical ageGross motorFine motor and other
2 monthsLifts head 45 degrees in prone; head bobs in supported sittingSocial smile; tracks past midline
4 monthsHead steady in sitting, no head lag on pull to sit, prone on forearms; rolls prone to supineHands to midline; reaches; grasp becoming voluntary
6 monthsProne on extended arms; rolls supine to prone; sits with arm support (tripod)Transfers objects hand to hand; raking grasp
8 monthsSits independently; pivots in prone; gets into sittingRadial digital grasp; babbles
9 to 10 monthsCreeps on hands and knees; pulls to stand; cruisesInferior pincer grasp; plays peekaboo
12 monthsWalks independently (normal range about 9 to 15 months; evaluate if not walking by 18 months), wide base, high guard armsFine pincer grasp; first words; releases objects voluntarily
18 monthsRuns stiffly; walks up stairs with hand held; squats to playStacks 3 to 4 blocks; scribbles
2 yearsJumps with both feet; kicks a ball; up and down stairs marking time (step to)Two word phrases; stacks 6 blocks
3 yearsAscends stairs reciprocally; pedals a tricycle; stands on one foot brieflyCopies a circle
4 yearsHops on one foot; descends stairs reciprocally; catches a ballCopies a cross and square
5 to 6 yearsSkips; rides a bicycle (with training wheels earlier); mature gait by about age 7Copies a triangle; ties shoes around age 6
Gross motor milestones, birth to 24 months (typical ages) 0 4 6 8 10 12 18 24 age in months Head control,no head lag (4) Rolls (4 to 6) Sits alone (6 to 8) Creeps, pullsto stand (9 to 10) Walks alone (12)refer if not by 18 Runs, stairs withhand held (18) Jumps both feet,kicks ball (24)
Figure 14.1 Gross motor milestones on a time line. The red marker is independent walking at about 12 months; failure to walk by 18 months warrants evaluation. Use corrected age for preterm infants.

Primitive reflexes and postural reactions

Primitive reflexes are stereotyped responses mediated at the spinal cord and brainstem that appear in utero or at birth and become integrated (inhibited by maturing higher centers) during the first months. Persistence beyond the usual age, an obligatory response (the infant cannot move out of it) or asymmetry suggests central nervous system dysfunction, as in cerebral palsy. Absence at birth can mean depression of the nervous system or a peripheral lesion (an absent unilateral Moro with a brachial plexus birth injury). As reflexes integrate, righting reactions (aligning head and body), protective reactions (arm extension to catch a fall: forward about 6 to 7 months, sideways about 7 to 8 months, backward about 9 to 10 months) and equilibrium reactions (trunk curving to keep balance; in sitting about 7 to 8 months, in standing about 12 to 21 months) emerge.

ReflexStimulusResponseUsual age range
RootingStroke the corner of the mouthTurns head toward the stimulusBirth to about 3 to 4 months
Palmar graspPressure in the palmFinger flexionBirth to about 4 to 6 months (must fade before voluntary release)
Plantar graspPressure at the ball of the footToe flexionBirth to about 9 to 12 months (must fade before standing and walking)
MoroSudden head drop backwardArm abduction and extension, then flexion and adduction, with cryingBirth to about 4 to 6 months
Asymmetric tonic neck (ATNR)Head rotation"Fencer" posture: extension of face side limbs, flexion of skull side limbsBirth to about 4 to 6 months; blocks hands to midline and rolling if it persists
Symmetric tonic neck (STNR)Neck flexion or extensionNeck flexion: arms flex, legs extend; neck extension: arms extend, legs flexAbout 6 to 8 months to 10 to 12 months; persistence blocks reciprocal creeping (bunny hopping)
Tonic labyrinthine (TLR)Prone or supine positionProne: flexion; supine: extensionBirth to about 6 months
Galant (trunk incurvation)Stroke paraspinal skin in proneLateral trunk flexion toward the stimulusBirth to about 2 months
Positive supportPressure on the soles in uprightLeg extension to bear weightBirth to about 1 to 2 months (later voluntary standing replaces it)
SteppingHeld upright, soles touch surfaceAlternating steppingBirth to about 2 months
LandauHeld horizontally in proneHead, trunk and hip extensionAbout 3 to 4 months to 12 to 24 months
When primitive reflexes are present (approximate) Stepping Galant Rooting Moro ATNR TLR Palmar grasp STNR Plantar grasp 024681012 age in months Persistence past these ages, an obligatory response, or asymmetrysuggests central nervous system dysfunction.
Figure 14.2 Usual windows of the primitive reflexes. Most integrate by about 6 months; the plantar grasp lasts until standing, and the symmetric tonic neck reflex appears late and integrates by about 12 months.

Cerebral palsy

Cerebral palsy (CP) is a group of permanent disorders of movement and posture caused by a nonprogressive disturbance of the developing fetal or infant brain. The lesion does not progress, but the musculoskeletal consequences (contracture, hip displacement, scoliosis, crouch) change with growth. Risk factors include prematurity and low birth weight (the strongest), intrauterine infection, multiple births, hypoxic ischemic injury, stroke and kernicterus. Associated problems include intellectual disability, epilepsy, visual and hearing impairment, feeding difficulty and pain. Diagnosis can now be made or suspected before 6 months using the General Movements Assessment (absent fidgety movements at about 3 to 5 months corrected age), the Hammersmith Infant Neurological Examination and MRI, which allows earlier intervention.

TypeLesionFeatures
Spastic (most common, about 70 to 80%)Motor cortex or corticospinal tractsVelocity dependent hypertonia, hyperreflexia, weakness, contracture risk. Distribution: diplegia (legs more than arms; classic in preterm infants with periventricular leukomalacia, because leg fibers run closest to the ventricles), hemiplegia (one side, often from perinatal stroke; arm usually more than leg), quadriplegia (all four limbs, most severe)
Dyskinetic (athetoid, dystonic)Basal ganglia (hypoxic injury, kernicterus)Involuntary writhing or dystonic movements that increase with effort and emotion, fluctuating tone, poor proximal stability
AtaxicCerebellumHypotonia, wide based gait, intention tremor, dysmetria, poor balance
MixedMultiple areasUsually spastic plus dyskinetic

The Gross Motor Function Classification System (GMFCS) classifies a child's usual mobility in five levels, with descriptions for age bands; the level is stable over time and predicts gross motor prognosis. In summary for ages 6 to 12: Level I walks at home, school and in the community without limitation, can run and jump with reduced speed and coordination; Level II walks in most settings but has limitations on uneven terrain, inclines and long distances, uses a railing on stairs, and may use wheeled mobility for long distances; Level III walks with a hand held mobility device indoors and uses wheeled mobility for longer distances; Level IV uses methods of mobility that need physical assistance or powered mobility in most settings; Level V is transported in a manual wheelchair and has limited head and trunk control. Gross motor ability usually plateaus by about age 7 in children at levels I and II, and children at levels III to V may lose function in adolescence as body size outpaces strength.

Management is lifelong and goal directed: task specific and functional training, strengthening (which does not increase spasticity), aerobic fitness, stretching, serial casting and night splints for contracture, orthoses, and equipment. Medical and surgical options include botulinum toxin injections for focal spasticity (followed by stretching, casting and training), oral baclofen, intrathecal baclofen pumps for severe generalized spasticity or dystonia, selective dorsal rhizotomy for selected children with spastic diplegia (good strength, GMFCS II to III), and orthopedic surgery such as tendon lengthening and osteotomies. Hip surveillance with periodic pelvic radiographs is recommended because hip displacement risk rises with GMFCS level, approaching or exceeding half of children at level V. Common gait patterns are equinus (toe walking), crouch (excessive hip and knee flexion with ankle dorsiflexion, often from hamstring tightness, weak plantar flexors or overlengthened heel cords), jump knee and scissoring from adductor spasticity.

Spina bifida (myelomeningocele)

Spina bifida is a neural tube defect from failure of the caudal neural tube to close by about the fourth week of gestation; maternal folic acid supplementation reduces risk. Spina bifida occulta is a bony defect without herniation, often marked by a hair tuft or dimple and usually asymptomatic. A meningocele is herniation of the meninges and cerebrospinal fluid without neural tissue, with few or no deficits. A myelomeningocele contains the spinal cord or roots and causes motor and sensory loss below the level, neurogenic bowel and bladder, and associated brain anomalies. Most children with myelomeningocele have the Chiari II malformation (downward displacement of the cerebellar tonsils, vermis and brainstem through the foramen magnum) and hydrocephalus requiring a ventriculoperitoneal shunt.

PT priorities in spina bifida are classic exam material:

  • Shunt malfunction: headache, vomiting, irritability, lethargy, change in school performance or personality, seizures, swelling along the shunt; in infants a bulging fontanelle, rapidly enlarging head and "sunsetting" eyes. This is an emergency; refer immediately.
  • Tethered cord: the cord scars to the surrounding tissue and stretches with growth, producing rapidly progressing scoliosis, new weakness or spasticity, changes in gait, back pain and changes in bladder function. Report changes promptly; a loss of muscle function on serial manual muscle tests is a reason to refer.
  • Chiari II symptoms: swallowing difficulty, stridor, apnea, upper extremity weakness.
  • Latex allergy: very common because of early repeated exposure; use latex free equipment.
  • Skin breakdown from insensate skin: teach daily skin checks and pressure relief; watch for fractures in osteoporotic insensate legs (presenting as swelling and warmth with no pain).
  • Obesity, contractures, hip dislocation and cognitive or learning issues (often good verbal skills with poor comprehension, sometimes called cocktail party speech).

Down syndrome, torticollis and hip dysplasia

Down syndrome (trisomy 21) causes hypotonia, ligamentous laxity, short stature, intellectual disability and delayed milestones (independent walking often around 2 years). About half of affected children have congenital heart disease (often atrioventricular septal defects), and many have hearing and vision problems, hypothyroidism and later obesity. Atlantoaxial instability from laxity of the transverse ligament is a key safety issue: watch for neck pain, torticollis, change in gait, new clumsiness, loss of bowel or bladder control and hyperreflexia, which suggest cord compression and require immediate referral. Activities with high neck loading (diving, tumbling, butterfly stroke) need medical clearance. Intervention emphasizes strengthening, balance, treadmill training to accelerate walking, joint protection rather than end range stretching of lax joints, and fitness.

Congenital muscular torticollis results from a shortened or fibrotic sternocleidomastoid. Because the SCM laterally flexes the head to the same side and rotates it to the opposite side, a right torticollis presents with the head tilted to the right and rotated to the left. A palpable mass (fibromatosis colli) may be present in the first weeks. It often coexists with plagiocephaly and sometimes with hip dysplasia, so screen the hips. Treatment begins as early as possible: stretching into lateral flexion away from the tight side and rotation toward it (for right torticollis: left lateral flexion and right rotation), active strengthening of the opposite neck muscles, positioning and handling that encourage turning toward the restricted side, plenty of supervised tummy time, and parent education. Referral is indicated for atypical findings (no improvement after several months, ocular or neurologic signs).

Developmental dysplasia of the hip (DDH) ranges from a shallow acetabulum to frank dislocation. Risk factors are female sex, breech position, first born, family history, oligohydramnios and tight swaddling with the hips extended and adducted. In newborns, the Barlow test (adduction with posterior force) dislocates an unstable hip and the Ortolani test (abduction with anterior lift) reduces a dislocated hip with a clunk. After about 3 months these become unreliable; look for limited hip abduction, asymmetric thigh folds, apparent leg length difference and a positive Galeazzi sign (lower knee height on the affected side with hips and knees flexed). Infants under about 6 months are treated with a Pavlik harness that holds the hips in flexion and abduction; caregivers must not remove or adjust it unless taught to, and must avoid hip extension and adduction. Older children may need closed or open reduction and casting.

ConditionTypical childHallmarks and PT points
Legg-Calve-Perthes diseaseBoy about 4 to 8 yearsAvascular necrosis of the femoral head; limp, groin or knee pain, limited abduction and internal rotation; maintain ROM and containment, limit high impact
Slipped capital femoral epiphysisOverweight adolescent in a growth spurtHip, thigh or knee pain, limp, obligatory external rotation with hip flexion; nonweight bearing and urgent surgical referral
Brachial plexus birth injuryLarge infant, shoulder dystociaErb palsy (C5 to C6): arm adducted, internally rotated, elbow extended, forearm pronated ("waiter's tip"); Klumpke (C8 to T1): weak hand; gentle ROM, positioning, avoid traction on the arm
Osteogenesis imperfectaAny ageCollagen defect, fractures with minor trauma, blue sclerae in some types; gentle handling, aquatic and protected weight bearing
Idiopathic scoliosisAdolescent girlRib hump on Adams forward bend; observe small curves, brace about 25 to 40 degrees in a growing child, surgery for larger curves; scoliosis specific exercise as an adjunct
Duchenne muscular dystrophyBoy, onset 3 to 5 yearsGowers sign, calf pseudohypertrophy, toe walking; avoid eccentric and high intensity exercise, maintain ROM, plan for wheelchair and respiratory care
Board tip. Torticollis is named for the tight muscle: head tilts toward it and rotates away. Stretch the opposite way (tilt away, rotate toward). A right SCM tightness means left lateral flexion and right rotation stretches.
Case. A 7 year old with lumbar myelomeningocele and a VP shunt comes to school based PT. Her teacher reports she has been sleepy, vomiting twice this week and complaining of headaches; today she is irritable.
Reasoning: Headache, vomiting, lethargy and behavior change in a child with a shunt suggest shunt malfunction, which can cause rapid neurologic deterioration. The best action is immediate medical referral (notify the school nurse and parents for emergency evaluation), not therapy. Assuming a viral illness or proceeding with gait training are the tempting wrong choices. Tethered cord is also possible in spina bifida, but its usual signs are progressive scoliosis, weakness and bladder change rather than acute vomiting and lethargy.
Key point

Know milestone ages (sit about 6 to 8 months, walk about 12, refer if not walking by 18) and reflex windows; recognize CP types and GMFCS levels; watch for shunt malfunction and tethered cord in spina bifida and atlantoaxial instability in Down syndrome; stretch torticollis opposite to the head position; and protect a DDH hip in flexion and abduction.

Section 2Pediatric settings and intervention

Early intervention under IDEA Part C

The Individuals with Disabilities Education Act (IDEA) guarantees services for children with disabilities. Part C covers infants and toddlers from birth to age 3 who have a developmental delay or a diagnosed condition with a high probability of delay. Services are family centered and delivered in natural environments, places where children without disabilities would usually be, such as the home or child care. The plan is the Individualized Family Service Plan (IFSP), which includes the child's present levels, the family's concerns, priorities and resources, measurable outcomes that the family chooses, services and their frequency, a named service coordinator, and a transition plan for leaving Part C at age 3. The IFSP is reviewed every 6 months and rewritten annually. After referral, the evaluation and initial IFSP meeting must occur within 45 days. Coaching caregivers to embed practice into daily routines (bath, meals, play) is the dominant service model.

School based practice under IDEA Part B and Section 504

Part B covers children from age 3 through 21 (until graduation or the end of the school year in which they turn 22 in some states) who need special education. Physical therapy is a related service: it is provided only when it helps the student benefit from special education. School PT therefore focuses on educationally relevant goals: getting on and off the bus, moving through hallways and stairs in time for class, carrying a lunch tray, sitting posture for writing, participating in physical education and recess, and managing equipment. The plan is the Individualized Education Program (IEP), written by a team that includes the parents, at least one general education teacher, a special education teacher, a district representative and, when appropriate, the student and related service providers. It states present levels of performance, measurable annual goals, services, accommodations and the extent of participation with peers. It is reviewed at least annually and the child is reevaluated at least every 3 years. Services are delivered in the least restrictive environment, as much as possible alongside students without disabilities. Transition planning toward adult life must be in the IEP by age 16.

Section 504 of the Rehabilitation Act applies to students with a disability that substantially limits a major life activity who do not need special education. A 504 plan provides accommodations (elevator pass, extra time between classes, adapted physical education, a second set of books). A student with juvenile idiopathic arthritis who performs well academically is the classic 504 student.

FeaturePart C early interventionPart B school basedSection 504
AgesBirth to 33 to 21Any age in federally funded programs
PlanIFSP (family outcomes)IEP (educational goals)504 plan (accommodations)
SettingNatural environmentsLeast restrictive environmentGeneral education with accommodations
ReviewEvery 6 months, annual rewriteAnnual review, reevaluation every 3 yearsPeriodic
PT roleCoach caregivers within routinesRelated service for educational benefitConsult on accommodations

Pediatric PT also occurs in neonatal intensive care units, hospitals and outpatient clinics, where the medical model applies and goals may target impairments that are not educationally relevant. In the NICU, care emphasizes developmentally supportive positioning and handling with attention to stress signs.

Developmental tests and outcome measures

Choose a test by age, purpose and population. Norm referenced tests compare a child with a normative sample (useful for eligibility and identifying delay); criterion referenced tests measure mastery of specific skills (useful for planning and measuring change). Discriminative tests identify delay; evaluative tests detect change over time; predictive tests forecast later outcomes.

TestAgesWhat it measures and why it is chosen
Apgar1 and 5 minutes after birthAppearance, pulse, grimace, activity, respiration (0 to 10); 7 to 10 normal
Test of Infant Motor Performance (TIMP)34 weeks postmenstrual age to about 4 months correctedPostural and selective control in young infants, including preterm; predicts later motor delay
General Movements AssessmentPreterm to about 5 months correctedObservation of spontaneous movement; absent fidgety movements strongly predict CP
Alberta Infant Motor Scale (AIMS)Birth to independent walking (about 18 months)Norm referenced observation of prone, supine, sitting and standing with minimal handling; screens for delay
Peabody Developmental Motor ScalesBirth to about 5 yearsNorm referenced gross and fine motor quotients; eligibility and programming
Bayley Scales of Infant and Toddler Development1 to 42 monthsCognitive, language, motor, social emotional and adaptive domains
Bruininks Oseretsky Test of Motor Proficiency (BOT)4 to 21 yearsFine and gross motor proficiency, including balance, coordination and strength; mild motor problems and developmental coordination disorder
Gross Motor Function Measure (GMFM-66 and GMFM-88)Children with CP (and Down syndrome for GMFM-88)Criterion referenced, evaluative; detects change in lying, sitting, crawling, standing and walking skills
Pediatric Evaluation of Disability Inventory (PEDI and PEDI-CAT)Birth to about 20 years (CAT version)Parent report of daily activities, mobility and social function; caregiver assistance
School Function AssessmentKindergarten to grade 6Participation and task performance in school settings; ideal for IEP goals
Movement Assessment Battery for Children3 to 16 yearsManual dexterity, aiming and catching, balance; developmental coordination disorder

Adaptive equipment, orthoses and mobility

Equipment should increase participation, protect joints and fit growth. Key choices:

  • Positioning and seating: a stable pelvis is the foundation (neutral to slight anterior tilt, level, hips at about 90 degrees with a lap belt at about 45 degrees across the pelvis), followed by trunk supports, head support and a tray. Good seating frees the hands and supports breathing, feeding and attention.
  • Standers: prone standers (leaning forward, need some head control), supine standers (for children with poor head control) and upright or mobile standers. Supported standing for about an hour a day, often in divided sessions, is used to promote hip development, bone density and range of motion, and to allow participation at table height.
  • Gait trainers and walkers: a posterior walker (reverse walker) promotes a more upright posture and is usually preferred for children with spastic diplegia; gait trainers with trunk and pelvic support suit children at GMFCS III to IV.
  • Ankle foot orthoses: a solid AFO controls equinus and gives stability in stance; a hinged (articulated) AFO allows dorsiflexion and controls plantar flexion for children with some control; a ground reaction AFO (anterior shell) creates a knee extension moment for crouch gait; a posterior leaf spring AFO assists dorsiflexion in swing for isolated foot drop; supramalleolar orthoses control mild pronation or supination. Night or resting splints maintain length.
  • Wheeled mobility: powered mobility can begin as early as about 18 to 24 months and supports cognitive, social and language development; it does not prevent walking. Manual wheelchairs are chosen for children with adequate arm function and endurance.
  • Adapted car seats, bath chairs, communication devices and adapted toys and switches complete the plan.
GMFCS levels (ages 6 to 12): mobility and typical equipment Level I Walks everywhere without limits; runs and jumps but with reducedspeed and coordination. Equipment: usually none, sometimes foot orthoses Level II Walks in most settings; limited on uneven ground, inclines and crowds;rail on stairs. Equipment: AFOs, wheeled mobility for long distances Level III Walks with a hand held mobility device indoors; wheels for distance.Equipment: posterior walker or crutches, AFOs, manual wheelchair Level IV Needs physical assistance or powered mobility in most settings.Equipment: gait trainer, stander, adapted seating, power chair Level V Transported in a manual wheelchair; limited head and trunk control.Equipment: tilt in space seating, supine stander, lift, hip surveillance
Figure 14.3 The GMFCS ladder. Each step down adds dependence on equipment and assistance; hip displacement risk rises steadily from level I to level V.
Board tip. In school, the test question is "Does it affect the child's education?" A goal to improve hamstring length in isolation is a clinic goal; a goal to walk from the bus to the classroom within the 5 minute passing period is a school goal.
Case. A 26 month old with Down syndrome is not yet walking and receives early intervention at home. The parents ask the PT to come to the clinic for treadmill sessions instead.
Reasoning: Under Part C, services occur in natural environments and are built around family chosen outcomes. The best response is to address the parents' walking goal by coaching them to practice supported stepping during daily routines at home and in child care, and to consider a home based treadmill program, which has evidence for earlier walking in Down syndrome. The IFSP must also include a transition plan because the child turns 3 within the year. A choice to move care to the clinic ignores the natural environment requirement unless the team documents why outcomes cannot be met there.
Key point

Part C (birth to 3) is family centered with an IFSP in natural environments; Part B (3 to 21) makes PT a related service with an IEP and educationally relevant goals in the least restrictive environment; Section 504 gives accommodations without special education. Choose tests by age and purpose (AIMS for infants, Peabody to age 5, BOT for school age, GMFM for change in CP) and equipment that supports participation and growth.

Section 3Geriatrics

Normal aging versus disease

Aging reduces physiologic reserve, so older adults function well at rest but decompensate under stress (illness, surgery, a new drug). Distinguish expected changes from disease: a slower gait is common, but a sudden decline is never "just age."

SystemTypical age related changePT implication
MuscleSarcopenia: loss of mass, strength and especially power, preferential type II fiber loss, fewer motor unitsStrength and power respond to training at any age; use progressive resistance at moderate to high intensity
CardiovascularLower maximal heart rate (estimated 220 minus age, or 208 minus 0.7 times age), lower VO2max, stiffer arteries with higher systolic pressure, blunted baroreflexLonger warm up and cool down; check for orthostatic hypotension (a drop of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing)
PulmonaryReduced chest wall compliance and vital capacity, increased residual volume, weaker coughBreathing exercises, upright positioning, early mobility after surgery
Nervous and sensorySlower reaction time and processing, reduced proprioception and vibration sense, presbyopia, cataracts, presbycusisAllow more time, use good lighting and contrast, face the patient when speaking
SkeletalBone loss (accelerated in women after menopause), cartilage changesWeight bearing and resistance exercise; fracture risk screening
SkinThinner dermis, slower healing, less sensationCareful handling, skin checks, lower thermal modality intensity
Renal and thermoregulationLower glomerular filtration, reduced thirst, impaired heat and cold toleranceHydration, drug accumulation risk, caution with heat and environmental extremes

Polypharmacy

Polypharmacy, commonly defined as five or more medications, raises the risk of falls, delirium, adverse reactions and interactions. Age related declines in renal and hepatic clearance prolong drug effects. The Beers Criteria list potentially inappropriate medications for older adults. Drug classes that most increase fall risk are sedative hypnotics and benzodiazepines, antidepressants, antipsychotics, opioids, antihypertensives and diuretics (orthostasis), and drugs with anticholinergic effects (confusion, blurred vision, urinary retention, constipation). Beta blockers blunt the heart rate response, so use rating of perceived exertion rather than heart rate targets. Report new dizziness, confusion or falls after a medication change to the prescriber; the PT does not change medications but should flag the pattern.

Cognition: delirium, dementia and depression

FeatureDeliriumDementiaDepression
OnsetAcute, hours to daysInsidious, months to yearsOften linked to a loss or change, weeks to months
CourseFluctuates, often worse at nightSlowly progressiveVariable, worse in the morning for some
Attention and consciousnessInattention and altered level of consciousnessAlert until late stagesAlert; poor effort, "I don't know" answers
CauseMedical: infection (urinary tract, pneumonia), drugs, dehydration, hypoxia, pain, surgeryNeurodegenerative (Alzheimer most common, vascular, Lewy body, frontotemporal)Mood disorder
Reversible?Usually, if the cause is treated: a medical emergencyNo (except reversible mimics such as B12 deficiency or hypothyroidism)Yes, with treatment

Screening tools include the Confusion Assessment Method for delirium (acute onset and fluctuating course plus inattention, plus either disorganized thinking or altered consciousness), the Mini-Cog, the Montreal Cognitive Assessment (below 26 of 30 suggests impairment and it is sensitive to mild cognitive impairment) and the Mini-Mental State Examination (below about 24 of 30 suggests impairment), and the Geriatric Depression Scale. For people with dementia, use simple one step commands, demonstration, consistent routines and the same staff, procedural (implicit) learning through repetition, and a calm environment; redirect rather than argue.

Frailty and falls

Frailty is a state of reduced reserve and vulnerability to stressors. The Fried frailty phenotype counts five criteria: unintentional weight loss (about 10 pounds or 5% in a year), self reported exhaustion, weak grip strength, slow gait speed and low physical activity. Three or more criteria indicate frailty, one or two prefrailty. Frailty predicts falls, hospitalization, disability and death, and it can be improved with multicomponent exercise and nutrition.

About one in four adults aged 65 and older falls each year, and falls are the leading cause of injury death in this group. The STEADI approach screens with three questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? A yes leads to a gait, strength and balance assessment, a medication review, orthostatic blood pressure, vision and foot checks, and a home safety assessment.

TestCommonly used fall risk cutoff (community dwelling older adults)
Timed Up and Go12 seconds or more (STEADI); 13.5 seconds or more in an often cited study; sources vary
Berg Balance Scale (0 to 56)45 or below (some use below 45); below about 40 indicates very high risk
30 second chair standBelow age and sex norms (for example fewer than 12 for ages 60 to 64, falling with age)
Five times sit to standMore than about 15 seconds in older adults
4 stage balance testUnable to hold tandem stance for 10 seconds
Dynamic Gait Index (0 to 24)19 or below
Functional Gait Assessment (0 to 30)22 or below
Gait speedBelow 1.0 m/s indicates increased risk of falls and adverse outcomes; below 0.4 m/s household ambulator, 0.4 to 0.8 limited community, above 0.8 community ambulator; about 1.2 m/s needed to cross a street safely
Gait speed: the "sixth vital sign" in older adults HouseholdLimited communityCommunity 0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 meters per second Below 1.0 m/s:higher fall, hospitaland mortality risk About 1.2:cross a street Measure over the middle of a 10 m walkway at comfortable pace (acceleration zones excluded). A change of about 0.1 m/s is commonly cited as meaningful.
Figure 14.4 Gait speed bands. Thresholds are approximate and come from different studies, but the exam uses 0.4 and 0.8 m/s for ambulation categories, 1.0 m/s for risk and about 1.2 m/s for street crossing.

Fall prevention with the strongest evidence is exercise that challenges balance, ideally with strength training, performed for at least 3 hours per week over time (for example tai chi or the Otago program, a home based strength and balance program for frail older adults). Add home hazard modification (especially after a fall or with visual impairment), medication reduction, treatment of orthostatic hypotension, cataract surgery when indicated, appropriate footwear, vitamin D for those deficient, and assistive devices.

Osteoporosis and home safety

Osteoporosis is defined by bone mineral density as a T-score of -2.5 or lower (osteopenia, or low bone mass, is -1.0 to -2.5), or clinically by a fragility fracture of the hip or spine. Common fractures are vertebral compression fractures (height loss, thoracic kyphosis, sudden back pain after a minor load), distal radius fractures and hip fractures. Exercise for bone uses progressive resistance training and weight bearing impact appropriate to fracture risk, plus balance training and postural extension exercises. Teach spine sparing movement: avoid loaded spinal flexion and twisting (sit ups, toe touches, twisting while lifting), and use a hip hinge. Hip protectors reduce hip fracture in high risk residents who wear them.

A home safety evaluation looks for: loose throw rugs and cords (remove), poor lighting (add bright lights, night lights from bed to bathroom, switches at both ends of stairs), stairs without rails (rails on both sides), slippery tub (grab bars, nonslip mat, tub bench, handheld shower), low toilet (raised seat or safety frame), frequently used items stored high or low (move to waist to shoulder height), clutter in walkways, and pets underfoot.

Board tip. Sudden confusion in an older adult is delirium until proven otherwise. The next step is medical evaluation (often for infection, dehydration or a drug effect), not a dementia diagnosis or more therapy.
Case. An 82 year old woman in a skilled nursing facility was walking 150 feet with a rolling walker yesterday. Today she is drowsy, inattentive and pulling at her clothes, and her nurse notes cloudy urine. Her history includes mild Alzheimer disease.
Reasoning: The acute change, fluctuating attention and altered alertness point to delirium, likely from a urinary tract infection, superimposed on dementia. The best action is to notify the nurse and provider for medical evaluation, hold challenging gait training, and keep her safe (supervised mobility, low bed, reorientation, glasses and hearing aids on). Attributing the change to dementia progression is the trap: dementia does not worsen overnight. Delirium is associated with falls, longer stays and higher mortality, so early recognition matters.
Key point

Aging reduces reserve without causing sudden decline; screen for orthostatic hypotension, risky medications and delirium; use STEADI questions and tests such as the TUG, Berg, 30 second chair stand and gait speed; prescribe challenging balance and strength exercise; manage osteoporosis with loading but without loaded spinal flexion; and modify the home.

Section 4Women's and men's health

Pregnancy and exercise

Pregnancy increases blood volume by about 40 to 50%, cardiac output by 30 to 50% and resting heart rate by 10 to 20 beats per minute, while systemic vascular resistance and blood pressure fall in the second trimester. Relaxin and other hormones increase ligamentous laxity. The center of mass moves anteriorly and superiorly, lumbar lordosis and thoracic kyphosis often increase, and the base of support widens. Edema increases carpal tunnel and tarsal tunnel symptoms. Low back pain and pelvic girdle pain (posterior pelvic or symphysis pubis pain worsened by single leg loading and rolling in bed) are common; manage with education, exercise, pelvic belts and positioning.

Healthy pregnant people should get at least 150 minutes per week of moderate aerobic activity and strength training; exercise reduces gestational diabetes, excessive weight gain and preeclampsia risk. Use the talk test or perceived exertion rather than heart rate. Avoid contact sports and activities with a high fall risk, scuba diving, exercise at high altitude without acclimatization in those not living there, overheating (hot yoga), and prolonged motionless standing. After about 20 weeks, limit prolonged supine positioning, because the uterus can compress the inferior vena cava and cause supine hypotension; use left side lying or an inclined position.

Absolute contraindications to aerobic exercise in pregnancyWarning signs to stop exercise
Hemodynamically significant heart disease; restrictive lung diseaseVaginal bleeding; fluid leaking from the vagina
Incompetent cervix or cerclageRegular painful contractions
Multiple gestation at risk of preterm laborDyspnea before exertion; chest pain
Persistent second or third trimester bleeding; placenta previa after 26 weeksDizziness or feeling faint; headache
Preterm labor or ruptured membranesMuscle weakness affecting balance
Preeclampsia or pregnancy induced hypertension; severe anemiaCalf pain or swelling (rule out thrombosis)

Diastasis recti abdominis

Diastasis recti abdominis (DRA) is separation of the rectus abdominis bellies along the linea alba, common in late pregnancy and postpartum. Test the patient in hook lying: she lifts her head and shoulders until the spines of the scapulae clear the table, and the examiner palpates finger widths of separation at, above and below the umbilicus. A separation greater than about 2 finger widths (about 2 cm) is commonly considered significant; also note the depth and tension of the linea alba. Management: teach transversus abdominis activation with exhalation, log rolling or side lying to rise from bed instead of a sit up, splinting (crossed hands pulling the recti toward midline) during head lifts and coughs, avoiding straining and heavy loads early, and progressive core loading as the patient controls doming. Most separations narrow by 8 weeks to 6 months postpartum. After a cesarean birth, protect the incision, splint for coughing and progress lifting gradually.

Pelvic floor and urinary incontinence

The pelvic floor (pelvic diaphragm) is formed mainly by the levator ani (puborectalis, pubococcygeus and iliococcygeus) and the coccygeus, innervated primarily by the pudendal nerve and direct branches of S2 to S4. It supports the pelvic organs, maintains continence by closing the urethra and anorectal angle, and contributes to sexual function and lumbopelvic stability. Pelvic floor dysfunction may be underactive (weakness, incontinence, prolapse) or overactive (high tone, pelvic pain, painful intercourse, constipation); overactive muscles need relaxation and down training before strengthening.

TypeMechanism and storyFirst line PT management
StressLeakage with rises in abdominal pressure (cough, sneeze, jump, lift) from weak pelvic floor or urethral support; common after childbirth and prostatectomyPelvic floor muscle training; "the knack" (contract before a cough); weight and impact management
UrgeSudden strong need to void with leakage; overactive detrusor; frequency and nocturiaBladder training (timed voiding with gradually longer intervals), urge suppression (stop, quick pelvic floor contractions, breathe, then walk calmly), reduce bladder irritants such as caffeine and alcohol
MixedStress and urge featuresCombine; treat the more bothersome component first
OverflowIncomplete emptying with dribbling from obstruction (enlarged prostate) or an underactive detrusor (diabetic neuropathy, spinal lesion)Refer; may need catheterization or medical treatment
FunctionalNormal bladder, but mobility, dexterity or cognition prevents reaching the toilet in timeMobility training, bedside commode, easy clothing, prompted voiding schedule
When does leakage occur? Cough, sneeze,lift, jump Sudden strongurge, frequency Dribbling,incompleteemptying Cannot reachtoilet in time Stress Urge Overflow Functional Pelvic floortraining,the knack Bladder training,urge suppression,fewer irritants Refer: obstructionor weak detrusor;medical care Mobility, commode,clothing, promptedvoiding Mixed incontinence combines stress and urge; treat the more bothersome part first.
Figure 14.5 Sorting urinary incontinence by its story. Stress, urge and functional types respond to PT; overflow needs medical referral.

Pelvic floor muscle training is first line care for stress and mixed incontinence in women (strong evidence). Confirm a correct contraction first: the patient should feel a squeeze and lift without breath holding, bearing down, or substituting with gluteals, adductors or abdominals; many people bear down when asked to contract, which worsens prolapse and leakage. Training includes maximal holds (slow twitch endurance, up to about 10 seconds) and quick flicks (fast twitch), commonly about 8 to 12 contractions three times a day for at least 12 weeks, progressing positions from lying to standing and functional activity. Biofeedback, electrical stimulation and vaginal weights are adjuncts. Pelvic organ prolapse (bladder, uterus or rectum descending, with a feeling of heaviness or a bulge that worsens through the day) also improves with pelvic floor training, avoidance of straining, and pessary referral.

Osteoporosis and bone health in women

Estrogen loss at menopause accelerates bone loss for several years, so postmenopausal women make up most people with osteoporosis. Screening with DXA is recommended for women 65 and older and younger postmenopausal women at increased risk. In young female athletes, low energy availability with or without disordered eating causes menstrual dysfunction and low bone density, the female athlete triad, now included in the broader concept of relative energy deficiency in sport. Stress fractures, amenorrhea and weight loss in an athlete warrant referral to a physician and dietitian.

Men's health and prostate cancer care

Prostate cancer is the most common noncutaneous cancer in men. Treatments include active surveillance, radical prostatectomy, radiation, and androgen deprivation therapy (ADT). After prostatectomy, damage to the internal urethral sphincter leaves continence dependent on the external sphincter and pelvic floor, so most men have early stress incontinence; pelvic floor muscle training, ideally started before surgery and resumed after the catheter is removed, speeds the return of continence. Erectile dysfunction is common and pelvic floor training may help. ADT causes loss of bone density, loss of muscle mass with fat gain, fatigue, hot flashes, insulin resistance and higher cardiovascular risk. Combined resistance and aerobic exercise counters fatigue, sarcopenia and functional loss during ADT and is safe for most men. Precautions: screen for bone metastases (prostate cancer spreads to the spine, pelvis and ribs; new night pain or focal bone pain needs evaluation, and loaded or high impact exercise is modified for involved bones), monitor blood counts during chemotherapy, and watch for fatigue and skin effects after radiation.

Board tip. For stress incontinence, the answer is pelvic floor training and the knack; for urge incontinence, bladder training and urge suppression; for overflow, refer. "Stop the urine stream" is a way to find the muscles once, not an exercise to repeat.
Case. A 31 year old at 28 weeks of pregnancy with an uncomplicated course asks for an exercise program. She ran three times a week before pregnancy. During the session she reports new fluid leakage that is not urine and mild cramping.
Reasoning: In healthy pregnancy, continuing moderate aerobic exercise (including running for an experienced runner) and strength training is recommended, monitored by the talk test, with limited prolonged supine positioning after 20 weeks. But leakage of amniotic fluid with cramping is a warning sign of ruptured membranes or preterm labor. The best action is to stop exercise and have her contact her obstetric provider immediately. Treating it as stress incontinence and teaching pelvic floor exercises is the trap.
Key point

Encourage moderate exercise in healthy pregnancy but know the contraindications and stop signs; test DRA with a head lift and manage it with transversus training and splinting; sort incontinence by story (stress, urge, mixed, overflow, functional) and use pelvic floor training first for stress; and help men through prostatectomy and androgen deprivation with pelvic floor and combined exercise while screening for bone metastases.

Section 5Integrated case review

A priority framework

Exam vignettes often contain several problems and ask for what to do first or what is most appropriate. Use a consistent hierarchy:

  1. Life threats and medical instability: airway, breathing, circulation, unstable vital signs, chest pain, signs of stroke, sepsis, hypoglycemia, autonomic dysreflexia. Stop, get help, call emergency services or the rapid response team.
  2. Red flags that require referral before or instead of treatment: suspected deep vein thrombosis, cauda equina syndrome, fracture, infection, cancer, shunt malfunction, cord compression, delirium.
  3. Safety for the session: precautions (weight bearing, hip, sternal, spinal), lines and tubes, vital sign limits, guarding and fall prevention.
  4. The patient's goals and function: the activity and participation limits that matter most to the patient and that drive discharge.
  5. Impairments that limit those functions.

Then match the action to the setting and the person's role: the PT, not the PTA, decides about plan changes; the setting determines who to call (nurse and provider in the hospital, emergency services in an outpatient clinic, the school nurse and parents in a school).

FindingConcernNext best action
Chest pain at rest, diaphoresis, nauseaAcute coronary syndromeStop, call emergency services or a code, monitor, prepare for CPR
Sudden facial droop, arm weakness, slurred speechStrokeNote the time, activate emergency response
Unilateral calf swelling, warmth, pain after surgeryDeep vein thrombosisHold exercise of the limb, notify the provider
Sudden dyspnea, chest pain and tachycardia after a DVTPulmonary embolismEmergency response
Saddle anesthesia, new urinary retention, bilateral leg weaknessCauda equina syndromeImmediate emergency referral
Fever, rising heart rate, low blood pressure, confusionSepsisNotify the provider urgently
Shaky, sweaty, confused patient with diabetesHypoglycemiaCheck glucose, give 15 g fast carbohydrate if able to swallow
Blood pressure 210/120 with headache in a T4 paraplegicAutonomic dysreflexiaSit up, lower legs, check bladder and clothing, get medical help
Systolic drop of 20 mmHg with dizziness on standingOrthostatic hypotensionReturn to sitting or supine, monitor, ankle pumps and graded positioning
1. Life threat or unstable vitals?chest pain, stroke signs, sepsis, low glucose 2. Red flag needing referral?DVT, cauda equina, fracture, delirium, shunt 3. Precautions and session safetyweight bearing, hip, sternal, lines, guarding 4. Patient goals and functiontransfers, gait, ADLs, discharge needs 5. Impairments behind the limitsstrength, ROM, balance, endurance Yes: stop and activateemergency response Yes: hold or modify,refer to the provider If no, continue down. The PT, not the PTA, changes the plan of care; the setting decides whom to call (nurse, 911, school nurse and parents).
Figure 14.6 A priority ladder for multisystem cases. Answer at the highest rung that applies: a life threat outranks a red flag, which outranks the treatment plan.

Worked integrated cases

Case. A 68 year old man is 2 days after a right total hip arthroplasty (posterior approach) in acute care. He has type 2 diabetes, heart failure and mild dementia. Before gait training his heart rate is 112, SpO2 89% on room air (baseline 95%), and he reports new pleuritic chest pain.
Reasoning: Several problems compete (hip precautions, diabetes, cognition), but the highest priority is a possible pulmonary embolism: tachycardia, new hypoxemia and pleuritic chest pain after hip surgery. Do not mobilize; keep him at rest, notify the nurse and provider at once, and activate the rapid response team if he worsens. Teaching posterior hip precautions or checking his glucose are reasonable later steps but are not first.
Case. A 75 year old woman receiving home health PT after a stroke reports two falls this week when getting up at night to urinate. She takes a new antihypertensive and an over the counter sleep aid containing diphenhydramine. Orthostatic testing shows a drop from 138/80 supine to 112/72 after 3 minutes standing, with dizziness.
Reasoning: The falls likely reflect orthostatic hypotension plus an anticholinergic sedating drug and nighttime urgency. The best action combines contacting the physician about the medication and blood pressure findings, teaching slow staged rising (sit at the edge of the bed, ankle pumps, then stand), a bedside commode or night lights to the bathroom, and continuing balance and strength training. Ordering a wheelchair or simply adding more lower extremity strengthening misses the medication and blood pressure causes.
Case. A 45 year old warehouse worker comes to outpatient PT by direct access with low back pain after lifting. He mentions trouble starting urination since yesterday and numbness "where I sit on a bike." Straight leg raise is positive bilaterally.
Reasoning: Urinary retention, saddle anesthesia and bilateral signs indicate possible cauda equina syndrome, a surgical emergency. The best action is immediate referral to the emergency department, not treatment and not a routine physician appointment. Directional preference exercises or a lumbar support are appropriate only after serious pathology is excluded.

Choosing across settings

Discharge questions ask for the most appropriate next setting. Consider medical stability, the amount of assistance needed, tolerance for therapy, the home and caregiver support, and payer rules. A patient who needs intensive multidisciplinary therapy, can tolerate about 3 hours a day and is expected to improve fits inpatient rehabilitation; one who needs daily skilled care but cannot tolerate that intensity fits a skilled nursing facility; one who is safe at home with help but leaves home only with considerable and taxing effort fits home health; one who can travel fits outpatient. Always match recommendations to the person's goals, cognitive status and caregiver availability, and include equipment and education in the plan.

Board tip. When several answers are reasonable, choose the one that addresses the most dangerous problem first, then the one that respects scope and setting, and only then the best exercise. "Continue the treatment and monitor" is rarely correct when a red flag is present.
Key point

Integrated cases reward a fixed order of thinking: life threats, then red flags and referral, then session safety and precautions, then the patient's functional goals, then impairments, with the action and person to contact matched to the setting and the discharge recommendation matched to tolerance, assistance and support.

The chapter in one breath

  • Infants hold their head at about 4 months, sit at 6 to 8, creep and pull to stand at 9 to 10, and walk at about 12 months; evaluate if not walking by 18 months, using corrected age for prematurity.
  • Most primitive reflexes integrate by about 6 months; persistence, asymmetry or obligatory responses suggest CNS dysfunction.
  • CP is a nonprogressive brain lesion with changing musculoskeletal effects; spastic diplegia follows periventricular leukomalacia; GMFCS I to V predicts mobility.
  • In myelomeningocele watch for shunt malfunction, tethered cord, latex allergy and skin breakdown; in Down syndrome screen for atlantoaxial instability.
  • Torticollis: head tilts toward and rotates away from the tight SCM; DDH is managed with a Pavlik harness in flexion and abduction.
  • Part C: birth to 3, IFSP, natural environments; Part B: 3 to 21, IEP, educationally relevant goals, least restrictive environment; 504 plans give accommodations.
  • Aging lowers reserve; screen for orthostatic hypotension, polypharmacy and delirium, which is acute, fluctuating and a medical emergency.
  • Fall risk: TUG 12 seconds or more, Berg 45 or below, gait speed below 1.0 m/s; balance plus strength exercise prevents falls.
  • Osteoporosis is a T-score of -2.5 or lower; load bone with resistance and impact but avoid loaded spinal flexion and twisting.
  • Exercise in healthy pregnancy (150 minutes a week) but stop for bleeding, fluid leakage, contractions, chest pain or calf swelling; DRA beyond about 2 finger widths is significant.
  • Stress incontinence gets pelvic floor training; urge gets bladder training; overflow gets referral; post-prostatectomy men benefit from pelvic floor training and exercise during ADT.
  • In multisystem cases address life threats, then red flags, then safety, then function, and match the action to the setting.

Words worth knowing

TermWhat it means
Corrected ageChronological age minus weeks of prematurity, used for infants born before 37 weeks until about age 2.
Asymmetric tonic neck reflexHead turning causes extension of the face side limbs and flexion of the skull side limbs.
Cerebral palsyPermanent movement and posture disorders from a nonprogressive lesion of the developing brain.
Periventricular leukomalaciaWhite matter injury near the ventricles in preterm infants, the classic cause of spastic diplegia.
GMFCSA five level classification of usual gross motor function in children with cerebral palsy.
MyelomeningoceleA neural tube defect in which the spinal cord and meninges protrude through a vertebral defect.
Chiari II malformationDownward displacement of the cerebellum and brainstem through the foramen magnum, common with myelomeningocele.
Tethered cordScarring of the spinal cord that stretches it with growth, causing progressive weakness, scoliosis and bladder change.
Atlantoaxial instabilityExcess motion between C1 and C2 from ligament laxity, a cord compression risk in Down syndrome.
Congenital muscular torticollisA shortened sternocleidomastoid that tilts the head toward and rotates it away from the involved side.
Ortolani testHip abduction with an anterior lift that reduces a dislocated infant hip with a clunk.
Pavlik harnessA dynamic brace that holds an infant's hips flexed and abducted to treat hip dysplasia.
IFSPIndividualized Family Service Plan for early intervention from birth to age 3.
IEPIndividualized Education Program describing special education and related services for a student aged 3 to 21.
Least restrictive environmentEducating a child with a disability alongside peers without disabilities to the greatest extent appropriate.
SarcopeniaAge related loss of muscle mass, strength and power.
PolypharmacyUse of many medications, commonly five or more, which raises the risk of falls and adverse effects.
DeliriumAn acute, fluctuating disturbance of attention and awareness caused by a medical problem.
FrailtyReduced physiologic reserve, often defined by three or more of weight loss, exhaustion, weakness, slowness and low activity.
Orthostatic hypotensionA fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.
T-scoreBone density compared with a young adult mean; -2.5 or lower defines osteoporosis.
Diastasis recti abdominisSeparation of the rectus abdominis along the linea alba, common in pregnancy and postpartum.
Stress incontinenceUrine leakage with increased abdominal pressure such as coughing or lifting.
The knackA deliberate pelvic floor contraction just before a cough or sneeze to prevent leakage.
Androgen deprivation therapyHormonal treatment for prostate cancer that lowers testosterone and causes bone and muscle loss.

Check yourself

A baby born at 30 weeks is now 7 months old chronologically. What is the corrected age, and should she be sitting independently?
Answer. Corrected age is 7 months minus 10 weeks (about 2.5 months), or about 4.5 months. Independent sitting is expected at about 6 to 8 months, so not yet sitting is not a delay at her corrected age.
An 8 month old cannot bring her hands to midline when her head is turned and is unable to roll. Which persistent reflex is most likely responsible?
Answer. The asymmetric tonic neck reflex, which normally integrates by about 4 to 6 months. Its persistence blocks midline hand use and rolling.
A child born at 28 weeks has spastic weakness much greater in the legs than the arms. What type of CP is this and what lesion explains it?
Answer. Spastic diplegia from periventricular leukomalacia; the corticospinal fibers to the legs pass closest to the lateral ventricles.
An infant has a left congenital muscular torticollis. Describe the head position and the stretch.
Answer. The head tilts to the left and rotates to the right. Stretch into right lateral flexion and left rotation, and encourage active turning to the left.
A 12 year old with Down syndrome develops neck pain, a new clumsy gait and brisk reflexes. What is the concern and the action?
Answer. Atlantoaxial instability with spinal cord compression. Stop activity, avoid neck loading, and refer for urgent medical evaluation.
A school PT is asked to write an IEP goal for a 9 year old with spastic diplegia. Which kind of goal is most appropriate?
Answer. An educationally relevant functional goal, such as walking from the classroom to the cafeteria with a posterior walker within the time allotted, rather than an isolated impairment goal such as hamstring length.
An 80 year old has a Timed Up and Go of 16 seconds, a Berg score of 41 and gait speed of 0.6 m/s. Interpret these results.
Answer. All three indicate increased fall risk (TUG 12 seconds or more, Berg 45 or below, gait speed below 1.0 m/s), and 0.6 m/s places her in the limited community ambulation category.
A woman with osteoporosis asks which exercises to avoid. What is the main precaution?
Answer. Avoid loaded spinal flexion and twisting (sit ups, toe touches, twisting while lifting), which raise vertebral compression fracture risk; emphasize resistance, appropriate impact, balance and spinal extension work.
A postpartum patient leaks urine when she sneezes and lifts her toddler. What type of incontinence and what first line treatment?
Answer. Stress urinary incontinence. Pelvic floor muscle training after confirming a correct contraction, with the knack before coughs, sneezes and lifts.
A man 6 weeks after radical prostatectomy is on androgen deprivation therapy and reports fatigue, leakage with coughing and new constant night pain in his thoracic spine. What is the priority?
Answer. The new constant night pain raises concern for bone metastasis and needs prompt referral before loading the spine. Pelvic floor training for stress incontinence and combined exercise for ADT fatigue follow once metastasis is evaluated.